Lewis's Medical-Surgical Nursing in Canada, 5th Edition [5 ed.] 9780323791571, 0323791573, 9780323791564, 0323791565, 9780323881951, 9780323716338

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C ONTE N T S SECTION 1 Concepts in Nursing Practice 1 Introduction to Medical-­Surgical Nursing Practice in Canada, 2 2 Cultural Competence and Health Equity in Nursing Care, 20 3 Health History and Physical Examination, 37 4 Patient and Caregiver Teaching, 48 5 Chronic Illness, 62 6 Community-­Based Nursing and Home Care, 76 7 Older Persons, 86 8 Stress and Stress Management, 106 9 Sleep and Sleep Disorders, 120 10 Pain, 135 11 Substance Use, 164 12 Complementary and Alternative Therapies, 189 13 Palliative and End-­of-­Life Care, 201

SECTION 2 Pathophysiological Mechanisms of Disease 14 15 16 17

I nflammation and Wound Healing, 217 Genetics, 241 Altered Immune Response and Transplantation, 252 Infection and Human Immunodeficiency Virus  Infection, 279 18 Cancer, 307 1 9 Fluid, Electrolyte, and Acid–Base Imbalances, 342

SECTION 3 Perioperative Care 20 N  ursing Management: Preoperative Care, 374 21 Nursing Management: Intraoperative Care, 391 22 Nursing Management: Postoperative Care, 408

SECTION 4 Conditions Related to Altered Sensory Input 23 N  ursing Assessment: Visual and Auditory Systems, 428 24 Nursing Management: Visual and Auditory Conditions, 449 25 Nursing Assessment: Integumentary System, 481 26 Nursing Management: Integumentary Conditions, 494 27 Nursing Management: Burns, 518

SECTION 5 Conditions of Oxygenation: Ventilation 28 N  ursing Assessment: Respiratory System, 544 29 Nursing Management: Upper Respiratory Conditions, 567 30 Nursing Management: Lower Respiratory Conditions, 588 31 Nursing Management: Obstructive Pulmonary ­Diseases, 630

SECTION 6 Conditions of Oxygenation: Transport 32 N  ursing Assessment: Hematological System, 681 33 Nursing Management: Hematological Conditions, 701

SECTION 7 Conditions of Oxygenation: Perfusion 34 N  ursing Assessment: Cardiovascular System, 751 35 Nursing Management: Hypertension, 773 36 Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome, 796 37 Nursing Management: Heart Failure, 829 38 Nursing Management: Dysrhythmias, 849 39 Nursing Management: Inflammatory and Structural Heart Disorders, 872 40 Nursing Management: Vascular Disorders, 898

SECTION 8 Conditions of Ingestion, Digestion, Absorption, and Elimination

SECTION 11 Conditions Related to Movement and Coordination

41 42 43 44

58 N  ursing Assessment: Nervous System, 1427 59 Nursing Management: Acute Intracranial ­Conditions, 1453 60 Nursing Management: Stroke, 1485 61 Nursing Management: Chronic Neurological ­Conditions, 1511 62 Nursing Management: Delirium, Alzheimer’s ­Disease, and Other Dementias, 1541 63 Nursing Management: Peripheral Nerve and Spinal Cord Conditions, 1560 64 Nursing Assessment: Musculoskeletal System, 1591 65 Nursing Management: Musculoskeletal Trauma and Orthopedic Surgery, 1606 66 Nursing Management: Musculoskeletal Conditions, 1642 67 Nursing Management: Arthritis and Connective Tissue Diseases, 1665

 ursing Assessment: Gastrointestinal System, 930 N Nursing Management: Nutritional Conditions, 951 Nursing Management: Obesity, 974 Nursing Management: Upper Gastrointestinal ­Conditions, 993 45 Nursing Management: Lower Gastrointestinal ­Conditions, 1036 4 6 Nursing Management: Liver, Pancreas, and Biliary Tract Conditions, 1080

SECTION 9 Conditions of Urinary Function 47 N  ursing Assessment: Urinary System, 1121 48 Nursing Management: Renal and Urological ­Conditions, 1143 49 Nursing Management: Acute Kidney Injury and Chronic Kidney Disease, 1180

SECTION 10 Conditions Related to Regulatory and Reproductive Mechanisms 50 51 52 53 54 55

 ursing Assessment: Endocrine System, 1214 N Nursing Management: Endocrine Conditions, 1237 Nursing Management: Diabetes Mellitus, 1269 Nursing Assessment: Reproductive System, 1308 Nursing Management: Breast Disorders, 1331 Nursing Management: Sexually Transmitted ­Infections, 1355 56 Nursing Management: Female Reproductive ­Conditions, 1372 5 7 Nursing Management: Male Reproductive ­Conditions, 1402

SECTION 12 Nursing Care in Specialized Settings 68 N  ursing Management: Critical Care Environment, 1700 69 Nursing Management: Shock, Sepsis, and Multiple-­ Organ Dysfunction Syndrome, 1729 70 Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome, 1753 71 Nursing Management: Emergency Care Situations, 1774 72 Emergency Management and Disaster Planning, 1796

Appendix Laboratory Values, 1817 Glossary, 1832 Index, 1853 Special Features, 1904

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21-CS-0280 TM/AF 6/21

FIFTH EDITION

LEWIS’S

Medical-­Surgical Nursing in Canada Assessment and Management of Clinical Problems Jane Tyerman

RN, BA, BScN, MScN, PhD, CCSNE

US Author Mariann M. Harding, RN, PhD, FAADN, CNE Professor of Nursing Kent State University at Tuscarawas New Philadelphia, Ohio

Assistant Professor School of Nursing Faculty of Health Sciences University of Ottawa Ottawa, Ontario Professeure Adjointe École des sciences infirmières Faculté des sciences de la santé Université d’Ottawa Ottawa, Ontario

Section Editors for the US 11th Edition Jeffrey Kwong, RN, DNP, MPH, ANP-­BC, FAAN, FAANP

Shelley L. Cobbett

Dottie Roberts, RN, EdD, MSN, MACI, OCNS-­C, CMSRN, CNE

RN, BN, GnT, MN, EdD

Assistant Professor, Nursing and BScN Site Administrator School of Nursing – Yarmouth Campus Dalhousie University Yarmouth, Nova Scotia

Professor Division of Advanced Nursing Practice School of Nursing Rutgers University Newark, New Jersey

Executive Director Orthopaedic Nurses Certification Board Chicago, Illinois

Debra Hagler, RN, PhD, ACNS-­BC, CNE, CHSE, ANEF, FAAN Clinical Professor Edson College of Nursing and Health Innovation Arizona State University Phoenix, Arizona

Courtney Reinisch, RN, DNP, FNP-­BC Undergraduate Program Director Associate Professor School of Nursing Montclair State University Montclair, New Jersey

LEWIS’S MEDICAL-­SURGICAL NURSING IN CANADA:  ASSESSMENT AND MANAGEMENT OF CLINICAL PROBLEMS, FIFTH EDITION Copyright © 2023 by Elsevier, Inc. All rights reserved.

ISBN: 978-­0-­323-­79156-­4

Previous editions copyrighted 2019, 2014, 2009, and 2006 by Elsevier Canada, a Division of Reed Elsevier Canada, Ltd. Adapted from Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 11th Edition, by Mariann M. Harding, Jeffrey Kwong, Dottie Roberts, Debra Hagler, and Courtney Reinisch. Copyright © 2020, Elsevier Inc., ISBN: 9780323551496 (hardcover). All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or ­mechanical, including photocopy, recording, or any information storage and retrieval system, w ­ ithout ­permission in writing from the publisher. Reproducing passages from this book without such written ­permission is an infringement of copyright law. Requests for permission to make copies of any part of the work should be mailed to: College Licensing ­Officer, access ©, 1 Yonge Street, Suite 1900, Toronto, ON M5E 1E5. Fax: (416) 868-­1621. All other inquiries should be directed to the publisher, www.elsevier.com/permissions. Every reasonable effort has been made to acquire permission for copyrighted material used in this text and to acknowledge all such indebtedness accurately. Any errors and omissions called to the publisher’s attention will be corrected in future printings.

Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Managing Director, Global Content Partners: Kevonne Holloway Senior Content Strategist (Acquisitions, Canada): Roberta A. Spinosa-­Millman Content Development Specialists: Tammy Scherer, Suzanne Simpson Publishing Services Manager: Catherine Jackson Health Content Management Specialist: Kristine Feeherty Design Direction: Amy Buxton Printed in Canada Last digit is the print number: 9 8 7 6 5 4 3 2 1

CONTENTS

SECTION 1 Concepts in Nursing Practice 1 Introduction to Medical-­Surgical Nursing Practice in Canada, 2 The Canadian Health Care Context, 2 The Nursing Process, 12 Nursing Care Plans, 16 Documentation, 16 Future Challenges of Nursing, 17 2 Cultural Competence and Health Equity in Nursing Care, 20 Cultural Landscape of Canada, 20 Exploring the Concepts: Definitions and Meanings, 22 The Nurse’s Self-­Assessment, 31 Culturally Competent Patient Assessment, 31 Bridging Cultural Distances, 32 Working in Diverse Teams, 32 Conclusion, 33 3 Health History and Physical Examination, 37 Data Collection, 37 Nursing History: Subjective Data, 39 Physical Examination: Objective Data, 41 Types of Assessment, 43 Problem Identification and Nursing Diagnoses, 43 4 Patient and Caregiver Teaching, 48 Role of Patient and Caregiver Teaching, 48 Teaching–Learning Process, 49 Process of Patient Teaching, 52 5 Chronic Illness, 62 The Epidemiology of Chronic Diseases, 63 Health: Acute Illness, Chronic Illness, and the Health–Illness Continuum, 63 Factors Contributing to Chronic Illness, 64 Prevention of Chronic Illness, 65 Disability in Chronic Illness, 65 Psychosocial Dimensions of Chronic Illness, 66 Living With Chronic Illness, 69 Chronic Illness and Caregiving, 69 Conceptual Models of Chronic Illness, 69 Self-­Management, 71 The Emerging Paradigm of Chronic Care, 72

6 Community-­Based Nursing and Home Care, 76 Community Health and the Patient’s Health Care Journey, 76 Community Health Settings, 77 Home Care, 78 Home Health Nursing Practice, 80 Summary, 82 7 Older Persons, 86 Demographics of Aging, 86 Attitudes Toward Aging, 87 Biological Theories of Aging, 87 Social Theories of Aging, 87 Universal Health Care, 87 Age-­Related Physiological Changes, 88 Older Populations at Risk, 90 COVID-19 and the Impact on Older Persons, 93 Social Support and the Older Person, 94 Care Alternatives for Older Persons, 95 Legal and Ethical Issues, 97 Nursing Management: Older Persons, 97 8 Stress and Stress Management, 106 Definition of Stress, 106 Physiological Influence, 108 Socioenvironmental Influence, 109 Individual Influence, 110 Effects of Stress on Health, 111 Stress Management, 112 Nursing Management: Stress, 116 9 Sleep and Sleep Disorders, 120 Sleep, 120 Inefficient Sleep and Sleep Disturbances, 122 Sleep Disorders, 123 Nursing Management: Insomnia, 126 Nursing and Interprofessional Management: Sleep Apnea, 129 Age-­Related Considerations, 131 Special Sleep Needs of Nurses, 131 10 Pain, 135 Pain, 135 Magnitude of the Pain Problem, 135 Definitions of Pain, 136 Dimensions of Pain and the Pain Process, 137 Causes and Types of Pain, 141

v

vi

CONTENTS Pain Assessment, 142 Pain Treatment, 146 Traditional Medicinal Therapies of Indigenous ­Populations in Canada, 154 Nursing and Interprofessional Management: Pain, 157 Institutionalizing Pain Education and Management, 158 Ethical Issues in Pain Management, 159 Special Populations, 160 Patients With Substance Use Problems, 160

11 Substance Use, 164 Substance Use in Canada, 164 Factors That Influence Substance Use, 165 Key Concepts and Approaches, 166 The Harm Reduction Perspective, 166 Nursing Management: Substance Use, 168 Health Promotion, 169 Common Substances, Treatment, and Nursing Interventions, 169 Nicotine, 169 Alcohol, 173 Cannabis, 177 Opioids, 178 Stimulants, 181 Cocaine, Amphetamines, and Prescription Stimulants, 181 Sedative–Hypnotics, 182 Other Substances, 182 Inhalants, 182 Hallucinogens, 182 Gamma Hydroxybutyrate (GHB), 182 Special Considerations, 183 12 Complementary and Alternative Therapies, 189 Natural Products, 190 Mind–Body Practices, 194 Other Complementary and Alternative Practices, 196 Energy-­Based Therapies, 197 Nursing Management: Complementary and Alternative Therapies, 198 13 Palliative and End-­of-­Life Care, 201 Hospice Palliative Care, 201 Physical Manifestations of the End of Life, 202 Psychosocial Manifestations of the End of Life, 203 Grief and Bereavement, 203 Spiritual Needs, 205 Culturally Competent Care, 205 Legal and Ethical issues Affecting End-­of-­Life Care, 205 Nursing Management: End of Life, 207 Special Needs of Caregivers in End-­of-­Life Care, 210 

SECTION 2 Pathophysiological Mechanisms of Disease 14 Inflammation and Wound Healing, 217 Cell Injury, 217 Defence Against Injury, 219 Nursing Management: Inflammation and Healing, 226 Pressure Injuries, 231 ­ ressure Nursing and Interprofessional Management: P Injuries, 231 15 Genetics, 241 Basic Principles of Genetics: Genes, Chromosomes, and DNA, 241 Human Genome Project, 244 Inheritance Patterns, 244 Genetics in Clinical Practice, 246 Nursing Management: Genetics, 249 16 Altered Immune Response and Transplantation, 252 Normal Immune Response, 252 Age-­Related Considerations, 258 Altered Immune Response, 258 Allergic Disorders, 262 Nursing Management: Immunotherapy, 265 Nursing and Interprofessional Management: Latex Allergies, 266 Autoimmunity, 266 Immunodeficiency Disorders, 267 Organ Transplantation, 269 Immunosuppressive Therapy, 271 Alternative Strategies, 273 New Technologies in Immunology, 275 17 Infection and Human Immunodeficiency Virus Infection, 279 Infections, 279 Age-­Related Considerations, 283 Human Immunodeficiency Virus Infection, 285 Nursing Management: Human Immunodeficiency Virus Infection, 296 18 Cancer, 307 Definition and Incidence, 307 Biological Processes of Cancer, 308 Classification of Cancer, 314 Prevention and Detection of Cancer, 315 Diagnosis of Cancer, 316 Interprofessional Care, 316

CONTENTS Surgical Therapy, 318 Chemotherapy, 318 Radiation Therapy, 323 Nursing Management: Radiation Therapy and Chemotherapy, 325 Late Effects of Radiation Treatment and C ­ hemotherapy, 331 Biological and Targeted Therapy, 331 Nursing Management: Biological Therapy, 334 Bone Marrow and Stem Cell Transplantation, 334 Gene Therapy, 335 Complications Resulting from Cancer, 335 Management of Cancer Pain, 337 Psychosocial Care, 337 19 Fluid, Electrolyte, and Acid–Base Imbalances, 342 Homeostasis, 342 Water Content of the Body, 343 Electrolytes, 343 Mechanisms Controlling Fluid and Electrolyte Movement, 344 Fluid Movement in Capillaries, 346 Fluid Movement Between Extracellular Fluid and Intracellular Fluid, 346 Fluid Spacing, 347 Regulation of Water Balance, 347 Fluid and Electrolyte Imbalances, 349 Nursing Management: Sodium and Volume I­ mbalances, 352 Nursing and Interprofessional Management: H ­ yperkalemia, 354 Nursing and Interprofessional Management: H ­ ypokalemia, 355 Nursing and Interprofessional Management: H ­ ypercalcemia, 357 Nursing and Interprofessional Management: Hypocalcemia, 357 Assessment of Fluid, Electrolyte, and Acid–Base Imbalances, 364 Oral Fluid and Electrolyte Replacement, 365 Intravenous Fluid and Electrolyte Replacement, 365 Central Venous Access Devices, 367 Nursing Management: Central Venous Access D ­ evices, 369 

SECTION 3 Perioperative Care 20  Nursing Management: Preoperative Care, 374 Surgical Settings, 374

vii

Surgical Wait Times, 375 Preoperative Admission Assessment, 375 Day-­of-­Surgery Assessment, 375 Nursing Assessment: Patient About to Undergo S­ urgery, 380 Nursing Management: Patient About to Undergo Surgery, 382 Day-­of-­Surgery Preparation, 385 21  Nursing Management: Intraoperative Care, 391 Physical Environment, 391 Surgical Team, 392 Nursing Management: Patient Before Surgery, 395 Nursing Management: Intraoperative Care, 395 Classification of Anaesthesia, 399 Exceptional Clinical Events in the Operating Room, 404 22 Nursing Management: Postoperative Care, 408 Postoperative Care in the Postanaesthesia Care Unit, 408 Potential Alterations in Respiratory Function, 410 Nursing Management: Respiratory Complications, 411 Potential Alterations in Cardiovascular Function, 412 Nursing Management: Cardiovascular Conditions, 414 Potential Alterations in Neurological Function, 415 Nursing Management: Neurological Complications, 415 Pain and Discomfort, 416 Nursing Management: Pain, 416 Potential Alterations in Temperature, 417 Nursing Management: Potential Temperature C ­ omplications, 417 Potential Gastrointestinal Conditions, 418 Nursing Management: Gastrointestinal Conditions, 418 Potential Alterations in Urinary Function, 419 Nursing Management: Potential Urinary Conditions, 419 Potential Alterations in the Integument, 419 Nursing Management: Surgical Wounds, 420 Potential Alterations in Psychological Function, 421 Nursing Management: Psychological Function, 421 Discharge from the Postanaesthesia Care Unit, 422 Care of the Postoperative Patient on the Clinical Unit, 422 Planning for Discharge and Follow-­Up Care, 422 

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CONTENTS

SECTION 4 Conditions Related to Altered Sensory Input 23 Nursing Assessment: Visual and Auditory Systems, 428 The Visual System, 428 Structures and Functions, 428 Assessment, 431 Diagnostic Studies, 439 The Auditory System, 439 Structures and Functions, 439 Assessment, 441 Diagnostic Studies, 445 24 Nursing Management: Visual and Auditory Conditions, 449 Visual Conditions, 449 Correctable Refractive Errors, 450 Uncorrectable Visual Impairment, 451 Nursing Management: Visual Impairment, 451 Eye Trauma, 453 Extraocular Disorders, 453 Nursing Management: Inflammation and Infection, 456 Dry Eye Disorders, 456 Strabismus, 456 Corneal Disorders, 456 Intraocular Disorders, 457 Nursing Management: Cataracts, 459 Retinopathy, 461 Retinal Detachment, 461 Age-­Related Macular Degeneration, 463 Glaucoma, 464 Nursing Management: Glaucoma, 465 Intraocular Inflammation and Infection, 467 Enucleation, 468 Ocular Tumours, 468 Ocular Manifestations of Systemic Diseases, 468 Auditory Conditions, 469 External Ear and Canal, 469 Nursing and Interprofessional Management: External Otitis, 469 Middle Ear and Mastoid, 470 Nursing Management: Chronic Otitis Media, 471 Nursing Management: Otosclerosis, 472 Inner Ear Conditions, 472 Nursing and Interprofessional Management: Ménière’s Disease, 472 Nursing and Interprofessional Management: Hearing Loss and Deafness, 474

25 Nursing Assessment: Integumentary System, 481 Structures and Functions of the Skin and Appendages, 481 Assessment of the Integumentary System, 484 Diagnostic Studies of the Integumentary System, 491 26 Nursing Management: Integumentary Conditions, 494 Health Promotion, 494 Malignant Skin Neoplasms, 497 Risk Factors, 497 Nonmelanoma Skin Cancers, 497 Melanoma, 498 Skin Infections and Infestations, 500 Allergic Dermatological Conditions, 503 Cutaneous Medication Reactions, 503 Benign Dermatological Conditions, 504 Interprofessional Care: Dermatological Conditions, 505 Nursing Management: Dermatological Conditions, 509 Cosmetic Procedures, 512 Nursing Management: Cosmetic Surgery, 514 Skin Grafts, 514 27 Nursing Management: Burns, 518 Types of Burn Injury, 519 Classification of Burn Injury, 521 Phases of Burn Management, 523 Nursing and Interprofessional Management: ­Emergent Phase, 527 Acute Phase, 533 Nursing and Interprofessional Management: Acute Phase, 534 Rehabilitation Phase, 537 Nursing and Interprofessional Management: ­Rehabilitation Phase, 538 Emotional Needs of the Patient and Caregivers, 539 Special Needs of the Nursing Staff, 540 

SECTION 5 Conditions of Oxygenation: Ventilation 28 Nursing Assessment: Respiratory System, 544 Structures and Functions of the Respiratory System, 544 Assessment of the Respiratory System, 551 Diagnostic Studies of the Respiratory System, 557 29 Nursing Management: Upper Respiratory Conditions, 567

CONTENTS Structural and Traumatic Disorders of the Nose, 567 Deviated Septum, 567 Nasal Fracture, 567 Nursing Management: Nasal Surgery, 568 Epistaxis, 568 Nursing and Interprofessional Management: Epistaxis, 568 Inflammation and Infection of the Nose and ­Paranasal Sinuses, 569 Allergic Rhinitis, 569 Nursing and Interprofessional Management: Allergic Rhinitis, 569 Acute Viral Rhinitis, 572 Nursing and Interprofessional Management: Acute Viral Rhinitis, 572 Influenza, 572 Nursing and Interprofessional Management: Influenza, 573 Sinusitis, 573 Nursing and Interprofessional Management: Sinusitis, 574 Obstruction of the Nose and Paranasal Sinuses, 575 Polyps, 575 Foreign Bodies, 575 Conditions Related to the Pharynx, 575 Acute Pharyngitis, 575 Nursing and Interprofessional Management: Acute Pharyngitis, 575 Peritonsillar Abscess, 575 Conditions Related to the Trachea and Larynx, 575 Airway Obstruction, 575 Tracheostomy, 576 Nursing Management: Tracheostomy, 576 Laryngeal Polyps, 581 Head and Neck Cancer, 581 Nursing Management: Head and Neck Cancer, 583 30 Nursing Management: Lower Respiratory Conditions, 588 Acute Bronchitis, 589 Pneumonia, 589 Nursing Management: Pneumonia, 594 Tuberculosis, 595 Nursing Management: Tuberculosis, 598 Atypical Mycobacteria, 600 Pulmonary Fungal Infections, 600 Bronchiectasis, 601 Nursing Management: Bronchiectasis, 601 Lung Abscess, 602 Nursing and Interprofessional Management: Lung Abscess, 602 Environmental Lung Diseases, 603

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Lung Cancer, 603 Nursing Management: Lung Cancer, 608 Other Types of Lung Tumours, 609 Chest Trauma and Thoracic Injuries, 610 Pneumothorax, 610 Fractured Ribs, 613 Flail Chest, 613 Chest Tubes and Pleural Drainage, 613 Nursing Management: Chest Drainage, 615 Chest Surgery, 617 Restrictive Respiratory Disorders, 618 Pleural Effusion, 618 Pleurisy, 620 Atelectasis, 621 Interstitial Lung Disease, 621 Idiopathic Pulmonary Fibrosis, 621 Sarcoidosis, 621 Vascular Lung Disorders, 621 Pulmonary Edema, 621 Pulmonary Embolism, 622 Nursing Management: Pulmonary Embolism, 624 Pulmonary Hypertension, 624 Primary Pulmonary Hypertension, 624 Secondary Pulmonary Hypertension, 625 Cor Pulmonale, 625 Lung Transplantation, 626 31  Nursing Management: Obstructive Pulmonary Diseases, 630 Asthma, 630 Nursing Management: Asthma, 645 Chronic Obstructive Pulmonary Disease, 648 Nursing Management: Chronic Obstructive ­Pulmonary Disease, 666 Cystic Fibrosis, 671 Nursing Management: Cystic Fibrosis, 674 

SECTION 6 Conditions of Oxygenation: Transport 32 Nursing Assessment: Hematological System, 681 Structures and Functions of the Hematological System, 681 Assessment of the Hematological System, 688 Diagnostic Studies of the Hematological System, 693 33 Nursing Management: Hematological Conditions, 701 Anemia, 702 Definition and Classification, 702 Clinical Manifestations, 702

x

CONTENTS Nursing Management: Anemia, 703 Anemia Caused by Decreased Erythrocyte ­Production, 703 Iron-­Deficiency Anemia, 704 Nursing Management: Iron-­Deficiency Anemia, 706 Thalassemia, 707 Megaloblastic Anemias, 707 Nursing Management: Megaloblastic Anemia, 709 Anemia of Chronic Disease, 709 Aplastic Anemia, 709 Nursing and Interprofessional Management: Aplastic Anemia, 710 Anemia Caused by Blood Loss, 710 Acute Blood Loss, 710 Nursing and Interprofessional Management: Acute Blood Loss, 711 Chronic Blood Loss, 711 Anemia Caused by Increased Erythrocyte ­Destruction, 711 Sickle Cell Disease, 711 Nursing and Interprofessional Management: Sickle Cell Disease, 713 Acquired Hemolytic Anemia, 714 Hemochromatosis, 715 Polycythemia, 716 Nursing Management: Polycythemia Vera, 717 Conditions of Hemostasis, 717 Thrombocytopenia, 717 Nursing Management: Thrombocytopenia, 721 Hemophilia and von Willebrand Disease, 722 Nursing Management: Hemophilia, 724 Disseminated Intravascular Coagulation, 724 Nursing Management: Disseminated Intravascular Coagulation, 726 Neutropenia, 727 Nursing and Interprofessional Management: Neutropenia, 728 Myelodysplastic Syndrome, 730 Nursing and Interprofessional Management: Myelodysplastic Syndrome, 730 Leukemia, 731 Nursing Management: Leukemia, 734 Lymphomas, 735 Hodgkin’s Lymphoma, 735 Nursing and Interprofessional Management: Hodgkin’s Lymphoma, 736 Non-­Hodgkin’s Lymphoma, 737 Nursing and Interprofessional Management: Non-­Hodgkin’s Lymphoma, 738 Multiple Myeloma, 740 Nursing Management: Multiple Myeloma, 741 Disorders of the Spleen, 742 Blood Component Therapy, 742 

SECTION 7 Conditions of Oxygenation: Perfusion 34 Nursing Assessment: Cardiovascular System, 751 Structures and Functions of the Cardiovascular System, 751 Assessment of the Cardiovascular System, 757 Diagnostic Studies of the Cardiovascular System, 762 35 Nursing Management: Hypertension, 773 Normal Regulation of Blood Pressure, 773 Hypertension, 775 Nursing Management: Primary Hypertension, 788 Hypertensive Crisis, 792 Nursing and Interprofessional Management: Hypertensive Crisis, 792 36 Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome, 796 Coronary Artery Disease, 796 Etiology and Pathophysiology, 797 Risk Factors for Coronary Artery Disease, 798 Chronic Stable Angina, 804 Prinzmetal’s Angina, 806 Interprofessional Management, 808 Acute Coronary Syndrome, 811 Etiology and Pathophysiology, 811 Manifestations of Acute Coronary Syndrome, 811 Myocardial Infarction, 811 Diagnostic Studies, 813 Interprofessional Care, 814 Nursing Management: Chronic Stable Angina and Acute Coronary Syndrome, 818 Sudden Cardiac Death, 825 Nursing and Interprofessional Management: Sudden Cardiac Death, 825 37 Nursing Management: Heart Failure, 829 Heart Failure, 829 Nursing and Interprofessional Management: Acute Decompensated Heart Failure, 835 Interprofessional Care: Chronic Heart Failure, 837 Medication Therapy: Chronic Heart Failure, 838 Nutritional Therapy: Heart Failure, 840 Nursing Management: Heart Failure, 841 Cardiac Transplantation, 845 38 Nursing Management: Dysrhythmias, 849 Rhythm Identification and Treatment, 849

CONTENTS Electrocardiographic Changes Associated With Acute Coronary Syndrome, 867 Syncope, 868 39 Nursing Management: Inflammatory and Structural Heart Disorders, 872 Inflammatory Disorders of the Heart, 872 Infective Endocarditis, 872 Nursing Management: Infective Endocarditis, 876 Acute Pericarditis, 877 Nursing Management: Acute Pericarditis, 879 Chronic Constrictive Pericarditis, 880 Nursing and Interprofessional Management: Chronic Constrictive Pericarditis, 880 Myocarditis, 880 Nursing Management: Myocarditis, 881 Rheumatic Fever and Heart Disease, 881 Nursing Management: Rheumatic Fever and Heart Disease, 883 Valvular Heart Disease, 884 Mitral Valve Stenosis, 884 Mitral Valve Regurgitation, 885 Mitral Valve Prolapse, 886 Aortic Valve Stenosis, 886 Aortic Valve Regurgitation, 887 Tricuspid and Pulmonic Valve Disease, 887 Diagnostic Studies for Valvular Heart Disease, 887 Nursing Management: Valvular Disorders, 890 Cardiomyopathy, 891 Dilated Cardiomyopathy, 892 Nursing and Interprofessional Management: Dilated Cardiomyopathy, 893 Hypertrophic Cardiomyopathy, 893 Nursing and Interprofessional Management: Hypertrophic Cardiomyopathy, 894 Restrictive Cardiomyopathy, 894 Nursing and Interprofessional Management: Restrictive Cardiomyopathy, 895 40 Nursing Management: Vascular Disorders, 898 Peripheral Artery Disease, 898 Etiology and Pathophysiology of Peripheral Artery Disease, 899 Peripheral Artery Disease, 899 Nursing Management: Lower Extremity Peripheral Artery Disease and Critical Limb Ischemia, 903 Acute Arterial Ischemic Disorders, 904 Other Peripheral Arterial Disorders, 906 Raynaud’s Phenomenon, 906 Other Vascular Disorders, 907 Aortic Aneurysms, 907 Nursing Management: Aortic Aneurysms, 910 Aortic Dissection, 912

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Nursing Management: Aortic Dissection, 913 Venous Disorders, 914 Phlebitis, 914 Venous Thromboembolism, 914 Nursing Management: Venous Thromboembolism, 920 Varicose Veins, 922 Nursing Management: Varicose Veins, 923 Chronic Venous Insufficiency and Venous Leg Ulcers, 923 Nursing Management: Chronic Venous Insufficiency and Venous Leg Ulcers, 924 

SECTION 8 Conditions of Ingestion, Digestion, Absorption, and Elimination 41 Nursing Assessment: Gastrointestinal System, 930 Structures and Functions of the Gastrointestinal System, 930 Assessment of the Gastrointestinal System, 937 Diagnostic Studies of the Gastrointestinal System, 941 42 Nursing Management: Nutritional Conditions, 951 Nutritional Conditions, 951 Healthy Nutrition, 952 Culturally Competent Care, 955 Malnutrition, 956 Nursing and Interprofessional Management: Malnutrition, 959 Specialized Nutrition Support, 963 Nursing Management: Parenteral Nutrition, 970 43 Nursing Management: Obesity, 974 Obesity, 974 Metabolic Syndrome, 979 Nursing and Interprofessional Management: Metabolic Syndrome, 979 Nursing and Conservative Interprofessional M ­ anagement: Patients With Obesity, 980 Medication Therapy, 984 Bariatric Surgical Therapy, 984 Nursing Management: Perioperative Care of the ­Patient With Obesity, 987 44 Nursing Management: Upper Gastrointestinal Conditions, 993 Nausea and Vomiting, 993 Nursing Management: Nausea and Vomiting, 996 Foodborne Illness, 997

xii

CONTENTS Oral Inflammations and Infections, 997 Oral Cancer, 998 Nursing Management: Oral Cancer, 1001 Esophageal Disorders, 1002 Gastroesophageal Reflux Disease, 1002 Nursing Management: Gastroesophageal Reflux Disease, 1005 Hiatal Hernia, 1006 Nursing and Interprofessional Management: Hiatal Hernia, 1006 Esophageal Cancer, 1007 Nursing Management: Esophageal Cancer, 1008 Other Esophageal Disorders, 1009 Disorders of the Stomach and Upper Small Intestine, 1010 Gastritis, 1010 Nursing and Interprofessional Management: Gastritis, 1012 Gastric Cancer, 1012 Nursing Management: Gastric Cancer, 1014 Upper Gastrointestinal Bleeding, 1016 Nursing Management: Upper Gastrointestinal B ­ leeding, 1019 Peptic Ulcer Disease, 1020 Nursing Management: Peptic Ulcer Disease, 1028 Nursing Management: Surgical Therapy for Peptic Ulcer Disease, 1031

45 Nursing Management: Lower Gastrointestinal Conditions, 1036 Diarrhea, 1036 Nursing Management: Acute Infectious Diarrhea, 1039 Constipation, 1040 Nursing Management: Constipation, 1042 Fecal Incontinence, 1043 Nursing Management: Fecal Incontinence, 1044 Acute Abdominal Pain, 1044 Nursing Management: Acute Abdominal Pain, 1045 Abdominal Trauma, 1047 Nursing and Interprofessional Management: Abdominal Trauma, 1048 Chronic Abdominal Pain, 1048 Irritable Bowel Syndrome, 1048 Inflammatory Disorders, 1048 Appendicitis, 1048 Nursing Management: Appendicitis, 1049 Peritonitis, 1049 Nursing Management: Peritonitis, 1050 Gastroenteritis, 1050 Nursing Management: Gastroenteritis, 1050 Inflammatory Bowel Disease, 1051

Ulcerative Colitis, 1051 Nursing Management: Ulcerative Colitis, 1054 Crohn’s Disease, 1056 Nursing Management: Crohn’s Disease, 1058 Malabsorption Syndrome, 1058 Celiac Disease, 1059 Lactase Deficiency, 1060 Nursing and Interprofessional Management: Lactase Deficiency, 1060 Short Bowel Syndrome, 1060 Intestinal Obstruction, 1061 Nursing Management: Intestinal Obstruction, 1063 Polyps of the Large Intestine, 1063 Colorectal Cancer, 1064 Nursing Management: Colorectal Cancer, 1066 Ostomy Surgery, 1068 Nursing Management: Ostomy Surgery, 1069 Diverticulosis and Diverticulitis, 1072 Nursing and Interprofessional Management: Diverticulosis and Diverticulitis, 1073 Hernias, 1074 Nursing and Interprofessional Management: Hernias, 1074 Anorectal Conditions, 1074 Hemorrhoids, 1074 Nursing Management: Hemorrhoids, 1075 Anal Fissure, 1076 Anorectal Abscess, 1076 Anal Fistula, 1076 Anal Cancer, 1076 Pilonidal Sinus, 1077 46 Nursing Management: Liver, Pancreas, and Biliary Tract Conditions, 1080 Disorders of the Liver, 1080 Viral Hepatitis, 1080 Nursing Management: Viral Hepatitis, 1087 Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis, 1090 Alcohol-­Associated Liver Disease (ALD), 1090 Autoimmune and Genetic Liver Diseases, 1091 Cirrhosis of the Liver, 1092 Nursing Management: Cirrhosis, 1100 Acute Liver Failure, 1102 Nursing and Interprofessional Management: Acute Liver Failure, 1103 Hepatocellular Carcinoma, 1103 Nursing and Interprofessional Management: Liver Cancer, 1104 Liver Transplantation, 1104 Disorders of the Pancreas, 1105 Acute Pancreatitis, 1105

CONTENTS Nursing Management: Acute Pancreatitis, 1108 Chronic Pancreatitis, 1109 Nursing Management: Chronic Pancreatitis, 1110 Pancreatic Cancer, 1110 Nursing Management: Pancreatic Cancer, 1111 Disorders of the Biliary Tract, 1111 Cholelithiasis and Cholecystitis, 1111 Nursing Management: Gallbladder Disease, 1114 Gallbladder Cancer, 1116 

SECTION 9 Conditions of Urinary Function 47 Nursing Assessment: Urinary System, 1121 Structures and Functions of the Urinary System, 1121 Assessment of the Urinary System, 1129 Diagnostic Studies, 1132 48 Nursing Management: Renal and Urological Conditions, 1143 Infectious and Inflammatory Disorders of the ­Urinary System, 1143 Urinary Tract Infection, 1143 Nursing Management: Urinary Tract Infection, 1146 Acute Pyelonephritis, 1148 Nursing Management: Acute Pyelonephritis, 1148 Chronic Pyelonephritis, 1149 Urethritis, 1149 Urethral Diverticula, 1150 Interstitial Cystitis, 1150 Nursing Management: Interstitial Cystitis, 1151 Renal Tuberculosis, 1151 Immunological Disorders of the Kidney, 1152 Glomerulonephritis, 1152 Acute Poststreptococcal Glomerulonephritis, 1152 Nursing and Interprofessional Management: Acute Poststreptococcal Glomerulonephritis, 1152 Goodpasture’s Syndrome, 1153 Nursing and Interprofessional Management: Goodpasture’s Syndrome, 1153 Rapidly Progressive Glomerulonephritis, 1153 Chronic Glomerulonephritis, 1153 Nephrotic Syndrome, 1153 Nursing Management: Nephrotic Syndrome, 1154 Obstructive Uropathies, 1154 Urinary Tract Calculi, 1155 Nursing Management: Renal Calculi, 1159 Strictures, 1160 Renal Trauma, 1160 Renal Vascular Conditions, 1161

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Nephrosclerosis, 1161 Renal Artery Stenosis, 1161 Renal Vein Thrombosis, 1161 Hereditary Renal Diseases, 1161 Polycystic Kidney Disease, 1161 Medullary Cystic Disease, 1162 Alport Syndrome, 1162 Renal Involvement in Metabolic and Connective Tissue Diseases, 1162 Urinary Tract Tumours, 1163 Kidney Cancer, 1163 Bladder Cancer, 1164 Nursing and Interprofessional Management: Bladder Cancer, 1164 Urinary Incontinence and Retention, 1165 Nursing Management: Urinary Incontinence, 1166 Nursing Management: Urinary Retention, 1170 Instrumentation, 1170 Surgery of the Urinary Tract, 1173 Renal and Ureteral Surgery, 1173 Urinary Diversion, 1173 Nursing Management: Urinary Diversion, 1175 49 Nursing Management: Acute Kidney Injury and Chronic Kidney Disease, 1180 Acute Kidney Injury, 1181 Nursing Management: Acute Kidney Injury, 1185 Chronic Kidney Disease, 1187 Nursing Management: Chronic Kidney Disease, 1194 Dialysis, 1196 General Principles of Dialysis, 1196 Peritoneal Dialysis, 1197 Hemodialysis, 1200 Kidney Transplantation, 1204 Nursing Management: Kidney Transplant Recipient, 1207 

SECTION 10 Conditions Related to Regulatory and Reproductive Mechanisms 50 Nursing Assessment: Endocrine System, 1214 Structures and Functions of the Endocrine System, 1215 Assessment of the Endocrine System, 1223 Diagnostic Studies of the Endocrine System, 1228 51 Nursing Management: Endocrine Conditions, 1237 Disorders of the Anterior Pituitary Gland, 1237 Acromegaly, 1237 Nursing Management: Acromegaly, 1239

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CONTENTS Hypofunction of the Pituitary Gland, 1240 Nursing and Interprofessional Management: Hypopituitarism, 1240 Disorders of the Posterior Pituitary Gland, 1240 Syndrome of Inappropriate Antidiuretic Hormone, 1240 Nursing Management: Syndrome of Inappropriate Antidiuretic Hormone, 1241 Diabetes Insipidus, 1242 Nursing Management: Central Diabetes Insipidus, 1243 Disorders of the Thyroid Gland, 1244 Goitre, 1244 Thyroid Nodules and Cancer, 1244 Nursing and Interprofessional Care: Thyroid Cancer, 1245 Multiple Endocrine Neoplasia, 1245 Thyroiditis, 1245 Hyperthyroidism, 1246 Nursing Management: Hyperthyroidism, 1249 Hypothyroidism, 1251 Nursing Management: Hypothyroidism, 1252 Disorders of the Parathyroid Glands, 1254 Hyperparathyroidism, 1254 Nursing Management: Hyperparathyroidism, 1255 Hypoparathyroidism, 1256 Nursing and Interprofessional Management: Hypoparathyroidism, 1256 Disorders of the Adrenal Cortex, 1256 Cushing’s Syndrome, 1256 Nursing Management: Cushing’s Syndrome, 1259 Adrenocortical Insufficiency, 1260 Nursing Management: Addison’s Disease, 1262 Corticosteroid Therapy, 1263 Nursing and Interprofessional Management: Corticosteroid Therapy, 1264 Hyperaldosteronism, 1264 Nursing and Interprofessional Management: Primary Hyperaldosteronism, 1264 Disorders of the Adrenal Medulla, 1265 Pheochromocytoma, 1265 Nursing and Interprofessional Management: Pheochromocytoma, 1265

52 Nursing Management: Diabetes Mellitus, 1269 Diabetes Mellitus, 1269 Nursing Management: Diabetes Mellitus, 1288 Acute Complications of Diabetes Mellitus, 1293 Diabetic Ketoacidosis, 1293 Hyperosmolar Hyperglycemic State, 1296 Nursing Management: Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State, 1296 Hypoglycemia, 1296 Nursing and Interprofessional Management: Hypoglycemia, 1297

Chronic Complications of Diabetes Mellitus, 1298 Macrovascular Complications, 1298 Microvascular Complications, 1299 Diabetic Retinopathy, 1300 Nephropathy, 1300 Neuropathy, 1301 Complications of the Foot and the Lower ­Extremity, 1302 Integumentary Complications, 1303 Infection, 1303 53 Nursing Assessment: Reproductive System, 1308 Structures and Functions of the Male and Female Reproductive Systems, 1308 Assessment of the Male and Female Reproductive Systems, 1316 Diagnostic Studies of Reproductive Systems, 1322 54 Nursing Management: Breast Disorders, 1331 Assessment of Breast Disorders, 1331 Diagnostic Studies, 1332 Benign Breast Disorders, 1333 Nursing and Interprofessional Management: Fibrocystic Changes, 1334 Nursing and Interprofessional Management: Fibroadenoma, 1335 Breast Cancer, 1336 Nursing Management: Breast Cancer, 1346 Mammoplasty, 1349 Nursing Management: Breast Augmentation and Reduction, 1351 55  Nursing Management: Sexually Transmitted Infections, 1355 Sexually Transmitted Infections, 1355 Factors Affecting Incidence of Sexually Transmitted Infection, 1356 Bacterial Infections, 1356 Gonorrhea, 1356 Syphilis, 1358 Chlamydial Infections, 1361 Viral Infections, 1362 Genital Herpes, 1362 Genital Human Papilloma Virus Infections, 1364 Nursing Management: Sexually Transmitted I­ nfections, 1366 56 Nursing Management: Female Reproductive Conditions, 1372 Infertility, 1372 Nursing and Interprofessional Management: Infertility, 1373 Abortion, 1374

CONTENTS Conditions Related To Menstruation, 1374 Premenstrual Syndrome, 1375 Dysmenorrhea, 1376 Nursing and Interprofessional Management: Dysmenorrhea, 1377 Abnormal Vaginal Bleeding, 1377 Nursing Management: Abnormal Vaginal Bleeding, 1378 Ectopic Pregnancy, 1378 Nursing and Interprofessional Management: Ectopic Pregnancy, 1379 Perimenopause and Postmenopause, 1379 Nursing Management: Perimenopause and Postmenopause, 1382 Conditions of the Vulva, Vagina, and Cervix, 1382 Nursing Management: Conditions of the Vulva, Vagina, and Cervix, 1383 Pelvic Inflammatory Disease, 1384 Nursing Management: Pelvic Inflammatory Disease, 1385 Chronic Pelvic Pain, 1385 Endometriosis, 1386 Nursing Management: Endometriosis, 1387 Benign Tumours of the Female Reproductive System, 1387 Leiomyomas, 1387 Cervical Polyps, 1388 Benign Ovarian Tumours, 1388 Cancer of the Female Reproductive System, 1389 Cervical Cancer, 1389 Endometrial or Uterine Cancer, 1391 Ovarian Cancer, 1391 Vaginal Cancer, 1393 Vulvar Cancer, 1393 Surgical Procedures: Female Reproductive System, 1393 Radiation Therapy: Cancers of the Female ­Reproductive System, 1394 Nursing Management: Cancers of the Female ­Reproductive System, 1394 Conditions With Pelvic Support, 1396 Uterine Prolapse, 1396 Cystocele and Rectocele, 1397 Nursing Management: Difficulties With Pelvic S­ upport, 1398 Fistula, 1398 Nursing Management: Fistulas, 1398 57 Nursing Management: Male Reproductive Conditions, 1402 Conditions of the Prostate Gland, 1402 Benign Prostatic Hyperplasia, 1402 Nursing Management: Benign Prostatic Hyperplasia, 1407 Prostate Cancer, 1409

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Nursing Management: Prostate Cancer, 1414 Prostatitis, 1415 Nursing and Interprofessional Management: Prostatitis, 1416 Conditions of the Penis, 1416 Congenital Conditions, 1416 Conditions of the Prepuce, 1416 Conditions of Erectile Mechanism, 1416 Cancer of the Penis, 1417 Conditions of the Scrotum and Testes, 1417 Inflammatory and Infectious Conditions, 1417 Congenital Conditions, 1417 Acquired Conditions, 1418 Testicular Cancer, 1418 Nursing snd Interprofessional Management: Testicular Cancer, 1418 Sexual Functioning, 1419 Vasectomy, 1419 Erectile Dysfunction, 1420 Nursing Management: Erectile Dysfunction, 1422 Andropause, 1423 Infertility, 1423 

SECTION 11 Conditions Related to Movement and Coordination 58 Nursing Assessment: Nervous System, 1427 Structures and Functions of the Nervous System, 1427 Assessment of the Nervous System, 1439 59 Nursing Mangement: Acute Intracranial Conditions, 1453 Intracranial Pressure, 1453 Increased Intracranial Pressure, 1455 Nursing Management: Increased Intracranial P ­ ressure, 1462 Head Injury, 1465 Nursing Management: Head Injury, 1469 Brain Tumours, 1472 Nursing Management: Brain Tumours, 1474 Cranial Surgery, 1475 Nursing Management: Cranial Surgery, 1477 Inflammatory Conditions of the Brain, 1478 Bacterial Meningitis, 1478 Nursing Management: Bacterial Meningitis, 1480 Viral Meningitis, 1481 Encephalitis, 1481 Nursing and Interprofessional Management: Viral Encephalitis, 1482 Brain Abscess, 1482

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CONTENTS

60 Nursing Management: Stroke, 1485 Pathophysiology of a Stroke, 1486 Risk Factors for Stroke, 1487 Types of Stroke, 1488 Nursing Management: Stroke, 1496 61 Nursing Management: Chronic Neurological Conditions, 1511 Headache, 1511 Migraine Headache, 1511 Tension-­Type Headache, 1512 Cluster Headache, 1513 Other Types of Headaches, 1513 Interprofessional Care for Headaches, 1513 Nursing Management: Headaches, 1515 Chronic Neurological Disorders, 1516 Seizure Disorder, 1516 Nursing Management: Seizure Disorders and E ­ pilepsy, 1522 Multiple Sclerosis, 1523 Nursing Management: Multiple Sclerosis, 1527 Parkinson’s Disease, 1528 Nursing Management: Parkinson’s Disease, 1532 Myasthenia Gravis, 1533 Nursing Management: Myasthenia Gravis, 1534 Restless Legs Syndrome, 1535 Nursing and Interprofessional Management: Restless Legs Syndrome, 1536 Amyotrophic Lateral Sclerosis, 1536 Huntington’s Disease, 1536 Normal Pressure Hydrocephalus, 1537 62 Nursing Management: Delirium, Alzheimer’s Disease, and Other Dementias, 1541 Delirium, 1541 Nursing and Interprofessional Management: Delirium, 1543 Dementia, 1544 Nursing Management: Dementia, 1550 63 Nursing Management: Peripheral Nerve and Spinal Cord Conditions, 1560 Cranial Nerve Disorders, 1560 Trigeminal Neuralgia, 1560 Nursing Management: Trigeminal Neuralgia, 1562 Bell’s Palsy, 1563 Nursing Management: Bell’s Palsy, 1564 Polyneuropathies, 1565 Guillain-­Barré Syndrome, 1565 Nursing Management: Guillain-­Barré Syndrome, 1566 Botulism, 1567

Tetanus, 1567 Nursing Management: Tetanus, 1568 Neurosyphilis, 1568 Spinal Cord Conditions, 1568 Spinal Cord Injury, 1568 Nursing Management: Spinal Cord Injury, 1576 Spinal Cord Injury Research in Canada, 1585 Spinal Cord Tumours, 1585 Nursing and Interprofessional Management: Spinal Cord Tumours, 1586 Postpolio Syndrome, 1586 Nursing and Interprofessional Management: Postpolio Syndrome, 1587 64 Nursing Assessment: Musculoskeletal System, 1591 Structures and Functions of the Musculoskeletal System, 1591 Assessment of the Musculoskeletal System, 1596 Diagnostic Studies of the Musculoskeletal System, 1599 65 Nursing Management: Musculoskeletal Trauma and Orthopedic Surgery, 1606 Soft Tissue Injuries, 1607 Nursing and Interprofessional Management: Sprains and Strains, 1608 Dislocation and Subluxation, 1609 Nursing and Interprofessional Management: Dislocation, 1609 Repetitive Strain Injury, 1609 Carpal Tunnel Syndrome, 1610 Nursing and Interprofessional Management: Carpal Tunnel Syndrome, 1610 Rotator Cuff Injury, 1610 Nursing and Interprofessional Management: Rotator Cuff Injury, 1611 Meniscus Injury, 1611 Nursing and Interprofessional Management: Meniscus Injury, 1611 Anterior Cruciate Ligament (ACL) Injury, 1612 Nursing and Interprofessional Management: Anterior Cruciate Ligament Injury, 1612 Bursitis, 1612 Nursing and Interprofessional Management: Bursitis, 1612 Fractures, 1612 Nursing Management: Fractures, 1618 Complications of Fractures, 1622 Types of Fractures, 1624 Colles Fracture, 1624 Fracture of the Humerus, 1625 Fracture of the Pelvis, 1625

CONTENTS Fracture of the Hip, 1625 Nursing Management: Hip Fracture, 1626 Femoral Shaft Fracture, 1628 Fracture of the Tibia, 1629 Stable Vertebral Fractures, 1629 Facial Fractures, 1630 Nursing Management: Mandibular Fracture, 1630 Amputation, 1631 Nursing Management: Amputation, 1632 Common Joint Surgical Procedures, 1635 Types of Joint Surgeries, 1635 Nursing Management: Joint Surgery, 1637 66 Nursing Management: Musculoskeletal Conditions, 1642 Osteomyelitis, 1642 Nursing Management: Osteomyelitis, 1644 Metabolic Bone Diseases, 1646 Osteoporosis, 1646 Nursing and Interprofessional Management: Osteoporosis, 1648 Medication Therapy, 1649 Paget’s Disease, 1650 Low Back Pain, 1651 Acute Low Back Pain, 1651 Chronic Low Back Pain, 1652 Nursing and Interprofessional Management: Chronic Low Back Pain, 1652 Nursing Management: Nonspecific Low Back Pain, 1652 Intervertebral Disc Disease, 1653 Nursing Management: Vertebral Disc Surgery, 1656 Neck Pain, 1657 Foot Disorders, 1657 Nursing Management: Foot Disorders, 1657 Bone Tumours, 1659 Benign Tumours, 1659 Enchondroma, 1660 Malignant Bone Tumours, 1660 Metastatic Bone Cancer, 1660 Nursing Management: Bone Cancer, 1661 67 Nursing Management: Arthritis and Connective Tissue Diseases, 1665 Arthritis, 1665 Osteoarthritis, 1666 Nursing Management: Osteoarthritis, 1672 Rheumatoid Arthritis, 1673 Nursing Management: Rheumatoid Arthritis, 1678 Gout, 1680 Nursing Management: Gout, 1682 Lyme Disease, 1682 Septic Arthritis, 1683

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Spondyloarthropathies, 1683 Ankylosing Spondylitis, 1684 Nursing Management: Ankylosing Spondylitis, 1684 Psoriatic Arthritis, 1685 Reactive Arthritis, 1685 Other Connective Tissue Disorders, 1685 Systemic Lupus Erythematosus, 1685 Nursing Management: Systemic Lupus Erythematosus, 1688 Scleroderma, 1690 Nursing Management: Scleroderma, 1691 Myositis, 1692 Nursing and Interprofessional Management: Myositis, 1693 Mixed Connective Tissue Disease, 1693 Sjögren Syndrome, 1693 Soft Tissue Rheumatic Syndromes, 1693 Myofascial Pain Syndrome, 1693 Fibromyalgia, 1694 Nursing Management: Fibromyalgia, 1695 Systemic Exertion Intolerance Disease, 1695 Nursing and Interprofessional Management: Systemic Exertion Intolerance Disease, 1696 

SECTION 12 Nursing Care in Specialized Settings 68 Nursing Management: Critical Care Environment, 1700 Critical Care Nursing, 1700 Hemodynamic Monitoring, 1707 Nursing Management: Hemodynamic Monitoring, 1712 Artificial Airways, 1713 Nursing Management: Artificial Airway, 1714 Mechanical Ventilation, 1717 Nursing Management: Mechanical Ventilation, 1722 Patient-­and Family-­Centred Care in Critical Care, 1722 Other Critical Care Content, 1724 69 Nursing Management: Shock, Sepsis, and Multiple-­ Organ Dysfunction Syndrome, 1729 Shock, 1729 Nursing Management: Shock, 1745 Sepsis, Septic Shock, and Multiple-­Organ ­Dysfunction Syndrome, 1747 Nursing and Interprofessional Management: Multiple-­Organ Dysfunction Syndrome, 1748

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CONTENTS

70 Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome, 1753 Acute Respiratory Failure, 1753 Nursing and Interprofessional Management: Acute Respiratory Failure, 1760 Acute Respiratory Distress Syndrome, 1764 Nursing and Interprofessional Management: Acute Respiratory Distress Syndrome, 1768 Severe Acute Respiratory Syndrome, 1771 71 Nursing Management: Emergency Care Situations, 1774 Care of the Emergency Patient, 1775 Triage, 1775 Primary Survey, 1776 Secondary Survey, 1778 Acute Care and Evaluation, 1780 Death in the Emergency Department, 1781 Emergency Department Wait Times, 1781 Environmental Emergencies, 1782 Heat-­Related Emergencies, 1782 Cold-­Related Emergencies, 1784

Submersion Injuries, 1785 Bites and Stings, 1787 Poisonings, 1788 Violence, 1790 Nursing Management: Sexual Assault, 1792 72 Emergency Management and Disaster Planning, 1796 Emergency Management and Disaster Planning, 1797 Emergency/Disaster Management, 1799 The Role of Nursing Leadership in Disaster ­Preparedness and Response, 1805 Disasters, 1805

Appendix Laboratory Values, 1817

GLOSSARY, 1832 INDEX, 1853 SPECIAL FEATURES, 1904

AB OUT TH E A UTH O R S JANE TYERMAN, RN, BA, BScN, MScN, PhD, CCSNE Jane Tyerman is an Assistant Professor at the University of Ottawa’s School of Nursing in Ottawa, Ontario. She holds a diploma in nursing from St. Lawrence College in Ottawa, Ontario; a Bachelor of Arts degree from the University of Ottawa; a Bachelor of Science in nursing from Athabasca University in Alberta; and a Master of Science in nursing and a PhD in nursing from Queen’s University in Kingston, Ontario. She has over 25 years of experience in acute care clinical practice and more than 15 years of academic teaching experience at the graduate and undergraduate levels. She is an Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) instructor with the Canadian Heart and Stroke Foundation. Dr. Tyerman has contributed to multiple NCLEX textbooks published by Elsevier and has been an HESI Live Review faculty member, delivering in-­person and online workshops to graduating students across Canada. She is also an editor for Edelman and Kudzma’s Canadian Health Promotion Throughout the Lifespan. She has made significant contributions to nursing education by advancing the pedagogy that underpins the effective use of clinical simulation and through her innovative use of technology to expand equity and access to high-­quality teaching and learning resources. She is dedicated to developing and researching bilingual virtual simulation games through her role as Co-­President of the Canadian Alliance of Nurse Educators Using Simulation (CAN-­Sim). Collaborating with nurse educators across Canada and internationally, she has authored multiple publications related to simulation and virtual simulation games. 

SHELLEY L. COBBETT, RN, BN, GnT, MN, EdD Shelley Cobbett began her nursing career at the Yarmouth Regional Hospital School of Nursing diploma program. She received her Post-­RN, BN and her MN degrees from Dalhousie University and her EdD from Charles Sturt University. Her clinical practice background is maternal-­child nursing, and she has been a nurse educator for over 33 years. Her main research area during the past 15 years has focused on the scholarship of learning and teaching, with over 50 peer-­reviewed publications, invited speaker engagements, and oral conference presentations. Dr. Cobbett is President for the Atlantic Region Canadian Association of Schools of Nursing, and she is part of the Education Advisory Committee for the Nova Scotia College of Nursing. She has been recognized for her commitment to the implementation and evaluation of best pedagogical practices within nursing education as recipient of a Dalhousie University Teaching Award and the Canadian Association of Schools of Nursing Excellence in Teaching Award. She is currently an Assistant Professor at Dalhousie University School of Nursing, Site Administrator of the BScN Program at the Yarmouth Campus, and Curriculum Implementation and Evaluation Lead for a new, innovative BScN degree that was initiated in 2016. 

11TH US EDITION AUTHOR Mariann M. Harding, RN, PhD, FAADN, CNE Mariann Harding is a Professor of Nursing at Kent State University Tuscarawas, New Philadelphia, Ohio, where she has been on the faculty since 2005. She received her diploma in nursing from Mt. Carmel School of Nursing in Columbus, Ohio; her Bachelor of Science in nursing from Ohio University in Athens, Ohio; her Master of Science in nursing as an adult nurse practitioner from the Catholic University of America in Washington, DC; and her doctorate in nursing from West Virginia University in Morgantown, West Virginia. Her 29 years of nursing experience have primarily been in critical care nursing and teaching in licensed practical, associate, and baccalaureate nursing programs. She currently teaches medical-­surgical nursing, health care policy, and evidence-­based practice. Her research has focused on promoting student success and health promotion among individuals with gout and facing cancer. 

SECTION EDITORS FOR THE US 11TH EDITION Jeffrey Kwong, RN, DNP, MPH, ANP-­BC, FAAN, FAANP Jeffrey Kwong is a Professor at the School of Nursing at Rutgers, the State University of New Jersey. He has worked for over 20 years in the area of adult primary care with a special focus on HIV. He received his undergraduate degree from the University of California– Berkeley, his nurse practitioner degree from the University of California–San Francisco, and his doctoral training at the University of Colorado–Denver. He also has a Master of Science degree in public health with a focus on health education and behavioural sciences from the University of California–Los Angeles, and he was appointed a Hartford Geriatric Interprofessional Scholar while completing his gerontology education at New York University. In addition to teaching, Dr. Kwong maintains a clinical practice at Gotham Medical Group in New York City. He is a Fellow in the American Association of Nurse Practitioners. 

Dottie Roberts, RN, EdD, MSN, MACI, OCNS-­C, CMSRN, CNE Dottie Roberts received her Bachelor of Science in nursing from Beth-­El College of Nursing, Colorado Springs, Colorado; her Master of Science in adult health nursing from Beth-­El College of Nursing and Health Sciences; her Master of Arts in curriculum and instruction from Colorado Christian University, Colorado Springs, Colorado; and her EdD in health care education from Nova Southeastern University, Ft. Lauderdale, Florida. She has over 25 years of experience in medical-­surgical and orthopedic nursing and holds certifications in both specialties. She has also taught in two baccalaureate programs in the southeast and is certified as a nurse educator.

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ABOUT THE AUTHORS

She currently serves as contributing faculty for the RN-­BSN program at Walden University. For her dissertation, Dottie completed a phenomenological study on facilitation of critical-­thinking skills by clinical faculty in a baccalaureate nursing program. She has been Executive Director of the Orthopaedic Nurses Certification Board since 2005 and editor of MEDSURG Nursing, official journal of the Academy of Medical-­Surgical Nurses, since 2003. Her free time is spent travelling, reading, and cross-­stitching. 

Debra Hagler, RN, PhD, ACNS-­BC, CNE, CHSE, ANEF, FAAN Debbie Hagler is a Clinical Professor in the Edson College of Nursing and Health Innovation at Arizona State University in Phoenix. She is Deputy Editor of The Journal of Continuing Education in Nursing. She received her Practical Certificate in nursing, Associate degree in nursing, and Bachelor of Science in nursing from New Mexico State University. She earned a Master of Science degree from the University of Arizona and a doctorate in learning and instructional technology from Arizona State University. Her clinical background is in adult health and critical care nursing. Her current role focuses on supporting students through the Barrett Honors program and helping faculty members develop their scholarly writing for publication.  Courtney Reinisch, RN, DNP, FNP-­BC Courtney Reinisch is the Undergraduate Program Director and Associate Professor for the School of Nursing at Montclair State University in New Jersey. She earned her Bachelor of Arts in biology and psychology from Immaculata University. She received her Bachelor of Science in nursing and Master of Science in family practice nurse practitioner degree from the University of Delaware. She completed her Doctor of Nursing Practice degree at Columbia University School of Nursing. Courtney’s nursing career has focused on providing care for underserved populations in primary care and emergency settings. She has taught in undergraduate and graduate nursing programs in New York and New Jersey. Courtney enjoys playing tennis, snowboarding, reading, and spending time with her family and dogs. She is the biggest fan for her nieces and nephews at their soccer games, cross-­country events, and track meets. She is an active volunteer in the Parents Association of her son’s school and advocates for the needs of students with learning differences and for the LGBTQ community.

C ONTR IB UT O R S CANADIAN CONTRIBUTORS Veronique M. Boscart, RN, MScN, MEd, PhD CIHR/Schlegel Industrial Research Chair for Colleges in Seniors Care Executive Director, Canadian Institute for Seniors Care Executive Dean, School of Health & Life Sciences Conestoga College Institute of Technology and Advanced Learning Kitchener, Ontario Wendy Bowles, NP F Vascular Surgery Royal Columbian Hospital, Fraser Health New Westminster, British Columbia; Regional Department Head, Department of Nurse Practitioners Vice-­Chair, Medical Advisory Committee Adjunct Professor University of Victoria Victoria, British Columbia Myriam Breau, RN, MSN, PhD(C) Professor École de science infirmière/Nursing School Université de Moncton Moncton, New Brunswick Danielle Byrne, RN, MN, CCSNE Adjunct Lecturer, Clinical Instructor, Simulation Specialist School of Nursing Dalhousie University Yarmouth, Nova Scotia Erica Cambly, RN, MN, CCNE Associate Professor, Teaching Stream Lawrence S. Bloomberg Faculty of Nursing University of Toronto Toronto, Ontario Rosemary Cashman, MA, MSc(A), ACNP, NP(A) Nurse Practitioner BC Cancer–Vancouver Centre Vancouver, British Columbia Ann Mary Celestini, RN, BA, BScN, MHST Lecturer, Teaching Intensive Trent/Fleming School of Nursing Trent University Peterborough, Ontario

Susan Chernenko, RN(EC), MN Nurse Practitioner Toronto Lung Transplant Program Toronto General Hospital, University Health Network Toronto, Ontario; Associate Graduate Lecturer Lawrence S. Bloomberg Faculty of Nursing University of Toronto Toronto, Ontario Shelley Clarke, RN, MScN, CCSNE Professor, Nursing Program Health & Community Studies Algonquin College Ottawa, Ontario Shelley L. Cobbett, RN, BN, GnT, MN, EdD Assistant Professor, Nursing and BScN Site Administrator School of Nursing – Yarmouth Campus Dalhousie University Yarmouth, Nova Scotia Sarah Crowe, MN, PMD-­NP(F), CNCC(C) Nurse Practitioner, Critical Care Surrey Memorial Hospital Surrey, British Columbia; Adjunct Professor School of Nursing University of British Columbia Langley, British Columbia Denise Delorey, BScN, RN, MAdEd Assistant Professor Rankin School of Nursing St. Francis Xavier University Antigonish, Nova Scotia Serena Eagland, RN (C), BSN Clinical Educator Vancouver Community Primary Care Vancouver Coastal Health Vancouver, British Columbia Laura Fairley, RN, MN, CHPCN(C), CCHN(C) Assistant Professor, Teaching Stream, Undergraduate Program Lawrence S. Bloomberg Faculty of Nursing University of Toronto Toronto, Ontario

Mary Ann Fegan, RN, MN Associate Professor, Teaching Stream Undergraduate Clinical Resource Faculty Lawrence S. Bloomberg Faculty of Nursing University of Toronto Toronto, Ontario Julie Fraser, RN, MN Interim Executive Director Patient Experience Professional Practice Fraser Health Surrey, British Columbia Natasha Fulford, BN, RN, MN Associate Director, Non-­Degree Programs Centre for Nursing Studies Memorial University of Newfoundland St. John’s, Newfoundland Mary Kate Garrity, RN, BScN, EdD Director of Care Sienna Senior Living Toronto, Ontario Emma Garrod, RN, BScN, MSN Clinical Nurse Educator–Substance Use Director British Columbia Centre on Substance Use Addiction Nursing Fellowship Adjunct Professor University of British Columbia School of Nursing Vancouver, British Columbia Renée Gordon, CD, RN, MSc, CMSN(C), CCNE, CCCI, CCSNE Associate Teaching Professor Faculty of Nursing University of New Brunswick Moncton, New Brunswick Leslie Graham, RN, MN, PhD(C), CNCC, CHSE, CCSNE Coordinator, RPN to BScN Nursing Program Professor, Nursing Durham College Oshawa, Ontario; Adjunct Professor Ontario Tech University Oshawa, Ontario

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CONTRIBUTORS

Krista Gushue, BN, RN, MN, CCCI Nurse Educator Centre for Nursing Studies St. John’s, Newfoundland Peggy D. Hancock, RN, MN Nurse Educator Western Regional School of Nursing Corner Brook, Newfoundland Jackie Hartigan-­Rogers, RN, MN Assistant Professor, Nursing School of Nursing Dalhousie University Yarmouth, Nova Scotia Kimberly Hellmer, RN, BN, MN Unit Manager, Medicine Foothills Medical Centre Alberta Health Services Calgary, Alberta Heather Helpard, RN, BScN, MN, PhD Assistant Professor Rankin School of Nursing Saint Francis Xavier University Antigonish, Nova Scotia Sarah Ibrahim, RN, MN, PhD, CHSE Adjunct Lecturer Lawrence S. Bloomberg Faculty of Nursing University of Toronto Toronto, Ontario Lynn Jansen, RN, PhD Assistant Dean and Associate Professor University of Saskatchewan Prince Albert and North Campus College of Nursing Prince Albert, Saskatchewan Sarah Johnston, RN, MN Assistant Professor, Teaching Stream Lawrence S. Bloomberg Faculty of Nursing University of Toronto Toronto, Ontario Evan Keys, RN, MNSc, ENC(C) Registered Nurse Schwartz/Reisman Emergency Centre Mount Sinai Hospital, Sinai Health Toronto, Ontario; Clinical Research Coordinator Clinical Cardiovascular Physiology Laboratory Toronto General Hospital Research Institute, University Health Network Toronto, Ontario

Carol A. Kuzio, RN, BScN, CBN Clinical Practice Lead Diabetes, Obesity and Nutrition Strategic Clinical Network Alberta Health Services Edmonton, Alberta Elizabeth Lee, NP, MN, CGN(C) Adjunct Lecturer Lawrence S. Bloomberg Faculty of Nursing University of Toronto Toronto, Ontario; Nurse Practitioner, Hepatology Toronto General Hospital, University Health Network Toronto, Ontario Jana Lok, RN, PhD, ENC(C), CHSE Assistant Professor, Teaching Stream Lawrence S. Bloomberg Faculty of Nursing University of Toronto Toronto, Ontario Bridgette Lord, RN, MN, NP-Adult Acute Care Nurse Practitioner Peter Gilgan Centre for Women’s Cancers Women’s College Hospital Toronto, Ontario Jean Jacque E. Lovely, BA, BScN, MN, MBA Director Core Business Operations–Digital Health Deloitte Canada Edmonton, Alberta Marian Luctkar-­Flude, RN, BScN, MScN, PhD, CCSNE Associate Professor School of Nursing Queen’s University Kingston, Ontario Janet MacIntyre, RN, PhD Assistant Professor Faculty of Nursing University of Prince Edward Island Charlottetown, Prince Edward Island Lesley MacMaster, RN, MScN Nursing Professor Georgian College Barrie, Ontario Lynn McCleary, RN, PhD Professor Department of Nursing, Faculty of Applied Health Sciences Brock University St. Catharines, Ontario

Susannah R. McGeachy, RN(EC), NP-­PHC, MN Nurse Practitioner University Health Network Toronto, Ontario Andrea Miller, MHSc, RD, FDC Registered Dietitian Private Practice Whitby, Ontario Tess Montada-­Atin, RN(EC), MN, CDE, CNeph (C) Adjunct Lecturer Lawrence S. Bloomberg Faculty of Nursing University of Toronto Toronto, Ontario Joanne Newell, RN, MN Adjunct Assistant Professor School of Nursing Dalhousie University Yarmouth, Nova Scotia Kathryn F. Nichol, RN, MScN, BA, CON(C), CHPCN(C) Palliative Care Nurse Specialist Supportive and Palliative Care Team The Ottawa Hospital Ottawa, Ontario Sara Olivier, RN, BScN, MN Advanced Practice Nurse Supportive & Palliative Care and Substance Use Programs The Ottawa Hospital Ottawa, Ontario Denise K.M. Ouellette, MSN, RN, CNN(C) Clinical Nurse Specialist, Neurosurgical Outreach Activities St Michael’s Hospital, Unity Health Toronto Toronto, Ontario; Adjunct Lecturer Lawrence S. Bloomberg Faculty of Nursing University of Toronto Toronto, Ontario Efrosini Papaconstantinou, RN, PhD Associate Professor Faculty of Health Sciences Ontario Tech University Oshawa, Ontario Marie-­Noëlle Paulin, RN, BScN, MScN Clinical Nurse Instructor School of Nursing Moncton University Bathurst, New Brunswick

CONTRIBUTORS

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April Pike, PhD Associate Professor Faculty of Nursing Memorial University of Newfoundland St. John’s, Newfoundland

Catherine Sheffer, RN PhD, PNC(C) Senior Instructor School of Nursing Dalhousie University Halifax, Nova Scotia

Ellen Vogel, RD, FDC, PhD Associate Professor Faculty of Health Sciences Ontario Tech University Oshawa, Ontario

Dawn Pittman, RN, MScN, PhD(C) Nurse Educator Western Regional School of Nursing Memorial University of Newfoundland and Labrador Corner Brook, Newfoundland

Sarah J. Siebert, RN, MSN, GNC(C) Director, Primary Care Fraser Health Surrey, British Columbia

Laura Wilding, BScN, RN, MHS, ENC(C) Advanced Practice Nurse, Regional Program Manager Champlain Regional Medical Assistance in Dying (MAiD) Network The Ottawa Hospital Ottawa, Ontario

Debbie Rickeard, RN, DNP, MSN, BScN, CCRN, CNE Experiential Learning Specialist Faculty of Nursing University of Windsor Windsor, Ontario Sheila Rizza, RN(EC), MN NP-­Adult, CNCC(C), CCN(C) Nurse Practitioner Heart Function Clinic Trillium Health Partners Mississauga, Ontario Anita Robertson, RN Nursing Instructor Health and Wellness Programs Nunavut Arctic College Iqaluit, Nunavut Susan E. Robinson, RN, BScN, MN, CON(C) Coroner Investigator Office of the Chief Coroner of Ontario Toronto, Ontario; Staff Nurse, Emergency Department Michael Garron Hospital Toronto, Ontario Kathy Rodger, MN, BSN, RN, CMSN(C) Associate Professor College of Nursing University of Saskatchewan Regina, Saskatchewan Kara Sealock, RN, BN, MEd EdD, CNCC(C), CCNE Senior Instructor Faculty of Nursing University of Calgary Calgary, Alberta Cydnee Seneviratne, RN, BScN, MN, PhD Senior Instructor Faculty of Nursing University of Calgary Calgary, Alberta

Catharine R. Simpson, RN, MN Senior Instructor Department of Nursing & Health Sciences University of New Brunswick Saint John, New Brunswick Rani H. Srivastava, RN, PhD Dean, School of Nursing Thompson Rivers University Kamloops, British Columbia; Adjunct Professor Faculty of Health York University Toronto, Ontario; Adjunct Professor School of Nursing Dalhousie University Halifax, Nova Scotia Jane Tyerman, RN, BA, BScN, MScN, PhD, CCSNE Assistant Professor School of Nursing Faculty of Health Sciences University of Ottawa Ottawa, Ontario Professeure Adjointe École des sciences infirmières Faculté des sciences de la santé Université d’Ottawa Ottawa, Ontario Christina Vaillancourt, RD, CDE, MHSc Associate Graduate Faculty, Master of Health Sciences, and Adjunct Professor Faculty of Health Sciences Ontario Tech University Oshawa, Ontario Brandi Vanderspank-­Wright, RN, PhD, CNCC(C) Associate Professor School of Nursing, Faculty of Health Sciences University of Ottawa Ottawa, Ontario

Barbara Wilson-­Keates, RN, PhD, CCSNE Academic Coordinator Faculty of Health Disciplines Athabasca University Athabasca, Alberta Kevin Woo, RN, PhD, NSWOC, WOCC(C) Professor School of Nursing Queen’s University Kingston, Ontario Colina Yim, NP, MN, AF-­AASLD Adjunct Lecturer Lawrence S. Bloomberg Faculty of Nursing University of Toronto Toronto, Ontario; Nurse Practitioner, Hepatology Toronto General Hospital, University Health Network Toronto, Ontario

CONTRIBUTORS TO THE US 11TH EDITION Vera Barton-­Maxwell, PhD, APRN, FNP-­ BC, CHFN Assistant Professor, Advanced Nursing Practice Family Nurse Practitioner Program Georgetown University Washington, District of Columbia; Nurse Practitioner Center for Advanced Heart Failure West Virginia University Heart and Vascular Institute Morgantown, West Virginia Cecilia Bidigare, MSN, RN Professor Nursing Department Sinclair Community College Dayton, Ohio

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CONTRIBUTORS

Megan Ann Brissie, DNP, RN, ACNP-­BC, CEN Acute Care Nurse Practitioner, Neurosurgery Duke Health Durham, North Carolina; Adjunct Instructor College of Nursing University of Cincinnati Cincinnati, Ohio Diana Taibi Buchanan, PhD, RN Associate Professor Biobehavioral Nursing and Health Systems University of Washington Seattle, Washington Michelle Bussard, PhD, RN RN to BSN Online eCampus Program Director College of Health and Human Services Bowling Green State University Bowling Green, Ohio Kim K. Choma, DNP, APRN, WHNP-­BC Women’s Health Nurse Practitioner Independent Consultant and Clinical Trainer, Kim Choma, DNP, LLC Scotch Plains, New Jersey Marisa Cortese, PhD, RN, FNP-­BC Research Nurse Practitioner, Hematology/ Oncology White Plains Hospital White Plains, New York Ann Crawford, RN, PhD, CNS, CEN Professor Department of Nursing University of Mary Hardin-­Baylor Belton, Texas Deena Damsky Dell, MSN, RN, APRN, AOCN(R), LNC Oncology Advanced Practice Registered Nurse Sarasota Memorial Hospital Sarasota, Florida Kimberly Day, DNP, RN Clinical Assistant Professor Edson College of Nursing and Health Innovation Arizona State University Phoenix, Arizona Hazel Dennison, DNP, RN, APNc, CPHQ, CNE Director of Continuing Nursing Education College of Health Sciences, School of Nursing Walden University Minneapolis, Minnesota; Nurse Practitioner, Urgent Care Virtua Health System Medford, New Jersey

Jane K. Dickinson, PhD, RN, CDE Program Director/Lecturer Diabetes Education and Management Teachers College, Columbia University New York, New York Cathy Edson, MSN, RN Nurse Practitioner, Emergency Department Team Health—Virtua Memorial Mt. Holly, New Jersey Jonel L. Gomez, DNP, ARNP, CPCO, COE Nurse Practitioner Ophthalmic Facial Plastic Surgery, Specialists, Stephen Laquis, MD Fort Myers, Florida Sherry A. Greenberg, PhD, RN, GNP-­BC, FGSA Courtesy-­Appointed Associate Professor, Nursing Rory Meyers College of Nursing New York University New York, New York Diana Rabbani Hagler, MSN-­Ed, RN, CCRN Staff Nurse, Intensive Care Unit Banner Health Gilbert, Arizona Julia A. Hitch, MS, APRN, FNPCDE Nurse Practitioner, Internal Medicine— Endocrinology Ohio State University Physicians Columbus, Ohio Haley Hoy, PhD, APRN Associate Professor College of Nursing University of Alabama in Huntsville Huntsville, Alabama; Nurse Practitioner Vanderbilt Lung Transplantation, Vanderbilt Medical Center Nashville, Tennessee Melissa Hutchinson, MN, BA, RN Clinical Nurse Specialist, MICU/CCU VA Puget Sound Health Care System Seattle, Washington Mark Karasin, DNP, APRN, AGACNP-­BC, CNOR Advanced Practice Nurse, Cardiothoracic Surgery Robert Wood Johnson University Hospital New Brunswick, New Jersey; Adjunct Faculty Center for Professional Development, School of Nursing Rutgers University Newark, New Jersey

Patricia Keegan, DNP, NP-­C, AACC Director Strategic and Programmatic Initiatives, Heart and Vascular Center Emory University Atlanta, Georgia Kristen Keller, DNP, ACNP-­BC, PMHNP-­ BC Nurse Practitioner, Trauma and Acute Care Surgery Banner Thunderbird Medical Center Glendale, Arizona Anthony Lutz, MSN, NP-­C, CUNP Nurse Practitioner Department of Urology Columbia University Irving Medical Center New York, New York Denise M. McEnroe-­Petitte, PhD, RN Associate Professor Nursing Department Kent State University Tuscarawas New Philadelphia, Ohio Amy Meredith, MSN, RN, EM Cert/Residency APN-­C Lead and APN Emergency Department Southern Ocean Medical Center Manahawkin, New Jersey Helen Miley, RN, PhD, AG-­ACNP Specialty Director of Adult Gerontology, Acute Care Nurse Practitioner Program School of Nursing Rutgers University Newark, New Jersey Debra Miller-­Saultz, DNP, FNP-­BC Assistant Professor of Nursing School of Nursing Columbia University New York, New York Eugene Mondor, MN, RN, CNCC(C) Clinical Nurse Educator, Adult Critical Care Royal Alexandra Hospital Edmonton, Alberta Brenda C. Morris, EdD, RN, CNE Clinical Professor Edson College of Nursing and Health Innovation Arizona State University Phoenix, Arizona

CONTRIBUTORS Janice A. Neil, PhD, RN, CNE Associate Professor College of Nursing, Department of Baccalaureate Education East Carolina University Greenville, North Carolina Yeow Chye Ng, PhD, CRNP, CPC, AAHIVE Associate Professor College of Nursing University of Alabama in Huntsville Huntsville, Alabama Mary C. Olson, DNP, APRN Nurse Practitioner, Medicine Division of Gastroenterology and Hepatology New York University Langone Health New York, New York Madona D. Plueger, MSN, RN, ACNS-­BC CNRN Adult Health Clinical Nurse Specialist Barrow Neurological Institute Dignity Health, St. Joseph’s Hospital and Medical Center Phoenix, Arizona Matthew C. Price, MS, CNP, ONP-­C, RNFA Orthopedic Nurse Practitioner Orthopedic One Columbus, Ohio; Director, Orthopedic Nurses Certification Board Chicago, Illinois Margaret R. Rateau, PhD, RN, CNE Assistant Professor School of Nursing, Education, and Human Studies Robert Morris University Moon Township, Pennsylvania Catherine R. Ratliff, RN, PhD Clinical Associate Professor and Nurse Practitioner School of Nursing/Vascular Surgery University of Virginia Health System Charlottesville, Virginia

Sandra Irene Rome, MN, RN, AOCN Clinical Nurse Specialist Blood and Marrow Transplant Program Cedars–Sinai Medical Center Los Angeles, California; Assistant Clinical Professor University of California Los Angeles School of Nursing Los Angeles, California Diane M. Rudolphi, MSN, RN Senior Instructor of Nursing College of Health Sciences University of Delaware, Newark Newark, Delaware Diane Ryzner, MSN, APRN, CNS-­BC, OCNS-­C Clinical Nursing Transformation Leader, Orthopedics Northwest Community Healthcare Arlington Heights, Illinois Andrew Scanlon, DNP, RN Associate Professor School of Nursing Montclair State University Montclair, New Jersey Rose Shaffer, MSN, RN, ACNP-­BC, CCRN Cardiology Nurse Practitioner Thomas Jefferson University Hospital Philadelphia, Pennsylvania Tara Shaw, MSN, RN Assistant Professor Goldfarb School of Nursing Barnes-­Jewish College St. Louis, Missouri Cynthia Ann Smith, DNP, APRN, CNN-­NP, FNP-­BC Nurse Practitioner Renal Consultants, PLLC South Charleston, West Virginia

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Janice Smolowitz, PhD, DNP, EdD Dean and Professor School of Nursing Montclair State University Montclair, New Jersey Cindy Sullivan, MN, ANP-­C, CNRN Nurse Practitioner Department of Neurosurgery Barrow Neurological Institute Phoenix, Arizona Teresa Turnbull, DNP, RN Assistant Professor School of Nursing Oregon Health and Science University Portland, Oregon Kara Ann Ventura, DNP, PNP, FNP Director, Liver Transplant Program Yale University School of Medicine New Haven, Connecticut Colleen Walsh, DNP, RN, ONC, ONP-­C, CNS, ACNP-­BC Contract Assistant Professor of Nursing College of Nursing and Health Professions University of Southern Indiana Evansville, Indiana Pamela Wilkerson, MN, RN Nurse Manager, Primary Care and Urgent Care Department of Veterans Affairs Veterans Administration, Puget Sound Tacoma, Washington Daniel P. Worrall, MSN, ANP-­BC Nurse Practitioner, Sexual Health Clinic Nurse Practitioner, General and Gastrointestinal Surgery Massachusetts General Hospital Boston, Massachusetts; Clinical Operations Manager The Ragon Institute of MGH, MIT, and Harvard Cambridge, Massachusetts

R EV I E WER S ‘Lara Alalade, RN, BN, MClSc-­WH Nursing Instructor Faculty of Health and Community Studies NorQuest College Edmonton, Alberta Jasmina Archambault, RN, BScN, MN Nursing Instructor Cégep Héritage Gatineau, Quebec Monique Bacher, RN, BScN, MSN/Ed Semester 3 PN Coordinator and Professor, Practical Nursing Program Sally Horsfall Eaton School of Nursing George Brown College Toronto, Ontario Renee Berquist, RN, BScN, MN, PhD Professor School of Baccalaureate Nursing St. Lawrence College Brockville, Ontario Diane Browman, RN, BScN Nursing Instructor Faculty of Nursing John Abbott College Sainte-­Anne-­de-­Bellevue, Quebec Lori Carre, RN, MN Professor School of Nursing Faculty of Applied Arts & Health Sciences Seneca College Toronto, Ontario Sharon R. Cassar, RN, MSN, NP–Primary Health Care Professor School of Nursing Faculty of Applied Arts & Health Sciences Seneca College Toronto, Ontario Annie Chevrier, N, MScA, CMSN(C) Bachelor of Nursing (Integrated) (BNI) Program Director, Online Education Initiatives and Continuing Nursing Education Assistant Professor Ingram School of Nursing McGill University Montreal, Quebec Sue Coffey, RN, PhD Associate Professor, Nursing Program Ontario Tech University Oshawa, Ontario

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Brenda Dafoe-­Enns, BA, MN, RN Nursing Instructor, Baccalaureate Nursing Program School of Health Sciences & Community Services Red River College Polytech Winnipeg, Manitoba Laurie Doxtator, RN, BNSc, MSc Professor, Practical Nursing Health Sciences St. Lawrence College Kingston, Ontario Donna Dunnet, LPN Licensed Practical Nurse Instructor Certificate School of Health Sciences / Practical Nursing Lethbridge College Lethbridge, Alberta Tammy Dwyer, RN, BScN, MEd Professor, Practical Nursing Program Faculty of Environmental Studies and Health Science Canadore College North Bay, Ontario Arnold Esguerra, RN (NP), BScN, MN Faculty, Orientation to Nursing in Canada for Internationally Educated Nurses School of Nursing Saskatchewan Polytechnic – Regina Campus Regina, Saskatchewan Natasha Fontaine, RN, BN, PIDP Professor Department of Nursing College of the Rockies Cranbrook, British Columbia Caroline Foster-­Boucher, RN, MN Assistant Professor Department of Nursing Science MacEwan University Edmonton, Alberta Sandra Fritz, RN, BN, MN, CCNE, CCSNE(C) Nursing Instructor Division of Science and Health University of Calgary—Medicine Hat Medicine Hat, Alberta Monica Gola, RN, MN, CPMHN(C) Sessional Lecturer School of Nursing York University Toronto, Ontario

Renée Gordon, CD, RN, MSc, CMSN(C), CCNE, CCCI, CCSNE Associate Teaching Professor Faculty of Nursing University of New Brunswick Moncton, New Brunswick Leslie Graham, RN, MN, PhD(c), CNCC, CHSE, CCSNE Coordinator, RPN to BScN Nursing Program Professor, Nursing Durham College Oshawa, Ontario; Adjunct Professor Ontario Tech University Oshawa, Ontario Tanya Heuver, BScN, RN, MN Assistant Professor Department of Nursing Science, Faculty of Nursing MacEwan University Edmonton, Alberta Kerry-­Anne Hogan, RN, PhD Part-Time Professor Faculty of Health Sciences University of Ottawa Ottawa, Ontario; Registered Nurse, Emergency Department Queensway Carleton Hospital Ottawa, Ontario Tania N. Killian, RN, BScN, BEd, MEd, CCN Professor School of Nursing Faculty of Applied Arts and Health Sciences Seneca College King City, Ontario; Registered Nurse, Emergency Department Royal Victoria Regional Health Centre Barrie, Ontario Natalie McMullin, RN, MN Nursing Instructor Faculty of Nursing Keyano College Fort McMurray, Alberta Andrea Miller, RN, BScN, MA Professor Faculty of Nursing McMaster-­Mohawk-­Conestoga Collaborative BScN Program Conestoga College Kitchener, Ontario

REVIEWERS Kathryn Morrison, RN, BScN, MScN Nursing Professor and Coordinator, Part-­ Time Practical Nursing and Specialty Nursing Programs Health, Wellness and Sciences Georgian College Barrie, Ontario Melanie Neumeier, RN, BScN, MN Assistant Professor Faculty of Nursing MacEwan University Edmonton, Alberta Cindy Pallister, RN, BScN, MScN Nursing Professor St. Clair College Windsor, Ontario Trina Propp, RN, BSN Nursing Instructor Practical Nursing Department Vancouver Community College Vancouver, British Columbia Gabriella Rispoli, RN, BEd, BScN Nursing Faculty Heritage College Gatineau, Quebec Margot Ellen Rykhoff, RN, BScN, MA(Ed) Faculty School of Health Sciences University of New Brunswick/Humber College Collaborative Nursing Degree Program Humber College Toronto, Ontario Ali Salman, MD, PhD, DNP, MN, RN Professor Faculty of Health Studies Brandon University Brandon, Manitoba

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Heather Schoenthal, RN, BScN Year 2 Clinical Instructor University of Saskatchewan College of Nursing Regina, Saskatchewan

Ashley Veilleux, RN, BScN, MN Professor Bachelor of Science in Nursing Program St. Lawrence College Cornwall, Ontario

Catherine Schwichtenber, Dip. Nursing, BScN, MSN GNIE Instructor and Graduate Nurse Kwantlen Polytechnic University Surrey, British Columbia

Yvonne Mayne Wilkin, RN, BScN, MSc, CEFP, EdD Year 3 Nursing Faculty Coordinator Department of Nursing Champlain College – Lennoxville Sherbrooke, Quebec

Jennifer Siemens, RN, BSN, MSN Nurse Educator Department of Nursing College of the Rockies Cranbrook, British Columbia Richard Snow, RN, BScN, MN Instructor School of Nursing Dalhousie University Yarmouth, Nova Scotia Laralea Stalkie, RN, BNSc, MSN Program Coordinator Faculty of Nursing St. Lawrence College/Laurentian University Collaborative St. Lawrence College Kingston, Ontario Karen Ursel, RN, BN, MHSA, PhD(C) Senior Teaching Associate Faculty of Nursing University of New Brunswick Moncton, New Brunswick Brandi Vanderspank-­Wright, RN, PhD, CNCC(C) Associate Professor School of Nursing Faculty of Health Sciences University of Ottawa Ottawa, Ontario

Jim Wohlgemuth, RN, MN, CTN-­B Instructor Nursing Education & Health Studies Grande Prairie Regional College Grande Prairie, Alberta

PHARMD REVIEWER Tom McFarlane, BScPhm, PharmD, RPh Clinical Lecturer School of Pharmacy University of Waterloo Kitchener, Ontario; Clinical Oncology Pharmacist Odette Cancer Centre, Sunnybrook Health Sciences, and Baruch/Weisz Cancer Centre, North York General Hospital Toronto, Ontario

To the Profession of Nursing and to the Important People in Our Lives Jane My husband Glenn, our children Kaitlyn, Kelsey, and Aiden, my grandson Benjamin, and my mother, Jessica Campney. You are my reason for everything. Shelley My husband Michael, our children and their partners, our grandsons Jace and Quinn, my mother Bev, and my amazing nursing colleagues at Dalhousie University’s Yarmouth Campus. Mariann My husband Jeff, our daughters Kate and Sarah, and my parents, Mick and Mary. Jeff My parents, Raymond and Virginia, thank you for believing in me and providing me the opportunity to become a nurse. Dottie My husband Steve and my children Megan, E. J., Jessica, and Matthew, who have supported me through four college degrees and countless writing projects; and to my son-­in-­law Al, our grandsons Oscar and Stephen, and my new daughter-­in-­ law, Melissa. Debbie My husband James, our children Matthew, Andrew, Amanda, and Diana, and our granddaughter Emma. Courtney To future nurses and the advancement of health care globally.

PR EFAC E The Fifth Edition of Lewis’s Medical-­Surgical Nursing in Canada: Assessment and Management of Clinical Problems has been thoroughly revised for the Canadian student and incorporates the most current medical-­surgical nursing information presented in an easy-­to-­use format. More than just a textbook, this is a comprehensive resource set in the Canadian context, containing essential information that nursing students need to prepare for lectures, classroom activities, examinations, clinical assignments, and the safe, comprehensive care of patients. In addition to the readable writing style and full-­colour illustrations, the text and accompanying resources include many special features to help students learn key medical-­surgical nursing content, such as sections that highlight the determinants of health, patient and caregiver teaching, age-­related considerations, nursing and interprofessional management, interprofessional care, cultural considerations, nutrition, home care, evidence-­informed practice, patient safety, and much more. The comprehensive content, special features, attractive layout, and student-­friendly writing style combine to make this the number one medical-­surgical nursing textbook, used in more nursing schools in Canada than any other medical-­surgical nursing textbook. The latest edition of Lewis’s Medical-­ Surgical Nursing in Canada retains the strengths of the first four editions, including the use of the nursing process as an organizational theme for nursing management. New features have been added to address some of the rapid changes in practice, and many diagrams and photos are new or improved. The content has been updated using the most recent important research and newest practice guidelines by Canadian contributors selected for their acknowledged excellence in specific content areas, ensuring a continuous thread of evidence-­informed practice throughout the text. Specialists in the subject area have reviewed each chapter to ensure accuracy, and the editors have undertaken final rewriting and editing to achieve internal consistency. In other words, all efforts have been made to build on the recognized strengths of the previous Canadian editions.

ORGANIZATION The content of this book is organized in two major divisions. The first division, Section 1 (Chapters 1 through 13), discusses concepts related to adult patients. The second division, Sections 2 through 12 (Chapters 14 through 72), presents nursing assessment and nursing management of medical-­surgical conditions. The various body systems are grouped in such a way as to reflect their interrelated functions. Each section is organized around two central themes: assessment and management. Each chapter that deals with the assessment of a body system includes a discussion of the following: 1. A brief review of anatomy and physiology, focusing on information that will promote understanding of nursing care 2. Health history and noninvasive physical assessment skills to expand the knowledge base on which decisions are made 3. Common diagnostic studies, expected results, and related nursing responsibilities to provide easily accessible information

Management chapters focus on the pathophysiology, clinical manifestations, laboratory and diagnostic study results in interprofessional care, and nursing management of various diseases and disorders. Nursing management sections are organized into assessment, nursing diagnoses, planning, implementation, and evaluation sections, following the steps of the nursing process. To emphasize the importance of patient care in various clinical settings, nursing implementation of all major health conditions is organized by the following levels of care: 1. Health promotion 2. Acute intervention 3. Ambulatory and home care 

CLASSIC FEATURES • C  anadian context. Once again, we are pleased to offer the reader a book that reflects the wide range of expertise of nurses from across Canada. In an effort to better reflect the nursing environments across the country, all chapters have been revised with enhanced Canadian research and statistics. SI units and metric measurements are used throughout the text, and the updated APA format, including digital object identifiers (DOIs), is used for the references. • Most recent research and clinical guidelines. Every effort has been made to use the most recent research, statistics, and clinical guidelines available. References older than 5 years at the time of writing are included because they are seminal studies or remain the most recent, authoritative source. Those references are marked “Seminal” in the References list. • Nursing management is presented in a consistent and comprehensive format, with headings for Health Promotion, Acute Intervention, and Ambulatory and Home Care. In addition, over 60 customizable Nursing Care Plans on the Evolve website and in the text help students to understand possible nursing diagnoses, goals, and nursing interventions for each condition. • Interprofessional care is highlighted in special Interprofessional Care sections in each of the management chapters and in Interprofessional Care tables throughout the text. • Patient and caregiver teaching is an ongoing theme throughout the text. Chapter 4, Patient and Caregiver Teaching, and numerous Patient & Caregiver Teaching Guides throughout the text emphasize the increasing importance and prevalence of patient management of chronic illnesses and conditions and the role of the caregiver in patient care. • Culturally competent care is covered in Chapter 2, Cultural Competence and Health Equity in Nursing Care, which discusses the necessity for culturally competent nursing care; culture as a determinant of health, with particular reference to Indigenous populations; health equity and health equality issues as they relate to marginalized groups in Canada; and practical suggestions for developing cultural competence in nursing care. • Coverage of prioritization includes: • Prioritization questions in Case Studies and Review Questions • Nursing diagnoses and interventions throughout the text listed in order of priority

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• F  ocused Assessment boxes in all assessment chapters provide brief checklists that help students do a more practical “assessment on the run” or bedside approach to assessment. • Safety Alerts highlight important safety issues in relation to patient care as they arise. • Pathophysiology Maps outline complex concepts related to diseases in flowchart format, making them easier to understand. • Community-­based nursing and home care are also emphasized in this Fifth Edition. Chapter 6 contains a comprehensive discussion, which is continued throughout the text. • Determinants of Health boxes focus on the determinants of health as outlined by Health Canada and the Public Health Agency of Canada, as they affect a particular disorder. The determinants are introduced and discussed in detail in Chapter 1, and then returned to throughout the text by way of Determinants of Health boxes, which have been extensively updated and revised for the new edition. Each box identifies a health issue specific to the chapter; lists the relevant determinants affecting the issue, supported by the most recent research; and includes references for further investigation. • Extensive medication therapy content includes Medication Therapy tables and concise Medication Alerts highlighting important safety considerations for key medications. • Chronic illness, which has become Canada’s most pressing health care challenge, is discussed in depth in Chapter 5. Nurses are increasingly called on to be active and engaged partners in assisting patients with chronic conditions to live well; this chapter places chronic illness within the larger context of Canadian society. • Older persons are covered in detail in Chapter 7, and issues particularly relevant to this population are discussed throughout the text under the headings “Age-­Related Considerations” and also in Age-­Related Differences in Assessment tables. • Nutrition is highlighted throughout the book, particularly in Chapter 42, Nutritional Conditions, and in Nutritional Therapy tables throughout that summarize nutritional interventions and promote healthy lifestyles for patients with various health conditions. Chapter 43, Obesity, looks in depth at this major factor contributing to so many other pathologies. • Complementary and alternative therapies are discussed in Chapter 12, which addresses timely issues in today’s health care settings related to these therapies, and in Complementary & Alternative Therapies boxes, where relevant, throughout the rest of the book that summarize what nurses need to know about therapies such as herbal remedies, acupuncture, and biofeedback. • Sleep and sleep disorders are explored in Chapter 9; they are key topics that affect multiple disorders and body systems, as well as nearly every aspect of daily functioning. • Genetics in Clinical Practice boxes build on the foundation of Chapter 15 and highlight genetic screening and testing, as well as the clinical implications of key genetic disorders that affect adults, as rapid advances in the field of genetics continue to change the way nurses practise. • Ethical Dilemmas boxes promote critical thinking with regard to timely and sensitive issues that nursing students contend with in clinical practice, such as informed consent,

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treatment decision making, advance directives, and confidentiality. Emergency Management tables outline the emergency treatment of health conditions that are most likely to require rapid intervention. Assessment Abnormalities tables in the assessment chapters alert the nursing student to abnormalities frequently encountered in practice, as well as their possible etiologies. Nursing Assessment tables summarize important subjective and objective data related to common diseases, with a sharper focus on issues most relevant to the body system under review. This focus provides for more rapid identification of salient assessment parameters and more effective use of student time. Health History tables in assessment chapters present relevant questions related to a specific disease or disorder that will be asked in patient interviews. Informatics boxes throughout the text reflect the current use and importance of technology and touch on everything from the proper handling of social media in the context of patient privacy, to teaching patients to manage self-­care using smartphone apps, to using smart infusion pumps. Unfolding assessment case studies in every assessment chapter are an engaging tool to help students apply nursing concepts in real-­life patient care. Appearing in three or four parts throughout the chapter, they introduce a patient, follow that patient through subjective and objective assessment to diagnostic studies and results, and include additional discussion questions to facilitate critical thinking. Student-­friendly pedagogy: • Learning Objectives at the beginning of each chapter help students identify the key content for a specific body system or disorder. • Key Terms lists provide a list of the chapter’s most important terms and where they are discussed in the chapter. A comprehensive key terms Glossary with definitions may be found at the end of the book. • Electronic resources lists at the start of each chapter draw students’ attention to the wealth of supplemental content and exercises provided on the Evolve website, making it easier than ever for them to integrate the textbook content with media supplements such as animations, video and audio clips, interactive case studies, and much more. • Case Studies bring patients to life. Management chapters have case studies at the end of the chapters that help students learn how to prioritize care and manage patients in the clinical setting. Unfolding case studies are included in each assessment chapter. Discussion questions that focus on prioritization and evidence-­informed practice are included in most case studies. Answer guidelines are provided on the Evolve website. • Review Questions at the end of the chapter correspond to the Learning Objectives at the beginning and thus help reinforce the important points in the chapter. Answers are provided on the same page, making the Review Questions a convenient self-­study tool. • Resources at the end of each chapter contain links to nursing and health care organizations and tools that provide patient teaching and information on diseases and disorders. 

PREFACE EXPANDED AND ENHANCED FEATURES In addition to the continued classic strengths of this text, we are pleased to include several updated features: • Evidence-­informed practice content challenges students to develop critical thinking skills and apply the best available evidence to patient care scenarios in Evidence-Informed Practice boxes and questions at the end of many case studies. • Medication Alerts concisely highlight important safety considerations for key medications. • Safety Alerts have been expanded throughout the book to cover surveillance for high-­risk situations. • New art enhances the book’s visual appeal and lends a more contemporary look throughout. • Content related to the COVID-­19 pandemic and the SARS-­ CoV-­2 virus is incorporated throughout, focusing on its impacts on nurses and patients alike. • Revised Chapter 1: Introduction to Medical-­Surgical Nursing Practice in Canada situates nursing practice within the unique societal contexts that continue to shape the profession of nursing in Canada. Patient-­centred care, interprofessional practice, and information-­communication technologies are forces that have an impact on and are affected by nurses. This chapter includes a section on patient safety and quality improvement and expanded content on teamwork and interprofessional collaboration. Nursing education in Canada incorporates clinical decision-­making models and guidelines that focus on critical thinking, clinical judgement, and clinical decision-­ making. These topics are defined along with a comparison between clinical judgement models (including the NGN Clinical Judgement Measurement Model) and the nursing process. As the nursing process best fits within Canadian nursing education, this Fifth Edition uses the nursing process as its guiding framework. • Revised Chapter 6: Community-­Based Nursing and Home Care includes additional content focusing on the impact of the COVID-­19 pandemic and changes required in primary care settings, including home health monitoring (HHM) and the integration of virtual care. • Revised Chapter 11: Substance Use now includes information about health care provider stigmatizing behaviours that negatively affect patient outcomes. The chapter also includes more detailed information about the impact of substance use experienced by Indigenous peoples of Canada and how health care providers can better meet the needs of this population. Expanded treatment options for opioid use disorder reflect current and innovative approaches to care now available in Canada. • Revised Chapter 31: Nursing Management: Obstructive Pulmonary Diseases includes expanded content specific to asthma. Additional content provides a comprehensive overview of environmental and physiological triggers, diagnostic testing, and treatment options. New information includes modifications to infection-­control practices and respiratory treatment protocols developed as a result of spread of the SARS-­CoV-­2 virus. • Revised Chapter 72: Emergency Management and Disaster Planning has been expanded to include Canada’s Strategic Emergency Management Plan and Emergency Response Plan and updated to include revisions to Canada’s Emergency Management Framework and Canada’s Incident ­Command System. Recent Canadian disasters have been included, and

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new information related to the COVID-­19 pandemic has been incorporated. The World Health Organization’s Emergency Response Plan has been added in detail, as well as the revised International Council of Nurses Framework of Disaster Nursing Competencies. 

A WORD ON TERMINOLOGY The authors and contributors of the text recognize and acknowledge the diverse histories of the First Peoples of the lands now referred to as Canada. It is recognized that individual communities identify themselves in various ways; within this text, the term Indigenous is used to refer to all First Nations, Inuit, and Métis people within Canada unless there are research findings that are presented uniquely to a population. Knowledge and language concerning sex, gender, and identity are fluid and continually evolving. The language and terminology presented in this text endeavour to be inclusive of all people and reflect what is, to the best of our knowledge, current at the time of publication. Gender pronouns have been removed whenever possible, using the terms they and them as acceptable singular references to achieve gender neutrality (see https:// en/oxforddictionaries.com/usage/he-­o r-­s he-­v ersus-­t hey). Patient profiles in Case Studies, Ethical Dilemmas boxes, and Evidence-­Informed Practice: Translating Research into Practice boxes include preferred pronouns and employ initials in place of full names. Throughout the textbook, when information is specific to the role of the RN, “Registered Nurse” or “RN” has been used; in all other instances, the term nurse is used to refer to an RN and/or RPN/LPN, depending on jurisdictional regulations. “Interprofessional collaboration” is used to refer to any collaboration among health care team members and others (for example, spiritual caregivers). “Health care provider” can include a physician, nurse practitioner, or an RN for whom the prescribing of medications or treatments is within their scope of practice. 

A WORD ON LABORATORY VALUES SI units are used for the laboratory values cited throughout the textbook. The Laboratory Values appendix lists SI units first, followed by US conventional units in parentheses in all relevant instances. It is important to note that reference ranges for laboratory values may vary among laboratories, depending on the testing techniques used. If discrepancies should exist between the body of the text and this appendix, the appendix should be considered the final authority. 

LEARNING SUPPLEMENTS FOR THE STUDENT • E  volve Student Resources are available online at http://evol ve.elsevier.com/Canada/Lewis/medsurg and include the following valuable learning aids that are organized by chapter: • NEW! PN Case Studies for Clinical Judgement • NEW! NGN-­Style Case Studies • Interactive Student Case Studies with state-­of-­the-­art animations and a variety of learning activities that provide students with immediate feedback • Printable Key Points summaries for each chapter • Review Questions • Answer guidelines to the case studies in the textbook

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PREFACE

• C  ustomizable Nursing Care Plans • Conceptual Care Map Creator and Conceptual Care Maps for selected case studies in the textbook • Managing Multiple Patients case studies for RNs present scenarios with multiple patients requiring care simultaneously, to develop prioritization and delegation skills. Answer guidelines are also provided. • Fluids and electrolytes tutorial • Audio glossary of key terms, available as a comprehensive alphabetical glossary • Supporting animations and audio for selected chapters More than just words on a screen, Elsevier eBooks come with a wealth of built-­in study tools and interactive functionality to help students better connect with the course material and their instructors. Plus, with the ability to fit an entire library of books on one portable device, students can study when, where, and how they want. 

TEACHING SUPPLEMENTS FOR INSTRUCTORS • E  volve Instructor Resources (available online at http://evolve. elsevier.com/Canada/Lewis/medsurg) remain the most comprehensive set of instructors’ materials available, containing the following: • TEACH for Nurses Lesson Plans focus on the most important content from each chapter and provide innovative strategies for student engagement and learning. These new lesson plans provide teaching strategies that integrate textbook content with activities for pre-class, inclass, online, group, clinical judgement, and interprofessional collaboration, all correlated with RN-NGN Clinical Judgement Model and PN Clinical Judgement Skills competencies. • Two test banks are provided: Test Bank for RN and Test Bank for PN. Each features examination-­ format test questions coded for nursing process and cognitive level. The Test Bank for PN is updated to reflect new 2019 PN national competencies, including those for Ontario and British Columbia. The robust ExamView® testing application, provided at no cost to faculty, allows instructors to create new tests; edit, add, and delete test questions; sort questions by category, cognitive level, and nursing process step; and administer and grade tests online, with automated scoring and gradebook functionality. • The Image Collection contains full-­colour images from the text for use in lectures. • PowerPoint® Lecture Slides consist of customizable text slides for instructors to use in lectures. • NEW! Next-­Generation NCLEX™ (NGN)-­style case studies for medical-­surgical nursing • NEW! Concept-­Based Curriculum Map • Animations

Simulation Learning System (SLS) The Simulation Learning System (SLS) is an online toolkit that helps instructors and facilitators effectively incorporate medium-­to high-­fidelity simulation into their nursing curriculum. Detailed patient scenarios promote and enhance the clinical decision-­making skills of students at all levels. The SLS provides detailed instructions for preparation and implementation of the simulation experience, debriefing questions that encourage critical thinking, and learning resources to reinforce

student comprehension. Each scenario in the SLS complements the textbook content and helps bridge the gap between lecture and clinical experience. The SLS provides the perfect environment for students to practise what they are learning in the text for a true-­to-­life, hands-­on learning experience. 

Sherpath Sherpath Book-Organized collections offer digital lessons, mapped chapter-­by-­chapter to the textbook, so the reader can conveniently find applicable digital assignment content. Sherpath features convenient teaching materials that are aligned with the textbook, and the lessons are organized by chapter for quick and easy access to invaluable class activities and resources.  Elsevier eBooks This exciting program is available to faculty who adopt a number of Elsevier texts, including Lewis’s Medical-­Surgical Nursing in Canada. Elsevier eBooks is an integrated electronic study centre consisting of a collection of textbooks made available online. It is carefully designed to “extend” the textbook for an easier and more efficient teaching and learning experience. It includes study aids such as highlighting, e-­note taking, and cut-­and-­paste capabilities. Even more importantly, it allows students and instructors to do a comprehensive search within the specific text or across a number of titles. Please check with your Elsevier Canada sales representative for more information.  Next Generation NCLEX™ (NGN) The National Council for the State Boards of Nursing (NCSBN) is a not-­for-­profit organization whose members include nursing regulatory bodies. In empowering and supporting nursing regulators in their mandate to protect the public, the NCSBN is involved in the development of nursing licensure examinations, such as the NCLEX-­RN®. In Canada, the NCLEX-­RN® was introduced in 2015 and is, as of the writing of this text, the recognized licensure exam required for practising RNs in Canada. As of 2023, the NCLEX-­RN® will be changing to ensure that its item types adequately measure clinical judgement, critical thinking, and problem-­solving skills on a consistent basis. The NCSBN will also be incorporating into the examination what they call the Clinical Judgement Measurement Model (CJMM), which is a framework the NCSBN has created to measure a novice nurse’s ability to apply clinical judgement in practice. These changes to the examination come as a result of findings indicating that novice nurses have a much higher than desirable error rate with patients (errors causing patient harm) and, upon NCSBN’s investigation, that the overwhelming majority of these errors were caused by failures of clinical judgement. Clinical judgement has been a foundation underlying nursing education for decades, based on the work of a number of nursing theorists. The theory of clinical judgement that most closely aligns with what NCSBN is basing their CJMM on is the work by Christine A. Tanner. The new version of the NCLEX-­RN® is identified loosely as the “Next-­Generation NCLEX,” or “NGN,” and will feature the following: • Six key skills in the CJMM: recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes.

PREFACE • A  pproved item types as of March 2021: multiple response, extended drag and drop, cloze (drop-­down), enhanced hot-­ spot (highlighting), matrix/grid, bow tie, and trend. More question types may be added. • All new item types are accompanied by mini–case studies with comprehensive patient information—some of it relevant to the question, and some of it not. • Case information may present a single, unchanging moment in time (a “single episode” case study) or multiple moments in time as a patient’s condition changes (an “unfolding” case study). • Single-­episode case studies may be accompanied by one to six questions; unfolding case studies are accompanied by six questions. For more information (and detail) regarding the NCLEX­RN® and changes coming to the exam, visit the NCSBN’s website: https://www.ncsbn.org/11447.htm and https://ncsbn.org/ Building_a_Method_for_Writing_Clinical_Judgment_It.pdf. For further NCLEX-­RN® examination preparation resources, see Elsevier’s Canadian Comprehensive Review for the NCLEX­RN Examination, Second Edition, ISBN 9780323709385. Prior to preparing for any nursing licensure examination, please refer to your provincial or territorial nursing regulatory body to determine which licensure examination is required in order for you to practise in your chosen jurisdiction. 

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ACKNOWLEDGEMENTS The editors are grateful to the entire editorial team at Elsevier for their leadership and dedication in the preparation of this very comprehensive, but much needed, Canadian medical-­ surgical textbook. In particular, we wish to thank Roberta A. Spinosa-­Millman, Senior Content Strategist, for her invaluable assistance, and Tammy Scherer and Suzanne Simpson, Content Development Specialists, for their professionalism, sense of humour, patience, and graciousness despite pressing deadlines. We would also like to thank Sarah Ibrahim for her help with the Laboratory Values appendix. We would like to recognize the commitment and expertise of all the authors, representing diverse areas of practice and regions of Canada. It has been a genuine pleasure to work with both the first-­time and returning authors on this project. We are also very grateful to the many reviewers for their valuable feedback on earlier versions of this textbook. It takes a large and coordinated team to create a textbook such as this, and we thank everyone for their individual contributions. We are proud to be able to provide a medical-­surgical nursing textbook written from a Canadian perspective that provides current and accurate information to enrich the learning of our nursing students.

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S E C T I O N

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Concepts in Nursing Practice

Source: © CanStock Photo / ABBPhoto

Chapter 1: Introduction to Medical-Surgical Nursing Practice in Canada Chapter 2: Cultural Competence and Health Equity in Nursing Care Chapter 3: Health History and Physical Examination Chapter 4: Patient and Caregiver Teaching Chapter 5: Chronic Illness Chapter 6: Community-Based Nursing and Home Care Chapter 7: Older Persons Chapter 8: Stress and Stress Management Chapter 9: Sleep and Sleep Disorders Chapter 10: Pain Chapter 11: Substance Use Chapter 12: Complementary and Alternative Therapies Chapter 13: Palliative and End-of-Life Care

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Introduction to Medical-­Surgical Nursing Practice in Canada Jane Tyerman  Originating US chapter by Mariann M. Harding

WEBSITE http://evolve.elsevier.com/Canada/Lewis/medsurg • R  eview Questions (Online Only) • Key Points • Conceptual Care Map Creator

• A  udio Glossary • Content Updates

LEARNING OBJECTIVES . Describe key challenges facing the current Canadian health care system. 1 2. Describe the practice of professional nursing in relation to the health care team. 3. Describe the key attributes of the practice of medical-­surgical nursing. 4. Explain how teamwork and interprofessional collaboration contribute to high-­quality patient outcomes. 5. Discuss the role of integrating patient-­centred care and safety and quality improvement processes into nursing practice.

. Evaluate the role of informatics and technology in nursing practice. 6 7. Apply concepts of evidence-­informed practice to nursing practice. 8. Describe the role of critical thinking and clinical reasoning skills and use of the nursing process to provide patient-­centred care.

KEY TERMS advanced practice nursing (APN) assessment clinical (critical) pathway collaborative problems continuing competence critical thinking determinants of health electronic health records (EHRs) evaluation

  

evidence-­informed nursing expected patient outcomes implementation medical-­surgical nursing nursing diagnosis nursing informatics nursing intervention nursing leadership nursing process

THE CANADIAN HEALTH CARE CONTEXT Health care is a subject of keen interest to the public. In Canada, everyone has access to health care through a government-­funded universal program, the costs of which are shared by the federal and the provincial/territorial governments. A multiyear health accord with a long-­term funding agreement between the federal and provincial/territorial governments determines the way that health care is delivered in Canada. In addition, the level of health care funding from the federal government to the provinces and territories depends on the economic health of the country. The Canada Health Act health care policy was established to promote, restore, and maintain the physical and mental health of all Canadians through equal access to health services (Government of Canada, 2020). These include most services provided in hospitals and by family health care providers. Because health services have evolved inconsistently across provinces, territories, and regions, however, Canada has a complex health

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patient-­centred approach patient safety planning regulated health care professions SBAR (situation, background, assessment, and recommendation) standard of practice telehomecare unregulated care providers (UCPs)

care system. The Canadian health care system continues to struggle with major challenges, including concerns about patient safety, service delivery, fiscal constraints, age-­related demographics, the emergence of new infectious diseases such as COVID-­19, the prevalence of chronic diseases, and the high cost of new technology and medications. In response, during 2019–2020, Health Canada prioritized the following health initiatives (Health Canada, 2019): 1. Expand resources to address the national opioid crisis and create harm reduction strategies, such as supervised consumption sites and overdose prevention programs 2. Promote smoking cessation (tobacco and vaping) through product regulations that protect youth 3. Improve access to, the affordability of, and appropriate use of prescription medications to all Canadians 4. Increase access to home, community care, and mental health services

CHAPTER 1  Introduction to Medical-Surgical Nursing Practice in Canada

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TABLE 1.1    PRINCIPLES TO GUIDE HEALTH CARE

TRANSFORMATION IN CANADA

• P  atient-­centred: Patients must be at the centre of health care, with seamless access to the continuum of care on the basis of their needs. • Q  uality: Canadians deserve quality services that are appropriate for patient needs, are respectful of individual choice, and are delivered in a manner that is timely, safe, effective, and according to the most currently available scientific knowledge. • H  ealth promotion and illness prevention: The health system must support Canadians in the prevention of illness and the enhancement of their well-­being, with attention paid to broader social determinants of health. • E  quitable: The health care system has a duty to Canadians to provide and advocate for equitable access to quality care and commonly adopted policies to address the social determinants of health. • S  ustainable: Sustainable health care requires universal access to quality health services that are adequately resourced and delivered across the board in a timely and cost-­effective manner. • A  ccountable: The public, patients, families, providers, and funders all have a responsibility for ensuring that the system is effective and accountable. Source: Canadian Nurses Association & Canadian Medical Association. (July, 2011). Principles to guide health care transformation in Canada. https://www.cna-­aiic.ca/∼/me dia/cna/files/en/guiding_principles_hc_e.pdf

5. Implement a multiyear Healthy Eating Strategy that builds on the revised Canada’s Food Guide (Government of Canada, 2021) 6. Support the implementation of Indigenous Services Canada (ISC) programs available to Indigenous peoples Together with the Canadian Medical Association (CMA), the Canadian Nurses Association (CNA) has defined a set of key principles designed to guide health care transformation in Canada. These principles, listed in Table 1.1, are important considerations for all nurses because they will shape the re-­engineered health care system of the future.

Complex Health Care Environments Nurses practice in virtually all health care settings and communities across the country. They are the frontline providers of health care (Figure 1.1). Rapidly changing technology and dramatically expanding knowledge are adding to the complexity of health care environments. Patient acuity is now more complicated because of polypharmacy, chronic health care conditions, and multiple comorbidities, which have paved the way for more research and robust technology to address these needs. Additional health care providers are required to work collaboratively to help restore, maintain, and promote health for all populations with complex health needs. Advanced communication technologies have created a more global environment that affects the delivery of health care worldwide. The number and complexity of advances in patient care technology are transforming how care is delivered. In addition, the Human Genome Project and advances in genetics are affecting the prevention, diagnosis, and treatment of health conditions. With advances in knowledge, ethical dilemmas and controversy arise with regard to the use of new scientific knowledge and the disparities that exist in patients’ access to more technologically advanced health care. Throughout this book, expanding knowledge and technology’s effects on nursing practice are highlighted in Genetics in Clinical Practice, Informatics in Practice, and Ethical Dilemmas boxes.

FIG. 1.1  Nurses are frontline professionals of health care. Source: iStock. com/monkeybusinessimages.

ETHICAL DILEMMAS Social Networking: Confidentiality and Privacy Violation Situation A nursing student logs into a closed group on a social networking site and reads a posting from a fellow nursing student. The posting describes in detail the complex care that the fellow student provided to an older patient in a local hospital the previous day. The fellow student comments on how stressful the day was and asks for advice on how to deal with similar patients in the future.

Ethical/Legal Points for Consideration • P  rotecting and maintaining patient privacy and confidentiality are basic obligations defined in the Code of Ethics (CNA, 2017), which nurses and nursing students should uphold. • Each province and territory has their own legislation to protect a patient’s private health information. Some examples include the Personal Information Protection Act (PIPA) in British Columbia and the Access to Information and Protection of Privacy Act (ATIPPA) in Newfoundland and Labrador. Private health information is any information about the patient’s past, present, or future physical or mental health. This includes not only specific details, such as a patient’s name or picture, but also information that gives enough details that someone else may be able to identify that patient. • A nurse may unintentionally breach privacy or confidentiality by posting patient information (diagnosis, condition, or situation) on a social networking site. Using privacy settings or being in a closed group does not guarantee the secrecy of posted information. Other users can copy and share any post without the poster’s knowledge. • Potential consequences for improperly using social networking vary according to the situation. These may include dismissal from a nursing program, termination of employment, or civil and criminal actions. 

Discussion Questions • H  ow would you address the situation involving a fellow nursing student? • How would you handle a situation in which you observed a staff member violating the provincial/territorial legislation related to a patient’s private health information?

Diverse Populations.  Patient demographics are more diverse than ever. Canadians are living longer, in part because of advances in medical science, technology, and health care delivery. As the population ages, the number of patients with chronic conditions increases. Unlike those who receive acute, episodic care, patients with chronic conditions have many needs and see a variety of health care providers in various settings over an

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TABLE 1.2    PUBLIC HEALTH AGENCY OF CANADA: KEY DETERMINANTS OF HEALTH Determinant of Health

Underlying Premise

Income and social status

Health status improves at each step up the income and social hierarchy. High income determines living conditions such as safe housing and ability to buy sufficient good food. The healthiest populations are those societies that are prosperous and have an equitable distribution of wealth. Support from families, friends, and communities is associated with better health. Such social support networks could be very important in helping people solve problems and deal with adversity, as well as in maintaining a sense of mastery and control over life circumstances. The caring and respect that occur in social relationships, and the resulting sense of satisfaction and well-­being, seem to act as a buffer against health problems. Health status improves with level of education, which is, in turn, tied to socioeconomic status. Education contributes to health and prosperity by equipping people with knowledge and skills for problem solving and helps provide a sense of control and mastery over life circumstances. It increases opportunities for job and income security and job satisfaction. Education also improves people’s ability to access and understand information to help keep them healthy. Unemployment, underemployment, and stressful or unsafe work are associated with poorer health. People who have more control over their work circumstances and fewer stress-­related demands of the job are healthier and often live longer than those who have more stressful or riskier types of work and activities. The array of values and norms of a society influences in varying ways the health and well-­being of individuals and populations. In addition, social stability, recognition of diversity, safety, good working relationships, and cohesive communities provide a supportive society that reduces or avoids many potential risks to good health. Social or community responses can add resources to an individual’s repertoire of strategies to cope with changes and foster health. The physical environment is an important determinant of health. At certain levels of exposure, contaminants in our air, water, food, and soil can cause a variety of adverse health effects, including cancer, birth defects, respiratory illness, and gastrointestinal ailments. In the built environment, factors related to housing, indoor air quality, and the design of communities and transportation systems can significantly influence physical and psychological well-­being. These refer to those actions by which individuals can prevent diseases and promote self-­care, cope with challenges, develop self-­reliance, solve problems, and make choices that enhance health. These influence lifestyle choice through at least five domains: personal life skills, stress, culture, social relationships and belonging, and a sense of control. Early childhood development is a powerful determinant of health. Early experiences affect brain development and school readiness, which can be affected by the physical environment (housing and neighbourhood), family income, parental education, access to nutritious food, genetics, and access to health care. All of the other determinants of health, in turn, affect the physical, social, mental, emotional, and spiritual development of children and youth. The basic biology and organic makeup of the human body are a fundamental determinant of health. Genetic endowment provides an inherited predisposition to a wide range of individual responses that affect health status. Socioeconomic and environmental factors are important determinants of overall health, but in some circumstances, genetic endowment appears to predispose certain individuals to particular diseases or health problems. Health services, particularly those designed to maintain and promote health, to prevent disease, and to restore health and function, contribute to the health of the overall population. The health services continuum of care includes treatment and secondary prevention. Gender refers to the array of society-­determined roles, personality traits, attitudes, behaviours, values, and relative power and influence that society ascribes to the two sexes on a differential basis. Gendered norms influence the health system’s practices and priorities. Many health issues are a function of gender-­based social status or roles. Some persons or groups may face additional health risks due to a socioeconomic environment, which is largely determined by dominant cultural values that contribute to the perpetuation of conditions such as marginalization, stigmatization, loss or devaluation of language and culture, and lack of access to culturally appropriate health care and services.

Social support networks

Education and literacy

Employment/working conditions Social environments

Physical environments

Personal health practices and coping skills Healthy child development

Biology and genetic ­endowment

Health services

Gender

Culture

© All rights reserved. What makes Canadians healthy or unhealthy? Public Health Agency of Canada, 2013. Adapted and reproduced with permission from the Minister of Health, 2021.

extended period. Nurses are also caring for a more culturally and ethnically diverse population and must provide culturally safe care (see Chapter 2). Immigrants, particularly undocumented immigrants and refugees, often lack the resources necessary to access health care. Inability to pay for health care is associated with a tendency to delay seeking care; thus, illnesses may become more serious.  Determinants of Health.  The determinants of health are the factors that influence the health of individuals and groups. Table 1.2 displays the determinants of health recognized by the Public Health Agency of Canada (PHAC, 2020). The primary factors that shape the health of Canadians are not medical treatments or lifestyle choices but rather the living conditions (the economic, social, and political) that they experience (Alberga et al., 2018; Hancock, 2017). The 12 determinants of health include income and social status, employment and working conditions, education and literacy, childhood experiences, physical environments, social supports and coping skills, healthy behaviours, access to health services, biology and genetic endowment,

gender, culture, and race and racism (PHAC, 2020). These determinants of health include biological components and social components. The social components can be further evaluated based on economic, social, and political structures. The determinants of health are used to evaluate components of health for an individual, community, subpopulation, or nation or on a global scale. They help identify many factors that contribute to one’s health beyond the biological, innate advantages and disadvantages. These determinants can either improve a person’s health status or heighten an individual’s risk for disease, injury, and illness. As these factors or determinants intersect with each other, the overall effect can be one of multiple exclusions beyond individual control, leading to compounded adverse effects on health and well-­being. 

Patient-­Centred Care Nurses have long demonstrated that they deliver patient-­ centred care based on each patient’s unique needs and an understanding of the patient’s preferences, values, and beliefs.

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TABLE 1.3    QUALITY AND SAFETY EDUCATION FOR NURSES (QSEN) COMPETENCIES Competency

Knowledge, Skills, and Attitudes

Patient-­Centred Care Recognize the patient or designee as the source of control and a full partner in providing compassionate and coordinated care that is based on respect for patient’s preferences, values, and needs.

• Provide care with sensitivity and respect, taking into consideration the patient’s perspectives, beliefs, and cultural background. • Assess the patient’s level of comfort, and treat appropriately. • Engage the patient in an active partnership that promotes health, well-­being, and self-­care management. • Facilitate patient’s informed consent for care.

Teamwork and Collaboration Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.

• Value the expertise of each interprofessional member. • Initiate referrals when appropriate. • Follow communication practices that minimize risks associated with handoffs and transitions in care. • Participate in interprofessional rounds.

Safety Minimize risk of harm to patients and providers through both system effectiveness and individual performance.

• Follow recommendations from national safety campaigns. • Appropriately communicate observations or concerns related to hazards and errors. • Contribute to designing systems to improve safety.

Quality Improvement Use data to monitor the outcomes of care and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.

• Use quality measures to understand performance. • Identify gaps between local and best practices. • Participate in investigating the circumstances surrounding a sentinel event or serious reportable event.

Informatics Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.

• Protect confidentiality of patient’s protected health information. • Document appropriately in electronic health records. • Use communication technologies to coordinate patient care. • Respond correctly to clinical decision-­making alerts.

Evidence-­Based or Evidence-­Informed Practice Integrate best current evidence with clinical expertise and the patient/family preferences and values for delivery of optimal health care.

• Read research, clinical practice guidelines, and evidence reports related to area of practice. • Base individual patient care plan on patient’s values, clinical expertise, and evidence. • Continuously improve clinical practice on the basis of new knowledge.

Source: Reprinted from Nursing Outlook, 55(3), Linda Cronenwett, Gwen Sherwood, Jane Barnsteiner, Joanne Disch, Jean Johnson, Pamela Mitchell, Dori Taylor Sullivan, Judith Warren, “Quality and safety education for nurses,” pages 122–131, Copyright 2007, with permission from Elsevier.

Patient-­centred care is interrelated with both quality and safety. A patient-­centred approach focuses on respectful and responsive care to patient preferences, needs, and values, ensuring they are involved in care decisions (Montague et al., 2017). In Canada, numerous provincial initiatives are underway to improve the person’s and their family’s experience. Many initiatives are partnering with individual users to ensure that the patient (and the patient’s family) is the focus of system reform (Registered Nurses’ Association of Ontario [RNAO], 2015). Patient Safety and Quality Improvement.  Patient safety is defined as the absence of preventable harm to a patient while receiving health care and the unnecessary harm associated with health care (World Health Organization [WHO], 2019). Entry-­to-­practice nursing competencies recognize the importance of the nurse’s ability to assess and manage situations that may compromise patient safety (College of Nurses of Ontario [CNO], 2019). Although patients turn to the health care system for help with their health conditions, there is overwhelming evidence that significant numbers of patients are harmed as a result of the health care they receive, resulting in permanent injury, increased lengths of hospital stay, and even death (WHO, 2019). There are approximately 190 000 patient safety incidences in Canada, resulting in 24 000 preventable deaths yearly, indicating that harmful incidents are a significant issue in Canadian

hospitals (Canadian Patient Safety Institute [CPSI], 2017). The Canadian Patient Safety Institute (CPSI) and other organizations address patient safety by providing safety goals for health care organizations and identifying safety competencies for health care providers. Tools and programs in four priority areas—medication safety, surgical care safety, infection prevention and control, and home care safety—are available from the CPSI (2021). By implementing various procedures and systems to improve health care delivery to meet safety goals, designers of health care systems are working to attain a culture of safety that minimizes the risk of harm to the patient. Because nurses have the greatest amount of interaction with patients, they are a vital part of promoting this culture of safety by providing care that reduces errors and actively promotes patient safety.  Quality and Safety Education for Nurses.  The Quality and Safety Education for Nurses (QSEN) Institute has made a major contribution to nursing by defining specific competencies that nurses need to have to practise safely and effectively in today’s complex health care system. Table 1.3 describes each of the QSEN competencies and the knowledge, skills, and attitudes (KSAs) necessary in six key areas: (1) patient-­centred care, (2) teamwork and collaboration, (3) quality improvement, (4) safety, (5) informatics and technology, and (6) evidence-­ informed practice (QSEN, 2014). The rest of this chapter describes how

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SECTION 1  Concepts in Nursing Practice

professional nursing practice focuses on acquiring the knowledge, skills, and attitudes for these competencies. 

The Profession of Nursing in Canada Health care in Canada is typically delivered by teams of workers with different responsibilities and scopes of practice. Regulated health care professions are governed by a legislative framework and are required to obtain an annual licence to practise in their respective province or territory (Canadian Institute for Health Information [CIHI], 2020). There are four regulated nursing groups: registered nurses (RNs), nurse practitioners, registered psychiatric nurses, and licensed practical nurses/registered practical nurses (LPN/RPNs). In contrast, unregulated care providers (UCPs) or unregulated health workers are paid employees who are not licensed or registered by a regulatory body, who have no legally defined scope of practice, for whom education or practice standards may or may not be mandatory, who provide care under the direct or indirect supervision of a nurse, and who are accountable for their own actions and decisions (CNA, 2015, p. 28). Some of the more common titles for UCPs include “health care aides,” “personal support workers,” “assistive personnel,” “care team assistants,” and “nursing aides.” Within Canada, nurses are granted the legal authority to use the designation “registered nurse” (RN) in accordance with provincial and territorial legislation and regulation. The provincial regulatory bodies set the standards for practice for RNs to protect the public in their province or territory (CNA, 2015). RN practice is defined by the CNA (2015) in the following way: RNs are self-­regulated health-­care professionals who work autonomously and in collaboration with others to enable individuals, families, groups, communities and populations to achieve their optimal levels of health. At all stages of life, in situations of health, illness, injury and disability, RNs deliver direct health-­care services, coordinate care and support clients in managing their own health. RNs contribute to the health-­care system through their leadership . . . in practice, education, administration, research and policy. (p. 5) Because RNs work with other regulated providers, as well as with UCPs, they must be aware of both their own and other providers’ scopes of practice. This is essential for safely enacting key nursing roles, such as delegation and prioritization and meeting the standards of practice. Standards of Practice.  A standard of practice and its guidelines describe nurses’ accountabilities to support the safe and ethical provision of care (CNO, 2019). Standards are intended to promote, guide, direct, and regulate professional nursing practice. Standards of practice demonstrate to the public, government, and other stakeholders that a profession is dedicated to maintaining public trust and upholding its professional practice criteria. Standards of practice are based on the values of the profession and articulated in the Code of Ethics for Registered Nurses (CNA, 2017). Provincial and territorial regulatory bodies for nursing are legally required to set standards for practice for RNs to protect the public. These standards, together with the Code of Ethics, form the foundation for nursing practice in Canada. Because of the rapid changes in resources, expectations, and technologies that characterize health care in Canada, nursing practice requires a commitment to lifelong learning to promote the highest quality of patient outcomes. Continuing competence refers to “the ongoing ability of a nurse to integrate and apply the knowledge, skills, judgement and personal attributes required to

FIG. 1.2  Advanced nursing practice (ANP) plays an important role in primary care delivery. Source: iStock.com/AnnaStills.

practice safely and ethically in a designated role and setting” (CNA/ Canadian Association of Schools of Nursing [CASN], 2004). RNs are initially prepared at the baccalaureate level (except in Quebec) and can pursue further studies at the graduate level. In the province of Quebec, RNs can also be diploma-prepared by receiving nursing education at a college or CEGEP. This diploma is recognized as eligibility to apply for registration with the provincial nursing body if all requirements have been met. Many nurses also seek recognition of their clinical expertise through certification in one of the 20 specialty areas of practice through the CNA (2021). Medical-­surgical nursing is one of the newer specialties to be recognized through the certification program.  Advanced Practice Nursing.  As Canada’s health care system changes, advanced practice nursing (APN) roles are also evolving to optimize patient care within the system. According to the Advanced Practice Nursing Pan-­Canadian Framework, advanced practice nursing “integrates graduate nursing education preparation with in-­depth, specialized clinical nursing knowledge and expertise in complex decision-­making to meet the health needs of individuals, families, groups, communities and populations” (CNA, 2019, p. 13). APN roles focus on health assessment, diagnosis, and treatment of conditions previously considered to be the physician’s domain (Figure 1.2). It involves analyzing and synthesizing knowledge; critiquing, interpreting and applying nursing theory; participating in and leading research; using advanced clinical competencies; and developing and accelerating nursing knowledge and the profession as a whole (CNA, 2019, p. 13). Examples of roles within APN in Canada include those of the clinical nurse specialist and the nurse practitioner. In addition to managing and delivering direct patient care, APN nurses have significant roles in health promotion, case management, administration, and research. There is substantial variation among the provinces and territories in the framework for and specific roles of nurses working in APN. Practice settings in which an APN nurse may be employed include primary and tertiary care, such as ambulatory care, long-­term care, hospital care, and community care. In the APN role, the nurse’s focus may be, for example, the management of primary care and health promotion for a wide variety of health issues in various specialties; activities include physical examination, diagnosis, treatment of health conditions, patient and family education, and counselling. In the management of complex patient care in various clinical specialty areas, the roles of APN may include direct care, consultation, research, education, case management, and administration.

CHAPTER 1  Introduction to Medical-Surgical Nursing Practice in Canada

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TABLE 1.4    INTERPROFESSIONAL TEAM MEMBERS Team Member

Description of Services Provided

Dietitian Occupational therapist (OT)

Provides general nutrition services, including dietary consultation about health promotion or specialized diets May help patient with fine motor coordination, performing activities of daily living, cognitive-­perceptual skills, sensory testing, and the construction or use of assistive or adaptive equipment Offers interdenominational spiritual support and guidance to patients and caregivers Prepares medications and infusion products Works with patients on improving strength and endurance, gait training, transfer training, and developing a patient education program Practises medicine and treats illness and injury by prescribing medication, performing diagnostic tests and evaluations, performing surgery, and providing other medical services and advice Diagnoses illness, orders and interprets diagnostic tests, prescribes medications and treatments, and performs specific procedures within their scope of practice Conducts physical exams, diagnoses and treats illnesses, and counsels on preventive health care in collaboration with a physician May provide oxygen therapy in the home, give specialized respiratory treatments, and teach the patient or caregiver about the proper use of respiratory equipment Assists patients with developing coping skills, meeting caregiver concerns, securing adequate financial resources or housing, or making referrals to social service or volunteer agencies Focuses on treatment of speech defects and disorders, especially by using physical exercises to strengthen muscles used in speech, speech drills, and audiovisual aids that develop new speech habits

Pastoral care Pharmacist Physiotherapist (PT) Physician (medical doctor [MD]) Nurse practitioner Physician assistant Respiratory therapist Social worker Speech pathologist

What Is Medical-­Surgical Nursing?  Medical-­surgical nursing is a challenging and dynamic type of nursing that involves caring for adults experiencing complex variations in health (Canadian Association of Medical and Surgical Nurses [CAMSN], 2020). Because the scope of medical-­surgical nursing is very broad, the nurse practising in this area is expected to acquire and maintain a great deal of knowledge and skill. This book provides the beginning nurse with much of the knowledge necessary to become a safe and competent practitioner. The medical-­surgical nurse is considered a leader and a key member of the interdisciplinary team. The medical-­surgical nurse’s primary responsibilities include prioritization, accountability, advocacy, organization, and coordination of evidence-­ informed care for multiple patients. Medical-­surgical patients and their caregivers come from diverse backgrounds and often possess multiple, complex illnesses; medical-­surgical nurses, therefore, must be knowledgeable and well prepared. Because of the rapidly changing and complex health concerns that may affect multiple body systems of medical-­surgical patients, safe and effective use of technology is an increasingly important competency required by these nurses. The effective medical-­ surgical nurse demonstrates adaptability and a strong commitment to ensuring the best possible patient outcomes. Medical-­ surgical nurses practise in diverse environments, ranging from outpatient and primary care environments through the continuum of care to tertiary care hospitals (CNA, 2015). As the largest group of nursing professionals in Canada (CAMSN, 2020), they utilize a broad range of evidence-­informed knowledge and clinical skills to address acutely ill adults’ and their families’ needs. The Canadian Association of Medical and Surgical Nurses (CAMSN) is a national organization that promotes excellence through best-practice standards to provide high-­quality, safe, and ethical care to patients across the continuum of care. RNs may choose to seek recognition of their expertise in this specialty through post-­licensure certification offered by the CNA. 

Teamwork and Interprofessional Collaboration Interprofessional Teams.  To deliver high-­quality care, nurses need to have effective working relationships with the health care team members. Supporting patients to achieve optimal health, nurses collaborate with a wide range of professionals, including

pharmacists, physicians, occupational therapists, physiotherapists, and social workers (Table 1.4). Successful collaboration with other health care providers has become a cornerstone of nursing practice. To be competent in interprofessional practice, nurses must collaborate in many ways by exchanging knowledge, sharing responsibility for problem-­solving, and making patient care decisions. Nurses are often responsible for coordinating care among the team members, taking part in interprofessional team meetings or rounds, and making referrals when expertise is needed in specialized areas to help the patient. To do so, nurses must be aware of other team members’ knowledge and skills and be able to communicate effectively with them. In the position statement Interprofessional Collaboration, the CNA (2012) recognized the growing importance of interprofessional collaboration in improving patient-­centred access to health care in Canada. The Registered Nurses’ Association of Ontario (RNAO, 2013) described a conceptual model for developing and sustaining interprofessional health care whereby outstanding interprofessional care is a result of health care teams demonstrating expertise in six key domains: care expertise; shared power; collaborative leadership; optimizing profession, role, and scope; shared decision making; and effective group functioning (RNAO, 2013). Nurses function in independent, dependent, and collaborative roles. Each province and territory has a Nurses’ Act that determines the scope of practice for that region. These acts allow nurses to take on delegated medical responsibilities and have a wider scope of practice when working as nurse practitioners.  Communication Among Health Care Team Members.  Effective communication is a key component of fostering teamwork and coordinating care. To provide safe, effective care, everyone involved in a patient’s care should understand the patient’s condition and needs. Unfortunately, many issues result from a breakdown in communication. Miscommunication often occurs during transitions of care. One structured model used to improve communication is the SBAR (situation, background, assessment, and recommendation) technique (Table 1.5). This technique provides a way for the health care team members to talk about a patient’s condition in a predictable, structured manner. Other ways to enhance communication during transitions include

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SECTION 1  Concepts in Nursing Practice

TABLE 1.5    GUIDELINES FOR COMMUNICATION USING SBAR Purpose: SBAR is a model for effective transfer of information by providing a standard structure for concise factual communications from nurse to nurse, nurse to physician, or nurse to other health professionals. Steps to Use: Before speaking with a health care provider about a patient issue, assess the patient yourself, read the most recent physician progress and nursing notes, and have the patient’s chart available. Situation

• What is the situation you want to discuss? What is happening right now? • Identify self, unit. State: I am calling about: patient, room number. • Briefly state the challenge: what it is, when it happened or started, and how severe it is. State: I have just assessed the patient and am concerned about: • Describe why you are concerned. • What is the background or what are the circumstances leading up to the situation? State pertinent background information related to the situation that may include: • Admitting diagnosis and date of admission • List of current medications, allergies, intravenous (IV) fluids • Most recent vital signs • Date and time of any laboratory testing and results of previous tests for comparison • Synopsis of treatment to date • Code status • What do you think the issue is? What is your assessment of the situation? State what you think the issue is: • Changes from prior assessments • Patient condition unstable or worsening • What should we do to correct the problem? What is your recommendation or request? State your request. • Specific treatments • Tests needed • Patient needs to be seen now

Background

Assessment

Recommendation/Request

Source: Adapted from SBAR Tool: Situation-­Background-­Assessment-­Recommendation, developed by Kaiser Permanente, sourced from www.IHI.org with permission of the Institute for Healthcare Improvement, ©2021.

TABLE 1.6    RIGHTS OF DELEGATION The Five Rights of Delegation The registered nurse uses critical thinking and professional judgement to be sure that the delegation or assignment is: 1. The right task 2. Under the right circumstances 3. To the right person 4. With the right directions and communication 5. Under the right supervision and evaluation

Rights of Delegation

Description

Questions to Ask

Right Task

One that can be delegated for a specific patient

Right Circumstances

Right Directions and Communication

Appropriate patient setting, available resources, and considering relevant factors, including patient stability Right person is delegating the right task to the right person to be performed on the right person Clear, concise description of task, including its objective, limits, and expectations

Right Supervision and Evaluation

Appropriate monitoring, evaluation, intervention, and feedback

Is it appropriate to delegate based on legal and facility factors? Has the person been trained and evaluated in performing the task? Is the person able and willing to do this specific task? What are the patient’s needs right now? Is staffing such that the circumstances support delegation strategies? Is the prospective delegatee a willing and able employee? Are the patient needs a “fit” with the delegatee? Have you given clear communication about the task? With directions, limits, and expected outcomes? Does the delegatee know what and when to report? Does the delegatee understand what needs to be done? Do you know how and when you will interact about patient care with the delegatee? How often do you need to directly observe? Will you be able to give feedback to the staff member if needed?

Right Person

Source: National Council of State Boards of Nursing, Inc. (NCSBN). (2015). National guidelines for nursing delegation. https://www.ncsbn.org/1625.htm

performing surgical time-­outs, standardizing the change-­of-­shift process, and conducting interprofessional rounds to identify risks and develop a plan for delivering care.  Delegation and Assignment.  Nurses delegate nursing care and supervise other staff members who are qualified to deliver care. Delegation is “a formal process through which a regulated health professional (delegator) who has the authority and competence to perform a procedure under one of the controlled acts delegates the performance of that procedure to another individual (delegatee)” (CNO, 2020). The delegation and assignment of nursing activities is a process that, when used appropriately, can

result in safe, effective, and efficient patient care. Delegation typically involves tasks and procedures that UCPs perform. The activities that UCPs perform include feeding and assisting patients at mealtimes, helping stable patients ambulate, and assisting patients with bathing and hygiene. Nursing interventions that require independent nursing knowledge, skill, or judgement (e.g., initial assessment, determining nursing diagnoses, patient teaching, evaluating care) are the nurse’s responsibility and cannot be delegated. Nurses need to use professional judgement and follow the Five Rights of Delegation (Table 1.6) to determine appropriate activities to delegate based on the

CHAPTER 1  Introduction to Medical-Surgical Nursing Practice in Canada patient’s needs. The most common delegated nursing actions occur during the implementation phase of the nursing process and are for patients who are stable with predictable outcomes. For example, the nurse might delegate measuring oral intake and urine output to a UCP, but the nurse uses nursing judgement to decide whether the intake and output are adequate. Delegation is patient-­specific, and the UCP can perform the delegated task for only a particular patient. Assignment is different from delegation. Assignment involves the “allocation of nursing care among providers in order to meet patient care needs” (Nurses Association of New Brunswick/Association of New Brunswick Licensed Practical Nurses, 2015, p. 10). The RN can only assign team members (LPN/UCP) activities that are within the team member’s scope of practice. For example, the nurse can assign an LPN/RPN to give a patient medication because it is within their scope of practice. The RN or LPN/RPN cannot assign a UCP to perform a complex dressing change as assessment of the wound, a task when performing dressing changes, is not within their scope of practice. Whether nurses delegate or are working with staff to whom they assign tasks, they are responsible for the patient’s total care during their work period. Nurses are responsible for supervising the UCP who is caring for their patient. It is important to clearly communicate what tasks must be done and to provide necessary guidance. Nurses are accountable for ensuring that delegated tasks are completed competently. This supervision includes evaluation and follow-­up as needed by the nurse. Delegation is a skill that is learned and must be practised to attain proficiency in managing patient care, and it requires the use of critical thinking and professional judgement. 

Informatics and Technology Rapidly changing technologies and dramatically expanding knowledge in the fields of arts and science affect all areas of health care. In telemedicine, telehealth, and telenursing, virtual technologies are used to provide professional education, consultation, and delivery of patient services. Telehomecare (digital health) is the delivery of health care and information through digital technologies, including high-­speed Internet, wireless, satellite, and video communications. Among the many uses of telehealth are triaging patients, monitoring patients with chronic or critical conditions, helping patients manage symptoms, providing patient and caregiver education and emotional support, and providing follow-­ up care (CMA, 2019). Telehomecare can increase access to care. The nurse engaged in telehealth can assess the patient’s health status, deliver interventions, and evaluate the outcomes of nursing care while separated geographically from the patient. Nursing Informatics.  Nursing informatics is a rapidly growing specialty in nursing. Nursing informatics refers to the integration of nursing science, computer science, and information technology to manage and communicate data, information, and knowledge in nursing practice (RNAO, 2012). Nursing is an information-­intense profession. Advances in informatics and technology have changed the way that nurses plan, deliver, document, and evaluate care. All nurses, regardless of their setting or role, use informatics and technology every day in practice. Informatics has changed how nurses obtain and review diagnostic information, make clinical decisions, communicate with patients and health care team members, and document and provide care.

9

Technology advances have increased the efficiency of nursing care, improving the work environment and the care that nurses provide. Computers and mobile devices enable nurses to document at the time they deliver care and give them quick and easy access to information, including clinical decision-­making tools, patient education materials, and references. Texting, video chat, and email enhance communication among health care team members and help them deliver the right message to the right person at the right time. Technology plays a key role in providing safe, quality patient care. Medication administration applications improve patient safety by flagging potential errors, such as look-­ alike and sound-­alike medications and adverse drug interactions, before they can occur. Computerized provider order entry (CPOE) systems can eliminate errors caused by misreading or misinterpreting handwritten orders. Sensor technology can decrease the number of falls by patients at high risk for falls. Care reminder systems provide cues that decrease the amount of missed nursing care. The ability to use technology skills to communicate and access information is now an essential component of professional nursing practice. Nurses must be able to use word processing software, communicate by email and messaging, access appropriate information, and follow security and confidentiality rules. They need to demonstrate the skills to safely use patient care technologies and navigate electronic documentation systems. The CASN (2012) has outlined three entry-­to-­practice competencies related to nursing informatics: (1) use of relevant information and knowledge to support the delivery of evidence-­ informed patient care; (2) use of ICTs in accordance with professional and regulatory standards and workplace policies; and (3) use of ICTs in the delivery of patient care (pp. 6–10). These nursing informatics competencies are considered the minimum knowledge and skills that new graduate nurses require to practise nursing. Throughout this book, Informatics in Practice boxes such as the one below offer suggestions for nurses on how to make information technology part of good nursing practice.

INFORMATICS IN PRACTICE Responsible Use of Social Media A nurse wants to post pictures (or videos) of himself and his nursing colleagues from the hospital. • Before sharing anything on social media, the nurse should ensure that the posts do not negatively reflect the nursing profession, workplace, self, or colleagues as health care providers. • The nurse should ensure that posts do not cause a breach of confidentiality and privacy for patients, colleagues, or the workplace. • The nurse should know and follow employer policies on using social media in the workplace.

Nurses have an obligation to ensure the privacy of their patients’ health information. To do so, it is necessary to understand their hospital’s policies regarding the use of technology. Nurses need to know the rules regarding accessing patient records and releasing personal health information, what to do if the information is accidentally or intentionally released, and how to protect any passwords they use. If nurses are using social media, they must be careful not to place online any personal health information that is individually identifiable and must adhere to certain principles in order to reduce risks to members

10

SECTION 1  Concepts in Nursing Practice

TABLE 1.7    6 PS OF SOCIAL MEDIA USE Professional: Act professionally at all times Positive: Keep posts positive Patient/Person-­free: Keep posts patient-­ or person-­free Protect yourself: Protect your professionalism, your reputation, and yourself Privacy: Keep your personal and professional life separate; respect privacy of others Pause before you post: Consider implications; avoid posting in haste or anger Source: International Nurse Regulator Collaborative. (2016). Social media use: Common expectations for nurses. http://www.cno.org/globalassets/docs/prac/incr-­social-­media-­ use-­common-­expectations-­for-­nurses.pdf

of the public (Table 1.7). They must also be guided by their professional code of conduct and standards of practice.  Electronic Health Records.  Informatics is most widely used in electronic health records (EHRs), also called electronic medical records. An EHR is a computerized record of patient information. It is shared among all health care team members involved in a patient’s care and moves with the patient—to other providers and across care settings. The ideal EHR is a single file in which team members review and update a patient’s health record, document care given, and enter patient care orders, including medications, procedures, diets, and results of diagnostic and laboratory tests. The EHR should contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, and test results. Many agencies have adopted electronic documentation. EHRs and the Canadian Health Outcomes for Better Information and Care (C-­HOBIC) project are examples of electronic collection of health care data, and they are being implemented across many parts of Canada (C-­HOBIC, 2015). The EHR integrates the output of several information systems. Canada has developed systems that form the essential building blocks of an EHR, such as digital imaging, summaries of drug prescriptions, and laboratory test results. Provinces and territories across Canada are working together with Canada Health Infoway to accelerate the development of these systems through programs such as PrescribeIT, an e-­prescribing service, and ACCESS Digital Health, which links patients and their health care providers with access to personal health information and digital health services (Canadian Health Infoway, 2020). EHRs can reduce medical errors associated with traditional paper records and improve clinical decision making, patient safety, and quality of care. Unfortunately, several obstacles remain in the way of fully implementing EHRs. Systems are expensive and technologically complex, and a number of resources are needed to implement and maintain them. Communication is still lacking among computer systems and software applications in use. Finally, patients must be assured of their privacy and that information is accessed only by members of their care team with a right to know. 

Critical Thinking in Nursing To provide high-­quality care in clinical environments of increasing complexity and greater accountability, nurses need to develop higher-­level thinking and reasoning skills. Critical thinking, the ability to focus one’s thinking to get the results needed in various situations, has been described as knowing how to learn, be creative, generate ideas, make decisions, and solve problems (Alfaro-­LeFevre, 2017). Critical thinking is not memorizing a list of facts or the steps of a procedure. Instead, it is the ability to make

TABLE 1.8    COMPARISON OF THE NURSING

PROCESS WITH TANNER’S CLINICAL JUDGEMENT MODEL AND THE NCSBN MODEL OF CLINICAL JUDGEMENT

Nursing Process (AAPIE)

Tanner’s Clinical Judgement Model

NCSBN Model of Clinical Judgement

Assessment Analysis Analysis Planning Implementation Evaluation

Noticing Interpreting Interpreting Responding Responding Reflecting

Recognize cues Analyze cues Prioritize hypothesis Generate solutions Take action Evaluate outcomes

Source: Ignatavicius, D. (2020). Getting ready for the Next-­Generation NCLEX® (NGN): Transitioning from the nursing process to clinical judgment. https://evolve.elsevier.com /education/expertise/next-­generation-­nclex/ngn-­transitioning-­from-­the-­nursing-­process-­ to-­clinical-­judgment/

judgements and solve problems by making sense of information. Learning and using critical thinking is a continual process that occurs inside and outside of the clinical setting. Clinical reasoning involves critical thinking to examine and analyze patient care issues at the point of care (Alfaro-­LeFevre, 2017). It involves understanding the medical and nursing implications of a patient’s situation when decisions regarding patient care are made. Nurses use clinical reasoning when they identify a change in a patient’s status, take into account the context and concerns of the patient and caregiver, and decide what to do about it. Clinical judgement is a problem-­solving activity in which nurses use critical thinking to apply knowledge, attitudes, and values using both inductive and deductive reasoning (Chin-­Yee & Upshur, 2018; Van Graan et al., 2016). It closely aligns to the nursing process and is a core competency of safe nursing care. The Tanner’s Clinical Judgement Model and the NCSBN Model of Clinical Judgement are two established paradigms fundamental to nursing. See Table 1.8. Given the complexity of patient care today, nurses are required to learn and implement critical thinking and clinical reasoning skills long before they obtain those skills through the experience of professional practice. Various experiences in nursing school offer opportunities for students to learn and make decisions about patient care. Various education activities, including interactive case studies and simulation exercises, promote critical thinking and clinical reasoning. Throughout this book, select boxes, case studies, and review questions promote critical thinking and clinical reasoning skills. 

Evidence-­Informed Practice Evidence-­informed nursing is a problem-­solving approach to clinical decision making. The CNA defines evidence-­informed decision making as “an ongoing process that incorporates evidence from research findings, clinical expertise, client preferences and other available resources to inform decisions that nurses make about clients” (CNA, 2018, p. 1). Using the best available evidence (e.g., research findings, QI data), combined with nursing expertise and the patient’s unique circumstances and preferences, leads to better clinical decisions and improved patient outcomes. Evidence-­informed practice (EIP) closes the gap between research and practice, providing more reliable and predictable care than that based on tradition, opinion, and trial and error. Basing health care decisions on evidence is essential for quality care in all domains of nursing practice.

CHAPTER 1  Introduction to Medical-Surgical Nursing Practice in Canada

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Clinical issue of interest

Patient preferences and actions

Clinical state, setting, and circumstances

Formulate a searchable, answerable question

Streamlined, focused search

Rapid critical appraisal

CLINICAL EXPERTISE Apply valid, relevant evidence

Research evidence

Generate evidence Internal: • Outcome management • Quality improvement External: • Research

Health care resources Evaluate outcomes based on evidence

FIG. 1.3  A model for evidence-­informed clinical decisions. Source: Adapted

by DiCenso, A., Guyatt, G., & Ciliska, D. (2005). In Haynes, R. B., Devereaux, P. J., & Guyatt, G. (2002). Clinical expertise in the area of evidence-­based medicine and patient choice. BMJ Evidence-­Based Medicine, 7(2), 36–38. Copyright © 2002, British Medical Journal.

Four primary elements contribute to the practice of evidence-­ informed nursing: (1) clinical state, setting, and circumstances; (2) patient preferences and actions; (3) best research evidence; and (4) health care resources (Figure 1.3). Clinical expertise, in which these four components are integrated, is the nurse’s “ability to integrate their accumulated knowledge from patient care experiences, formal education, and current evidence to make clinical decisions” (Abraham-­Settles & Williams, 2019, p. 100). It refers to the nurse’s cumulated experience, education, and clinical skills. EIP produces better outcomes in the most effective and efficient way. Application of EIP results in more accurate diagnoses, the most effective and efficient interventions, and the most favourable patient outcomes. EIP’s most distinguishing feature is that the new scientific base for practice is built through a summary of studies on a topic. These summaries are called evidence syntheses, systematic reviews, or integrative reviews, depending on the organization that produces them. The evidence synthesis summarizes all research results into a single conclusion about the state of the science. From this point, the clinician translates the knowledge into a clinical practice guideline, implements it through individual and organizational practice changes, and evaluates it in terms of the effectiveness and efficiency of producing intended health care outcomes (Figure 1.4). Clinical practice guidelines can take the form of policies, clinical pathways, practice guidelines, policy statements, computer-­based policies, or algorithms. Best-practice guidelines are increasingly used to guide clinical practice in health care. Such guidelines are “systematically developed statements based on best available evidence to assist practitioners’ and patients’ decisions about appropriate health care” (RNAO, n.d.). Examples of the current best-practice guidelines include Adult Asthma Care Guidelines for Nurses: Promoting Control of Asthma (RNAO, 2017); A Palliative Approach to

FIG. 1.4  Process of evidence-­informed practice.

TABLE 1.9    STEPS OF THE EVIDENCE-­INFORMED

PRACTICE PROCESS

1. Ask clinical questions by using the PICOT format: Patients/population of interest Intervention Comparison or comparison group Outcome(s) Time period (as applicable) 2. Collect the most relevant and best evidence. 3. Critically appraise and synthesize the evidence. 4. Integrate all evidence with your clinical expertise and the patient’s preferences and values in making a practice decision or change. 5. Evaluate the practice decision or change. 6. Share the outcomes of the decision or change.

Care in the Last 12 Months of Life (RNAO, 2020); Person-­ and Family-­Centred Care (RNAO, 2015); and Preventing Violence, Harassment and Bullying Against Health Workers (RNAO, 2019). Throughout this book, two different types of EvidenceInformed Practice boxes are available for selected topics. Research Highlight boxes provide answers to specific clinical questions. These boxes contain the PICOT (patients/population of interest, intervention, comparison or comparative group, outcome[s], and time period as applicable) question (Table 1.9); critical appraisal of the syntheses of evidence or primary studies; implications for nursing practice; and the source of the evidence. Translating Research Into Practice boxes provide an opportunity to practise critical thinking skills in applying evidence to patient scenarios. Evidence can support current practice and increase confidence that nursing care will continue to produce the desired outcome, or evidence may necessitate a change in practice. Steps in the Evidence-­Informed Practice Process.  The six steps of the EIP process are provided in Table 1.9 and Figure 1.4. Step 1.  Step 1 is to ask a clinical question in the PICOT format. Developing the clinical question is the most important step in the EIP process (Melynk et al., 2016). A good clinical question sets the context for integrating evidence, clinical judgement,

12

SECTION 1  Concepts in Nursing Practice

and patient preferences. In addition, the question guides the literature search for the best evidence to influence practice. An example of a clinical question in PICOT format is “In adult patients undergoing abdominal surgery (patients/population), is splinting with an elasticized abdominal binder (intervention) or a pillow (comparison) more effective in reducing pain associated with ambulation (outcome) on the first postoperative day (time period)?” A properly stated clinical question may not have all components of PICOT; some include only four components. The (T) timing or (C) comparison component may not be appropriate for a particular question.  Step 2.  Step 2 is to search for the best evidence in the literature. The question directs the clinician to the most appropriate databases. The search begins with the strongest external evidence to answer the question. Preappraised evidence tools, such as systematic reviews and evidence-­informed guidelines, are appropriate time-­saving resources in the EIP process. Systematic reviews of randomized controlled trials are considered the strongest level of evidence to answer questions about interventions (i.e., cause and effect). However, a limited number of systematic reviews are available to answer the many clinical questions. In addition, systematic reviews or meta-­analyses may not always provide the most appropriate answers to all clinically meaningful questions. If the clinical question is about how a patient experiences or copes with a health issue or lifestyle change, searching for a meta-­synthesis of qualitative evidence may be the most appropriate approach. When research is insufficient to guide practice, evidence from opinion leaders or authorities or reports from expert committees may be all that exists. This type of evidence should not be the sole substantiation for interventions. Care based on expert opinions requires diligent, ongoing, rigorous outcome evaluation to generate more robust evidence.  Step 3.  Step 3 is to critically appraise and synthesize the data from studies found in the search. A successful critical appraisal process focuses on three essential questions: (1) Are the results of the study valid? (2) What are the results? (3) Are the findings clinically relevant to the clinician’s patients? The purpose of critical appraisal is to determine the flaws of a study and the value of the research to practice. To determine best practice, clinicians must determine the strength of the evidence and synthesize the findings in relation to the clinical question.  Step 4.  Step 4 involves implementing the evidence in practice. Recommendations that are based on sufficient, strong evidence (e.g., interventions with systematic reviews of well-­ designed randomized controlled trials) can be implemented in practice in combination with clinicians’ expertise and patient preferences. Clinical judgement will influence how patient preferences and values are assessed, integrated, and entered into the decision-­making process. For example, although evidence may support the effectiveness of morphine as an analgesic, its use in a patient with renal failure may not be appropriate.  Step 5.  Step 5 is to evaluate identified outcomes in the clinical setting. Outcomes must match the clinical project that has been implemented. For example, when the effectiveness of morphine for pain control is compared with that of fentanyl, evaluating the cost of each medication will not provide the required data about clinical effectiveness. Outcomes must reflect all aspects of implementation and capture the interdisciplinary contributions elicited by the EIP process.  Step 6.  Step 6 is to share the outcomes of the EIP change. If nurses performing research do not share EIP outcomes, then

other health care providers and patients cannot benefit from what they learned from their experience. Information is shared locally through unit-­or hospital-­based newsletters and posters and regionally and nationally through journal publications and presentations at conferences.  Implementation of Evidence-­Informed Practice.  To implement EIP, nurses need to continuously seek scientific evidence that supports the care that they provide. The incorporation of evidence should be balanced with clinical expertise and each patient’s unique circumstances and preferences. EIP closes the gap between research and practice, resulting in care that produces more reliable and predictable outcomes than does care that is based on tradition, opinion, and a trial-­and-­error method. EIP provides nurses with a mechanism to manage the explosion of new literature, introduce new technologies, concern about health care costs, and increase emphasis on quality care and patient outcomes. In collaboration with the First Nations and Inuit Health Branch of Health Canada, the CNA launched a Web-­based portal for nurses called myCNA (see the Resources section at the end of this chapter). The portal provides opportunities for nurses to access libraries and information related to EIP and clinical practice issues through a dedicated Web-­based portal. 

THE NURSING PROCESS Nurses provide patient-­centred care using an organizing framework called the nursing process. The nursing process is an assertive, problem-­solving approach to the identification and treatment of patient health issues. It provides a nursing process framework to organize the knowledge, judgements, and actions that nurses supply during patient care. Using the nursing process, the nurse can focus on patients’ unique responses to actual or potential health issues.

Phases of the Nursing Process The nursing process consists of five phases: assessment, diagnosis, planning, implementation, and evaluation (Figure 1.5). There is a basic order to the nursing process, beginning with the assessment. Assessment involves collecting subjective and objective information about the patient. Diagnosis involves analyzing the assessment data, drawing conclusions from the information, and labelling the human response. Planning consists of setting goals and expected outcomes with the patient and, when feasible, the patient’s family and determining strategies

Implementation 1. Nurse-initiated 2. Physician-initiated 3. Collaborative

Planning 1. Priorities 2. Nursing care plan: • Outcomes • Interventions

Evaluation 1. Outcomes met? 2. If not, re-evaluate: • Data • Diagnosis • Etiologies • Outcomes • Interventions

Assessment 1. Subjective data 2. Objective data

Diagnosis 1. Data analysis 2. Problem identification 3. Nursing diagnosis

FIG. 1.5  The nursing process.

CHAPTER 1  Introduction to Medical-Surgical Nursing Practice in Canada for accomplishing the goals. Implementation involves the use of nursing interventions to activate the plan. The nurse also promotes self-­care and family involvement when appropriate. Evaluation is an extremely important part of the nursing process that is too often not addressed sufficiently. In the evaluation phase, the nurse first determines whether the identified outcomes have been met. Then the overall accuracy of the assessment, diagnosis, and implementation phases is evaluated. If the outcomes have not been met, new approaches are considered and implemented as the process is repeated. 

Interrelatedness of Phases The five phases of the nursing process do not occur in isolation from one another. For example, nurses may gather data about the wound condition (assessment) as they change the soiled dressing (implementation). There is, however, a basic order to the nursing process, which begins with assessment. Assessment provides the data on which planning is based. An evaluation of the nature of the assessment data usually follows immediately, resulting in the formulation of a diagnosis. A plan based on the nursing diagnosis then directs the implementation of nursing interventions. Evaluation continues throughout the cycle and provides feedback on the effectiveness of the plan or the need for revision. Revision may be needed in the data collection method, the diagnosis, the expected outcomes or goals, the plan, or the intervention method. Once initiated, the nursing process is not only continuous but also cyclical in nature. Assessment Phase Data Collection.  Sound data form the foundation for the entire nursing process. Collection of data is a prerequisite for diagnosis, planning, and intervention (Figure 1.6). Humans have needs and problems in biophysical, psychological, sociocultural, spiritual, and environmental domains. A nursing diagnosis made without supporting data pertaining to all of these dimensions can lead to incorrect conclusions and depersonalized care. For example, if a hospitalized patient does not sleep all night, a disturbed sleep pattern may be mistakenly diagnosed, whereas the patient may have worked nights her entire adult life, and it is normal for her to be awake at night. Information concerning her sleeping habits is necessary to provide individualized care to her by ensuring that sleep medication is not routinely administered to her at 2200 hours. The importance of person-­centred assessment in the process of clinical decision making cannot be overemphasized.

FIG. 1.6  Collection of data is a prerequisite for diagnosis, planning, and intervention. Source: iStock.com/IPGGutenbergUKLtd.

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Because nursing interventions are only as sound as the data on which they are based, the database must be accurate and complete. When possible, collateral information obtained from sources such as the patient’s record, other health care workers, the patient’s family, and the nurse’s observations should be validated with the patient. If the patient’s statements seem questionable, they should be validated by a knowledgeable person.  Diagnosis Phase

Data Analysis and Problem Identification.  The diagnosis phase

begins with clustering of information and, after analysis of the assessment data, ends with an evaluative judgement about a patient’s health status. Analysis involves sorting through and organizing the information and determining unmet needs, as well as the strengths, of the patient. The findings are then compared with documented norms to determine whether anything is interfering or could interfere with the patient’s needs or ability to maintain their usual health pattern. After a thorough analysis of all available information, one of two possible conclusions is reached: (1) the patient has no health conditions that necessitate nursing intervention or (2) the patient needs nursing assistance to solve a potential or actual health problem.  Nursing Diagnosis.  The term nursing diagnosis has many different meanings. To some, it merely connotes the identification of a health issue. More commonly, a nursing diagnosis is viewed as the conclusion about an identified cluster of signs and symptoms. The diagnosis is generally expressed as concisely as possible according to specific policies. Nursing diagnosis is the act of identifying and labelling human responses to actual or potential health issues. Throughout this book, the term nursing diagnosis means (1) the process of identifying actual and potential health problems and (2) the label or concise statement that describes a clinical judgement concerning a human response to health conditions/life processes, or susceptibility for that response, by an individual, family, group or community. A nursing diagnosis supports the identification and prioritization of nursing interventions to achieve optimal patient outcomes. Many human responses identified result from a disease process. For example, a patient may have a medical diagnosis of pancreatitis. In this case, the nursing diagnosis would focus on how the illness affects the patient’s current health status. Examples of patient responses to pancreatitis might be ineffective breathing pattern, deficit fluid volume, nausea, imbalanced nutrition, and ineffective health maintenance.  Diagnostic Process.  The diagnostic process involves analysis and synthesis of the data collected during assessment of the patient. Data that indicate dysfunctional or risk patterns are clustered, and a judgement about the data is made. It is important to remember that not all conclusions resulting from data analysis lead to nursing diagnoses. Nursing diagnoses refer to health states that nurses can legally diagnose and treat. Data may also point to health conditions that nurses treat collaboratively with other health care providers. During this phase of the nursing process, the nurse identifies both nursing diagnoses and treatments that necessitate collaborative nursing intervention. Nursing diagnostic statements are considered acceptable when written as two-­or three-­part statements. When written in three parts, the statement is in the PES (problem, etiology, and signs

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SECTION 1  Concepts in Nursing Practice

and symptoms) format. A two-­part statement is deemed acceptable if the signs and symptoms data are easily available to other nurses caring for the patient through the nursing history or progress notes. “Risk” nursing diagnoses are also two-­part statements because signs and symptoms are not relevant. Use of a three-­part statement is recommended during the learning process: Problem (P): A brief statement of the patient’s potential or actual health issue (e.g., pain) Etiology (E): A brief description of the probable cause of the issue; contributing or related factors (e.g., resulting from surgical incision, localized pressure, edema) Signs and symptoms (S): A list of the objective and subjective data cluster that leads the nurse to pinpoint the health issue; critical, major, or minor defining characteristics (e.g., as evidenced by verbalization of pain, isolation, withdrawal) It is important to remember that gathering the “S” comes first in the diagnostic process, even though it is last in the PES statement format. Identifying the Problem.  The NANDA International (NANDA-­I; formerly known as the North American Nursing Diagnosis Association) classification system is one framework that is useful for formulating actual nursing diagnoses and at-­ risk diagnoses. Clinically relevant cues are clustered into functional health patterns based on Gordon’s (2014) 11 functional health patterns: health perception–health management pattern; nutritional–metabolic pattern; elimination pattern; activity–exercise pattern; sleep–rest pattern; cognitive–­perceptual pattern; self-­ perception–self-­ concept pattern; role–relationship pattern; sexuality–reproductive pattern; coping–stress tolerance pattern; and value–belief pattern. The process of making a nursing diagnosis from clustered cues begins with the recognition of dysfunctional patterns. Checking the definition of nursing diagnoses classified according to the functional pattern helps identify the problem’s appropriate label. The nursing diagnosis deemed most accurate is based on the individual patient’s data.  Etiology.  The etiology underlying a nursing diagnosis is identified in the diagnostic statement. Taking time to properly link the health issue with its etiology directs the nurse to the

correct interventions. Interventions to manage the issue are planned by directing nursing efforts toward the etiology. The etiology can be a pathophysiological, maturational, situational, or treatment-­related factor (Ladwig, Ackley, & Makic, 2019). The etiology is written after the diagnostic label. These two components are separated by the phrase “related to.” For example, in Nursing Care Plan 1.1, the nursing diagnosis is “Activity intolerance caused by an imbalance between oxygen supply/demand.” The etiology directs the nurse to select the appropriate interventions to modify the factor of fatigue. When the etiology is not included in the diagnosis, the nurse cannot plan the correct intervention to treat the specific cause of the condition. When possible, the etiology should be validated with the patient. When the etiology is unknown, the statement reads “related to unknown etiology.” When identifying “risk for” nursing diagnoses, the specific risk factors present in the patient’s situation are identified as the etiology, and the phrase “as evidenced by” is used rather than “related to.”  Signs and Symptoms.  Signs and symptoms are the clinical cues that, in a cluster, point to the nursing diagnosis. The signs and symptoms are often included in the diagnostic statement after the phrase “as evidenced by.” The complete nursing diagnostic statement in Nursing Care Plan 1.1 is “Activity intolerance caused by an imbalance between oxygen supply/demand resulting in an abnormal heart rate response to activity, exertional dyspnea, and fatigue.” Throughout this book, nursing diagnoses are listed for many diseases and patient situations. These diagnoses sometimes include additional explanatory material in parentheses.  Collaborative Problems.  Collaborative problems are potential or actual complications of disease or treatment that nurses manage together with other health care providers. A look at the primary nursing goals helps differentiate between nursing and medical diagnoses (see Table 1.4). A medical diagnosis identifies current symptoms associated with a disease to predict the disease course and modify outcomes. A nursing diagnosis involves a clinical judgement about an individual, family, or community response to an actual or potential health issue (Chiffi & Zanotti, 2015). During the nursing process diagnosis phase, the nurse identifies the risks for these physiological

NURSING CARE PLAN 1.1 Heart Failure* NURSING DIAGNOSIS

Activity intolerance caused by an imbalance between oxygen supply/demand resulting in an abnormal heart rate response to activity, exertional dyspnea, and fatigue

Expected Patient Outcomes

Nursing Interventions and Rationales

• Achieves a realistic program of activity that balances physical activity with energy-­conserving activities • Vital signs, O2 saturation, and colour are within normal limits in response to activity

Energy Management • Encourage alternate rest and activity periods to reduce cardiac workload and conserve energy. • Provide calming diversionary activities to promote relaxation to reduce O2 consumption and to relieve dyspnea and fatigue. • Monitor patient’s oxygen response (e.g., pulse rate, cardiac rhythm, colour, O2 saturation, and respiratory rate) to self-­care or nursing activities to determine level of activity that can be performed. • Teach patient and caregiver techniques of self-­care to minimize O2 consumption (e.g., self-­monitoring and pacing techniques for performance of ADLs).

Activity Therapy • Collaborate with occupational therapist, physiotherapist, or both to plan and monitor activity and exercise program. • Determine patient’s commitment to increasing frequency or range of activities, or both, to provide patient with obtainable goals. ADLs, activities of daily living. *The complete nursing care plan for heart failure is provided in Nursing Care Plan 37.1 in Chapter 37.

CHAPTER 1  Introduction to Medical-Surgical Nursing Practice in Canada complications in addition to nursing diagnoses. Identification of collaborative problems requires knowledge of pathophysiology and possible complications of medical treatment. For example, collaborative problems with heart failure described in Nursing Care Plan 1.1 could include pulmonary edema, hypoxemia, dysrhythmias, cardiogenic shock, or a combination of these. In the interdependent role, nurses use both physician-­prescribed and nursing-­prescribed interventions to prevent, detect, and manage collaborative problems. Collaborative problem statements are usually written as “potential complication: _____” (e.g., “potential complication: pulmonary edema”) without a “related to” statement. When potential complications are used in this textbook, “related to” statements have been added to increase understanding and link the potential complication to possible causes.  Planning Phase

Priority Setting.  After the nursing diagnoses and collaborative

problems are identified, the nurse must determine the urgency of the identified problems, with actual problems being prioritized over potential problems. Diagnoses of the highest priority necessitate immediate intervention. Those of lower priority can be addressed later. When setting priorities, the nurse should first intervene for life-­threatening conditions involving airway, breathing, or circulation issues. Maslow’s (1954) hierarchy of needs also acts as a useful guide in determining priorities. These needs include the physical needs; safety, love, and belonging; esteem; and self-­actualization. Lower-­level needs must be satisfied before a higher level can be addressed. Another guideline in setting priorities is to determine the patient’s perception of what is important. When the patient’s priorities are not congruent with the actual situation, the nurse may have to give explanations or do some teaching to help the patient understand the need to do one thing before another. Often it is more efficient to meet the need that the patient deems a priority before moving on to other priorities.  Identifying Outcomes.  After priorities are established, expected outcomes or goals for the patient are identified. Outcomes are simply the results of care. Expected patient outcomes are goals that articulate what is desired or expected as a result of care. The terms goals and expected outcomes are often used interchangeably: Both terms describe the degree to which the patient’s response, as identified in the nursing diagnosis, should be prevented or changed as a result of nursing care. Expected outcomes should be agreed on with the patient, if feasible, just as priorities of interventions are considered with the patient when possible. Goals are often developed using the SMART algorithm: S–smart; M–measurable; A–achievable; R–realistic; and T–timely. Although the ultimate goal for the patient is to maintain or attain a state of dynamic equilibrium at the highest possible level of wellness, the setting of more specific expected outcomes, both short-­and long-­term, is necessary for systematic evaluation of the patient’s progress. Expected patient outcomes identified in the planning stage indicate which criteria are to be used in the evaluation phase of the nursing process. The nurse identifies both long-­term and short-­term goals by writing specific expected patient outcomes in terms of desired, realistic, measurable patient behaviours to be accomplished by a specific date. For example, a short-­term expected outcome for the patient in Nursing Care Plan 1.1 might be “The patient will maintain normal vital signs in response to activity in 2 days,” whereas

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a long-­term expected outcome might be “The patient will identify a realistic activity level to achieve or maintain by the time of discharge.” These outcomes would be evaluated in 2 days and at discharge, and the care plan would be revised as necessary if the outcomes were not met. However, these statements are less than optimal because they provide no criteria by which to evaluate the patient’s degree of progress from admission to discharge.  Determining Interventions.  After patient outcomes are identified, nursing interventions to accomplish the desired status of the patient should be planned (Saba, 2017). A nursing intervention is a single nursing action, treatment, procedure, activity, or service designed to achieve an outcome of a nursing or medical diagnosis for which the nurse is accountable (Ladwig, Ackley & Makic., 2019). Interventions can be independent or dependent nursing actions. Independent interventions can be carried out by the nurse without consultation (e.g., elevating the head of the bed for a patient short of breath). Dependent nursing interventions require an order from a physician or nurse practitioner (e.g., application of oxygen). Sound knowledge, good judgement, and decision-­making ability are necessary to effectively choose the interventions that the nurse will use (Figure 1.7). The nurse should foster the use of a research-­based approach to interventions. In the absence of a nursing research base, scientific principles from the behavioural and biological sciences should guide the selection of interventions.  Implementation Phase.  Carrying out the specific, individualized plan constitutes the implementation phase of the nursing process. The nurse performs the interventions or may designate and supervise other health care workers who are qualified to intervene. Throughout the implementation phase, the nurse must evaluate the effectiveness of the methods chosen to implement the plan.  Evaluation Phase.  All phases of the nursing process must be evaluated (see Figure 1.5). Evaluation occurs after implementation of the plan but also continuously throughout the process. The nurse evaluates whether sufficient assessment data have been obtained to allow a nursing diagnosis to be made. The diagnosis is, in turn, evaluated for accuracy. For example, pain might have actually been related to a wound itself or to pressure from a constricting dressing. Next, the nurse evaluates, with the patient when possible, whether the expected patient outcomes and interventions are realistic and achievable. If not, a new plan should be formulated.

FIG. 1.7  Collaboration among the patient, the family, and the nurse is necessary in setting goals and coordinating high-­quality care. Source: iStock. com/monkeybusinessimages.

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SECTION 1  Concepts in Nursing Practice

This may involve revision of expected patient outcomes and interventions. Consideration must be given to whether the plan should be maintained, modified, totally revised, or discontinued in view of the patient’s status. 

NURSING CARE PLANS When the nurse has determined the nursing diagnoses, the outcomes, and the interventions for a patient, the plan is recorded to ensure continuity of care by other nurses and health care providers. The plan should contain specific directions for carrying out the planned interventions, including how, when, for how long, how often, where, by whom, and with what resources the activities should be performed. Various methods and formats are used to record the nursing care plan. One of the important factors influencing a choice of care plan format has to do with the frameworks used in a particular hospital. Care plans are often written on a specific form adopted by an institution, but they may also be entered electronically to organize nursing data. Every nurse who cares for the patient must have access to the plan, whether handwritten or computer generated, to provide the planned care. The care plan is part of the patient’s medical record and may be used in legal proceedings. The nurse must document the patient’s nursing care requirements, changes that are made as the plan is implemented, and the outcomes of the nursing interventions. Not every activity that the nurse implements with the patient will be recorded on the care plan. Standardized care plans are sometimes used as guides for routine nursing care and as a basis for developing individualized care plans. When standardized care plans are used, they should be personalized and specific to the unique needs and problems of each patient.

Concept Maps A concept map is another method of recording a nursing care plan. In a concept map care plan, the nursing process is recorded in a visual diagram of patient issues and interventions that illustrates the relationships among clinical data. Nurse educators use concept mapping to teach nursing process and care planning. There are various formats for concept maps. Conceptual care maps blend a concept map and a nursing care plan. On a conceptual care map, assessment data used to identify the patient’s primary health concern are centrally positioned. Diagnostic testing data, treatments, and medications surround the assessment data. Positioned below are nursing diagnoses that represent the patient’s responses to the health state. Listed with each nursing diagnosis are the assessment data that support the nursing diagnosis, outcomes, nursing interventions with rationales, and evaluation. After completing the map, connections can be drawn between identified relationships and concepts. A conceptual care map creator is available online on the website for this book. For selected case studies at the end of the management chapters, related concept maps are available on the website at http://evolve.elsevier.com/Canada/Lewis/medsurg.  Clinical (Critical) Pathways Care related to common health issues experienced by many patients is delineated with the use of clinical (critical) pathways. A clinical (critical) pathway directs the entire health care team in the daily care goals for select health care conditions. It includes a nursing care plan, specific interventions for each day of hospitalization, and a documentation tool.

The clinical pathway organizes and sequences the caregiving process at the patient level to better achieve desired quality and cost outcomes. It is a cyclical process organized for specific case types by all related health care departments. The case types selected for clinical pathways are usually those that occur in high volume and are highly predictable, such as myocardial infarction, stroke, and angina. The clinical pathway describes the patient care required at specific times in the treatment. An interprofessional approach helps the patient progress toward desired outcomes within an estimated length of stay. The exact content and format of clinical pathways vary among institutions. 

DOCUMENTATION It is critical that the patient’s progress be documented in a systematic way. Proper documentation enables safe and effective patient care. Patient records are also frequently used as evidence when there are legal issues related to negligence and competency. Nurses in Canada should be aware of the Canadian Nurses Protective Society. This is the agency that provides liability coverage and is a source of information and education on issues such as documentation and charting. Many documentation methods and formats are used, depending on personal preference, hospital policy, and regulatory standards. Many provinces are now moving to implement EHRs (see “Electronic Health Records” earlier in this chapter). Funding and support are available through organizations such as the Canada Health Infoway. Patient progress may be documented by nurses with the use of flow sheets; narrative notes; SOAP (subjective, objective, assessment, plan) charting (described in the next section); clinical pathways; and computer-­based charting. Every method or combination of methods is designed to document the assessment of patient status, the implementation of interventions, and the outcome of interventions. There are several methods of documentation that address the nursing process. The SOAP method is a common way of evaluating and recording patient progress. Some institutions use SOAPIER notes (subjective, objective, assessment, plan, intervention, evaluation, and revision of plan). A SOAP or SOAPIER progress note is issue-specific and incorporates the elements in Table 1.10. The following is the process of SOAP documentation: 1. Additional subjective and objective data related to the area of concern are gathered. 2. On the basis of old and new data, the patient’s progress toward the expected patient outcome and the effectiveness of each intervention are assessed. TABLE 1.10    COMPONENTS OF A SOAP

PROGRESS NOTE

SOAP Component

Explanation

Subjective

Information supplied by patient or knowledgeable other person Information obtained by nurse directly by observation or measurement, from patient records, or through diagnostic studies Nursing diagnosis of issue according to subjective and objective data Specific interventions related to a diagnostic or issue with consideration of diagnostic, therapeutic, and patient education needs

Objective

Assessment Plan

CHAPTER 1  Introduction to Medical-Surgical Nursing Practice in Canada 3. On the basis of the reassessment of the situation, the initial plan is maintained, revised, or discontinued. The following is an example of SOAP charting for the nursing diagnosis “Risk for infection as evidenced by alteration in skin integrity and invasive procedure (surgery)”: S: Wound is more painful today. O: Temperature of 39.4°C, facial grimacing in response to movement, dressing saturated with purulent drainage A: Risk for wound infection P: Notify surgeon, take temperature q2h, reinforce dressing. A second method of documentation is the PIE (problem, intervention, and evaluation) method, which is similar to SOAP charting and is also problem-oriented. It does not include assessment data because those are recorded on flow sheets. A third documentation format is DARP (data, both subjective and objective; action or nursing intervention; response of the patient; and plan) progress notes. It is also called focus charting, and it addresses patient concerns, not just issues. Charting by exception is another method of documentation that focuses on documenting deviations from predefined normal findings. Assessments are standardized on flow sheets, and nurses make a narrative note only when there are exceptions to the standardized statements. 

FUTURE CHALLENGES OF NURSING Nursing roles continually evolve as society changes and health care providers learn to integrate new knowledge and technology into current practices. Although nursing is defined in different ways, past and current definitions of nursing include commonalities of health, illness, and caring. It is important that these concepts be addressed in nursing education as greater demands are placed on the profession. Future nursing practice will continue to call for the use of reasoning, analytical thinking skills, and synthesis of rapidly expanding knowledge to assist patients in maintaining or attaining optimal health. An increasing emphasis on leadership, accountability, courage and persistence, innovation and risk taking, and decision

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making is essential if nursing is to move forward. This has never been more relevant than during the 2020 SARS-CoV-­2 global pandemic. Nurses were stressed to maintain standards of nursing practice when resources were scarce. Many of Canada’s emergency departments and hospitals that experienced pre-­existing capacity issues were further challenged. Nursing roles changed depending on the needs of the community. Nurses were brought out of retirement and deployed to assessment centres that supported the increased need for testing of community members, while others were transitioned into critical care areas based on capacity needs. The unprecedented role that nurses and nursing leaders played in all areas of health care helped to mitigate the impact SARS-CoV-­2 had on the country. Nurses must take a leadership role in creating health care systems that provide safe, high-­quality, patient-­centred care. Nursing leadership refers not only to people holding certain positions but also to an attitude and approach in which lifelong learning and a commitment to excellence in practice are valued. In its attempt to keep pace, nursing would do well to remember what the Red Queen in Through the Looking Glass said to Alice: “Now here, you see, it takes all the running you can do to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that” (Carroll, 1865/1973). This appears to be the future of nursing. Nursing leaders must ask some fundamental questions about what the contribution of nurses must be for the twenty-­first century. Nurses must increasingly challenge the status quo by relying on research and the wisdom that results from asking difficult questions. Nurse leaders must have an attitude of open-­mindedness while remaining grounded in values that overcome the tendency to promote self-­interest. Medical-­surgical nursing can positively influence the complex health care system in Canada by increasing interprofessional collaboration, improving patient care and safety, utilizing advanced informatics and technology, applying EIP, and continuing to develop nurses’ critical thinking and clinical reasoning skills.

 REVIEW QUESTIONS The number of the question corresponds to the same-­numbered learning outcome at the beginning of the chapter. 1. Which of the following is a current challenge facing the Canadian health care system? a. Lack of long-­term funding model between provinces/territories and federal government b. Lack of innovation in health care c. Expanding knowledge and technology d. Health care ranking as a low-­priority public health policy issue by Canadians 2. Which of the following is an example of a nursing activity that reflects the Canadian Nurses Association’s definition of nursing? a. Establishing that the client with jaundice has hepatitis b. Determining the cause of hemorrhage in a postoperative client on the basis of vital signs c. Identifying and treating dysrhythmias that occur in a client in the coronary care unit d. Determining that a client with pneumonia cannot effectively cough up pulmonary secretions

3. W  hich of the following actions best describes the work of medical-­ surgical nurses? a. Providing care only in acute care hospital settings b. Requiring certification by the Canadian Nurses Association in this specialty c. Addressing the needs of acutely ill adults and their families d. Caring primarily for perioperative clients 4. Which of the following characteristics of health care teams are important for outstanding interprofessional care? (Select all that apply.) a. Care expertise b. Diverse mix of health care providers c. Interprofessional leadership d. Effective group functioning e. Clear differentiation between roles

SECTION 1  Concepts in Nursing Practice

5. Th  e nurse is caring for a client with diabetes who has just undergone debridement of an infected toe. Which of the following statements best demonstrates client-­centred care? a. “Administer analgesics every 4 hr prn.” b. “Keep foot elevated to promote venous return.” c. “Elicit expectations of client and family for relief of pain, discomfort, or suffering.” d. “Initiate process of teaching the client and family about self-­ care management.” 6. What are advantages of using informatics in health care delivery? (Select all that apply.) a. Reduced need for nurses in acute care b. Increased client anonymity and confidentiality c. The ability to achieve and maintain high standards of care d. Access to standard plans of care for many health issues e. Improved communication of the client’s health status to the health care team

7. “ In adults older than 60 with chronic obstructive pulmonary disease, is structured pulmonary rehabilitation more effective than classroom instruction in reducing the incidence of exacerbation?” In this question, what is the outcome of interest? a. Adults older than age 60 b. Adults with chronic obstructive pulmonary disease c. Structured pulmonary rehabilitation d. Reduced incidence of exacerbation 8. The nurse identifies the nursing diagnosis of constipation resulting from laxative abuse for a client. What is the most appropriate expected client outcome related to this nursing diagnosis? a. The client will stop the use of laxatives. b. The client ingests adequate fluid and fibre. c. The client passes normal stools without aids. d. The client’s stool is free of blood and mucus. 1. a; 2. d; 3. c; 4. a, c, d; 5. c; 6. c, d, e; 7. d; 8. c.

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For even more review questions, visit http://evolve.elsevier.com/Canada/ Lewis/medsurg.

REFERENCES Abraham-­Settles, B., & Williams, D. N. (2019). Apply Clinical Expertise in the Healthcare Environment. (99). Certified Academic Clinical Nurse Educator (CNE®cl) Review Manual. Alberga, A. S., McLaren, L., Russell-­Mayhew, S., et al. (2018). Canadian Senate report on obesity: Focusing on individual behaviours versus social determinants of health may promote weight stigma. Journal of Obesity, 1–7. https://doi.org/10.1155/2018/8645694 Alfaro-­LeFevre, R. (2017). Critical thinking, clinical reasoning and clinical judgment (6th ed.). Saunders. Canadian Association of Medical and Surgical Nurses (CAMSN). (2020). About us. https://medsurgnurse.ca/about-­us/ Canadian Association of Schools of Nursing. (2012). Nursing informatics competencies: Entry-­to-­practice competencies for registered nurses. http://www.casn.ca/wp-­content/uploads/2014/12/Nursing-­ Informatics-­Entry-­to-­Practice-­Competencies-­for-­RNs_updated-­ June-­4-­2015.pdf. (Seminal). Canadian Health Infoway. (2020). Driving access to care. https://infoway-­inforoute.ca/en/what-­we-­do/driving-­access-­to-­care Canadian Health Outcomes for Better Information and Care (C-­HOBIC). (2015). C-­HOBIC. Phase 2 final report. www.cna-­ aiic.ca/-­/media/cna/page-­content/pdf-­en/2015jan_chobic-­phase2-­ final-­report.pdf?la=en&hash=F857EFEFDB59BDE71130CAE5BA713DEAE45DC724. (Seminal). Canadian Institute for Health Information. (2020). Canada’s health care providers, 2015 to 2019—Methodology notes. https://www.ci hi.ca/sites/default/files/document/canada-­health-­care-­providers-­ 2015-­2019-­meth-­notes-­en.pdf Canadian Medical Association (CMA). (2019). CMA health summit: Virtual care in Canada: Discussion paper. https://www.cma.ca/sites /default/files/pdf/News/Virtual_Care_discussionpaper_v2EN.pdf Canadian Nurses Association (CNA). (2012). Interprofessional collaborative teams. www.cna-­aiic.ca/-­/media/cna/page-­content/pdf-­ en/interprofteams-­virani-­en-­web.pdf?la=en&hash=8D073AA488 3C9D0AFBD4433D8E02190233BEAC3B. (Seminal). Canadian Nurses Association (CNA). (2015). Framework for the practice of registered nurses in Canada, 2015. https://www.cna-­aiic.ca/ ∼/media/cna/page-­content/pdf-­en/framework-­for-­the-­pracice-­of-­ registered-­nurses-­in-­canada.pdf?la=en. (Seminal).

Canadian Nurses Association(CNA). (2017). Code of ethics for registered nurses. https://www.cna-­aiic.ca/html/en/Code-­of-­Ethics-­ 2017-­Edition/files/assets/basic-­html/page-­1.html# Canadian Nurses Association (CNA). (2018). Position statement: Evidence-­informed decision-­making and nursing practice. https://www.cna-­aiic.ca/-­/media/cna/page-­content/pdf-­ en/evidence-­informed-­decision-­making-­and-­nursing-­practice-­ position-­statement_dec-­2018.pdf Canadian Nurses Association (CNA). (2019). Advanced practice nursing—a pan-­canadian framework. https://www.cna-­ aiic.ca/-­/media/cna/page-­content/pdf-­en/apn-­a-­pan-­canadian-­ framework.pdf Canadian Nurses Association (CNA). (2021). Specialties. https://mycna.ca/en/my-­certification/what-­is-­ certification/competencies-­per-­specialty-­area Canadian Nurses Association (CNA) & Canadian Association of Schools of Nursing (CASN). (2004). Joint position statement: Promoting continuing competence for registered nurses. https://www.cna-­aiic.ca/∼/media/cna/page-­content/pdf-­ en/promoting-­continuing-­competence-­for-­registered-­ nurses_position-­statement.pdf?la=en. (Seminal). Canadian Nurses Association & Canadian Medical Association. (2011). Principles to guide health care transformation in Canada. https://www.cna-­aiic.ca/∼/media/cna/files/en/guiding_principles_ hc_e.pdf. (Seminal). Canadian Patient Safety Institute (CPSI). (2017). The case for investing in patient safety in Canada. https://www.patientsafetyinstitute. ca/en/About/Documents/The%20Case%20for%20Investing%20in %20Patient%20Safety.pdf Canadian Patient Safety Institute (CPSI). (2021). About CPSI. http://www. patientsafetyinstitute.ca/en/About/Pages/default.aspx Carroll, L. (1973). Alice’s adventures in Wonderland and through the looking glass. Collier (Original work published 1865). Chiffi, D., & Zanotti, R. (2015). Medical and nursing diagnoses: a critical comparison. Journal of Evaluation in Clinical Practice, 21, 1–6. https://doi.org/10.1111/jep.12146 Chin‐Yee, B., & Upshur, R. (2018). Clinical judgement in the era of big data and predictive analytics. Journal of Evaluation in Clinical Practice, 24(3), 638–645. https://doi.org/10.1111/ jep.12852

CHAPTER 1  Introduction to Medical-Surgical Nursing Practice in Canada College of Nurses of Ontario (CNO). (2019). Practice standard—Code of conduct. https://www.cno.org/globalassets/docs/prac/49040_co de-­of-­conduct.pdf College of Nurses of Ontario (CNO). (2020). Practice guideline—Authorizing mechanisms. https://www.cno.org/globalassets/docs/prac /41075_authorizingmech.pdf Gordon, M. (2014). Manual of nursing diagnosis (13th ed.). Jones & Bartlett (Seminal). Government of Canada. (2020). Canada Health Act. https://www.canada.ca/en/health-­canada/services/health-­care-­ system/canada-­health-­care-­system-­medicare/canada-­health-­act.html. Government of Canada. (2021). Canada’s food guide. https://food-­ guide.canada.ca/en/ Hancock, T. (2017). Beyond health care: The other determinants of health. CMAJ: Canadian Medical Association Journal, 189(50), E1571. https://doi.org/10.1503/cmaj.171419 Health Canada. (2019). 2019-­20 Departmental Plan: Health Canada. https://www.canada.ca/en/health-­canada/corporate/transparency /corporate-­management-­reporting/report-­plans-­priorities/2019-­ 2020-­report-­plans-­priorities.html#a3 Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academies Press. http://books.nap.edu/ openbook.php?record_id=12956&page=R1. (Seminal). Ladwig, G. B., Ackley, B. J., & Makic, M. B. (2019). Mosby’s guide to nursing diagnosis e-­book. Elsevier Health Sciences. Maslow, A. (1954). Motivation and personality. Harper & Row (Seminal). Melnyk, B. M., Gallagher-­Ford, L., & Fineout-­Overholt, E. (2016). Implementing the evidence-­based practice (EBP) competencies in healthcare: a practical guide for improving quality, safety, and outcomes. Sigma Theta Tau. Montague, T., Gogovor, A., Aylen, J., et al. (2017). Patient-­centred care in Canada: Key components and the path forward. Healthcare Quarterly, 20(1), 50–56. https://doi.org/10.12927/ hcq.2017.25136 Public Health Agency of Canada (PHAC). (2020). Social determinants of health and health inequalities. https://www.canada.ca/en/public-­ health/services/health-­promotion/population-­health/what-­ determines-­health.html Quality and Safety Education for Nurses. (2014). QSEN Institute: Competencies. http://qsen.org/competencies/pre-­licensure-­ksas. (Seminal). Registered Nurses’ Association of Ontario (RNAO). (n.d.). Nursing best practice guidelines: Definition of terms. https://bpgmobile.rn ao.ca/node/1328 Registered Nurses’ Association of Ontario (RNAO). (2012). Nurse educator eHealth resource. http://rnao.ca/ehealth/educator_resource Registered Nurses’ Association of Ontario (RNAO). (2013). Developing and sustaining interprofessional health care: Optimizing patients/clients, organizational, and system outcomes. Registered Nurses’ Association of Ontario. Registered Nurses’ Association of Ontario (RNAO). (2015). Person-­ and family-­centred care. http://rnao.ca/bpg/guidelines/person-­and-­ family-­centred-­care. (Seminal). Registered Nurses’ Association of Ontario (RNAO). (2017). Adult asthma care: Promoting control of asthma. https://rnao.ca/bpg/guid elines/adult-­asthma-­care

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Registered Nurses’ Association of Ontario (RNAO). (2019). Preventing violence, harassment and bullying against health workers. https://rnao.ca/bpg/guidelines/preventing-­violence-­harassment-­ and-­bullying-­against-­health-­workers Registered Nurses’ Association of Ontario (RNAO). (2020). A palliative approach to care in the last 12 months of life. https://rnao.ca/bp g/guidelines/palliative-­approach-­care-­last-­12-­months-­life Saba, V. K. (2017). Clinical care classification system—Nursing interventions. https://www.sabacare.com/framework/nursing-­ interventions/ Van Graan, A. C., Williams, M. J., & Koen, M. P. (2016). Professional nurses’ understanding of clinical judgement: A contextual inquiry. Health SA Gesondheid, 21(1), 280–293. https://doi.org/10.1016/j. hsag.2016.04.001 World Health Organization (WHO). (2019). Patient safety. https://www.who.int/news-­room/fact-­sheets/detail/patient-­safety

RESOURCES Canadian Association of Medical and Surgical Nurses (CAMSN) https://medsurgnurse.ca/ Canadian Association of Schools of Nursing (CASN) https://www.casn.ca Canada Health Infoway https://www.infoway-­inforoute.ca/ Canadian Health Outcomes for Better Information and Care (C-­ HOBIC) Project https://www.cna-­aiic.ca/-­/media/cna/page-­content/pdf-­ en/2015jan_chobic-­phase2-­final-­report.pdf?la=en&hash=F857EFEFDB59BDE71130CAE5BA713DEAE45DC724 Canadian Interprofessional Health Collaborative http://www.cihc-­cpis.com Canadian Nurses Association (CNA) https://www.cna-­aiic.ca/en Canadian Nurses Protective Society https://www.cnps.ca/ Canadian Nursing Students’ Association (CNSA) https://www.cnsa.ca/en/home Canadian Nursing Informatics Association https://cnia.ca/ Canadian Patient Safety Institute (CPSI) https://www.patientsafetyinstitute.ca/en/Pages/default.aspx myCNA https://www.myCNA.ca Registered Nurses’ Association of Ontario (RNAO) https://www.rnao.org/bestpractices NANDA International (NANDA-­I) https://www.nanda.org/ Quality and Safety Education for Nurses (QSEN) https://qsen.org/ Sigma Theta Tau International (STT) https://www.sigmanursing.org For additional Internet resources, see the website for this book at http://evolve.elsevier.com/Canada/Lewis/medsurg.

CHAPTER

2

Cultural Competence and Health Equity in Nursing Care Rani H. Srivastava

WEBSITE http://evolve.elsevier.com/Canada/Lewis/medsurg • R  eview Questions (Online Only) • Key Points • Answer Guidelines for Case Study

• C  onceptual Care Map Creator • Audio Glossary • Content Updates

LEARNING OBJECTIVES 1. Define the terms culture, cultural competence, cultural safety, ethnocentrism, cultural imposition, worldview, intersectionality, and health equity. 2. Describe how culture has evolved as a determinant of health. 3. Discuss the factors that lead to health inequities in Indigenous and culturally diverse populations.

4. Examine how culture and social location may influence the approach and delivery of nursing care. 5. Describe strategies for effective cross-­cultural communication. 6. Develop strategies for demonstrating cultural competence and promoting health equity in care encounters. 7. Identify the benefits and challenges associated with a diverse workforce.

KEY TERMS acculturation cultural competence cultural imposition cultural safety culture

  

diversity ethnicity ethnocentrism explanatory model health equity

Globalization and changes in demographic and cultural compositions of Canada necessitate that health care providers understand the influence of culture on health. Culture influences individual beliefs about health, illness, care, cure, and even expectations of health care providers. As well, just being different from the norm creates challenges that affect health. Understanding these differences is crucial for providing care that is safe, meaningful, and effective for patients and families.

CULTURAL LANDSCAPE OF CANADA Canada is known as a settler nation and a land of immigrants. Except for the Indigenous people, all other Canadians came to Canada, at some point in time, as newcomers to this land. Canadian society is often described as an ethnocultural mosaic characterized by ethnoracial, linguistic, and religious diversity, as well as diversity in sexual orientation and gender identity. The ethnocultural dimension of diversity is defined by a variety of criteria, including geographic origin, identification with predefined ethnic groups, languages spoken,

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intersectionality race racialization stereotyping worldview

birthplace, visible minority status, and religion (Morency et al., 2017). Canada’s immigration rates have increased from approximately 14% in 1867 to 21.9% in 2016 (Morency et al., 2017). This means that one in five Canadians identifies as immigrant, and this number is expected to increase to nearly 30% by 2036. If second-­generation individuals (Canadian-­ born people whose parents were born outside Canada) are added, the projected number increases to almost 49%. In other words, by 2036, nearly one in two persons will identify as a first-­or second-­generation immigrant (Morency et al., 2017). Over the past three decades, Canadian immigration patterns have undergone a significant shift in terms of the countries that people come from and where they settle. Before the 1970s, the majority of immigrants to Canada came from European countries such as the United Kingdom, Italy, Germany, and the Netherlands; however, the proportion of European-­born immigrants has continued to decline steadily. By the turn of the twenty-­first century most immigrants were coming from Asia, with China, India, and the Philippines being the main source countries. Census data from 2016 show over 250 ethnic origins with nearly

CHAPTER 2  Cultural Competence and Health Equity in Nursing Care 62% of newcomers coming from Asia and 13.4% from Africa. The change in and diversity of newcomers to Canada have had a significant impact on Canada’s cultural landscape and have implications for health care. There are also changes to settlement patterns. Large centres such as Toronto, Vancouver, and Montreal continue to be destination cities for most immigrants. While Ontario and Quebec continue to receive large proportions of immigrants, newcomers are settling across Canada in increasing numbers (Statistics Canada, 2017b). The shift in source countries for immigrants has led to increased linguistic and religious diversity and the proportion of newcomers who identify as visible minorities. The term visible minority is a uniquely Canadian term used by Statistics Canada and refers to “persons, other than Aboriginal persons, who are non-­Caucasian in race or non-­white in colour” (Morency et al., 2017, p. 139). In 2016, visible minorities accounted for over 22% of Canada’s population. Of this number, approximately twothirds were born outside the country and one-third were born in Canada (Statistics Canada, 2017b). The Black population in Canada, while relatively small in size, is also growing in number and diversity. Between 1996 and 2016, Canada’s Black population doubled in size to 3.5% of the total population. Whereas previously much of the Black population came from Haiti and Jamaica, since the 2000s over 60% of Black immigrants have come from Africa. Like other groups, the Black population is also multigenerational, with approximately 35% of the population being born in Canada. This pattern varies across the country. For example, Nova Scotia has the fifth largest Black population in Canada, with nearly 72% being third-­generation or more (Statistics Canada, 2019). Indigenous people have been in Canada long before the European settlers arrived. Until the late eighteenth century, the relationship between First Nations and the British was based on mutual interests. However, in the early 1800s a new perspective, reflecting the presumed cultural superiority of the British, led to intensive efforts to “civilize” the Indian and assimilate First Nations people into Christianity and British society through changes in legislation and the constitution via the1867 Indian Act and subsequent establishment of residential schools. The “Sixties Scoop” saw Indigenous children forcibly removed from their families and placed with adoptive or foster families. These initiatives led to restrictions and controls on the lives of First Nations people, resulting in forced abandonment of traditional culture, religion, and ways of life. The long-­term negative consequences for children, parents, and the community include loss of land, culture, and cultural identity, as well as trauma (Bombay et al., 2020; Statistics Canada, 2017a/2019; Truth and Reconciliation Commission of Canada [TRC], 2015). In 1996, the findings in the report of the Royal Commission on Aboriginal Peoples began to shed light on the realities and injustices for First Nations communities. The subsequent work, report, and recommendations of the Truth and Reconciliation Commission are charting a new path forward toward understanding, reconciliation, and decolonization (Richmond & Cook, 2016). It is important to note that Indigenous people’s relationship to dominant Canadian society is vastly different from that of newly arrived immigrants and refugees. Understanding the experiences of Indigenous, immigrant, and the many visible minority communities is important toward understanding the larger structural and social processes that lead to exclusion and marginalization and that threaten patient safety and quality care.

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Some of these experiences extend to other communities, such as people with nondominant sexual orientation or gender identity, nondominant language, low socioeconomic status, and mental or physical disabilities. While each community and group has a unique history and their own complexities, the impact of discrimination (conscious, unconscious, or structural) can lead to inequities in health.

Culture as a Determinant of Health The extent to which people are healthy or not depends on many factors, including characteristics, behaviours, and the social, economic, and physical environment. Culture is recognized as one of the 12 determinants of health identified by the Public Health Agency of Canada (PHAC, 2018); however, it also influences all other determinants of health, by mediating the impact of other social factors (Kirmayer & Jarvis, 2019). For example, culture influences how an individual may be perceived with respect to social status; ability to secure stable employment or housing; social supports and obligations; and historical legacies of discrimination, disadvantage, and trauma (Kirmayer & Jarvis, 2019). Indigenous perspectives on health involve interconnections between physical, social, environmental, and spiritual dimensions and entail three levels of social determinants. Proximal determinants are conditions that have a direct impact on health (e.g., health behaviours); intermediate determinants constitute factors that are the basis or origins of the proximal determinants (e.g., community infrastructure, kinship networks, ceremonies, and knowledge sharing); and distal or structural determinants represent the political, economic, and social contexts, including colonialism, racism, Indigenous worldviews, and self-­ determination (PHAC, 2018). Health and illness are inextricably linked to cultural issues. The effect of culture on health is significant and pervasive and can be both positive and negative (Srivastava & Srivastava, 2019). Culture influences an individual’s or community’s approach to health protection and promotion, perception and experience of illness, what symptoms are reported, what remedies are sought, and who is consulted in the process. For instance, in a 20-­year evidence review of Indigenous culture on health and well-­being, Bourke et al. (2018) note that “culture is significantly and positively associated with physical health, social and emotional wellbeing, and reduces risk-­taking behaviours” (p. 11). Language barriers can pose a major threat to patient safety and quality of care (Alimezelli et al., 2015; Gil et al., 2016; Minnican & O’Toole, 2020). The resettlement process for immigrants and refugees presents inherent challenges as these individuals experience difficulties in employment, housing, and access to social support. Individuals may also face health risks as a result of marginalization and lack of access to culturally appropriate diet, activity, and health care services. Disruptions in traditional lifestyles along with discrimination can lead to greater social exclusion and increased risk for substance use. Delays in seeking help and lack of culturally competent health care providers and services can result in health concerns and symptoms being minimized or ignored, as well as inadequate follow-­up for prescribed treatments (McKenzie et al., 2016). It must be emphasized that although culture is regarded as a determinant of health, it should not be confused with being the cause of illness or health inequities; rather, the inequities are rooted in social and structural factors that can and must be addressed. 

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SECTION 1  Concepts in Nursing Practice

EXPLORING THE CONCEPTS: DEFINITIONS AND MEANINGS Terminology related to cultural diversity is subject to multiple interpretations and continues to evolve over time. Culture is an elusive concept. Although many people equate culture with ethnicity, race, country of origin, or religion, this is an erroneous oversimplification. Culture can include many additional dimensions, such as socioeconomic class, professional status, age, sexual orientation, group history, and life experiences (Srivastava & Srivastava, 2019). Culture serves as a guide for people’s values, beliefs, and practices, including those related to health and illness, and at the level of the individual, group, and larger society. In the quest for health equity, it is important to recognize that the culture of health care providers and the context of the health care system matter as much as the culture of the patient (Began, 2015; Berg et al., 2019). Culture exists at the level of the individual, the group or team, or professional discipline, as well as the level of the health care organization or broader society (Srivastava, 2007a). Cultural values are often unconsciously developed and are responsible for perceptions of acceptable and unacceptable behaviour. Cultural beliefs and ways of being are often referred to as a worldview. A worldview is a paradigm or a set of assumptions, values, concepts, and practices that influences how people perceive, interpret, and relate to the world around them. Culture has many distinguishing features, as highlighted in Table 2.1. A key thing to note is that everyone has a culture. In fact, as discussed later, we are all part of many cultures. Culture is about shared patterns that individuals share with others in a group and can be described as commonly understood learned traditions and unconscious rules of engagement (Srivastava, 2007a). Although individuals within a cultural group have many similarities through their shared values, beliefs, and practices, there is also much diversity within groups. Sometimes the differences within a group can be greater than differences across groups. These variations in group patterns and individual differences mean that each person is both a cultural being and a unique individual. As noted by Murray and Kluckhohn (1953), each person is like no other person, some other persons, and all other persons. Cultural practices change over time through processes such as acculturation. Acculturation is a multidimensional process in which individuals undergo stages of adjustment, as well as TABLE 2.1    KEY CHARACTERISTICS OF CULTURE Culture is . . . Learned through the processes of language acquisition and socialization Shared by members of the cultural group to varying degrees Adapted to specific conditions such as context and environmental factors Dynamic and ever-­changing in relation to historical, political, social conditions and experiences Invisible and often sensed but not seen Selective and differentiating by creating in-­group and out-­of-­group members, reflecting patterns and experiences of social power or lack of it Ubiquitous in that it influences all aspects of life including how one is perceived by others Source: Canadian Nurses Association & Canadian Medical Association. (July, 2011). Principles to guide health care transformation in Canada. https://www.cna-­aiic.ca/. Adapted from Srivastava, R. (2007). Culture care framework I: Overview and cultural sensitivity. In R. Srivastava (Ed.), The healthcare professional’s guide to clinical cultural competence (pp. 53–74). Elsevier Canada.

changes in domains such as language, socioeconomic status, values, and attitudes (Delara, 2016). This gradual process results in increased similarity between two cultures. Ethnocentrism is a tendency of people to believe that their way of viewing and responding to the world is the most correct one (Minnican & O’Toole, 2020). To some extent, this is a universal tendency; each person has the greatest familiarity with, and a preference for, their own way of doing things. However, the conscious or unconscious belief that a particular way is the only way or the best way for everyone may lead to a categorization of other beliefs as unusual, inappropriate, bizarre, and somehow inferior. Ethnocentrism can prevent people from considering alternative perspectives, recognizing the strengths they have, and from respecting others’ worldviews. Cultural imposition, a closely related concept, is when a person’s own cultural beliefs and practices are, intentionally or unintentionally, imposed on another person or group of people. In health care, it can result in disregarding or trivializing a patient’s health beliefs or practices. Ethnicity refers to characteristics of a group whose members share a common social, cultural, linguistic, or religious heritage and often implies a geographic or national affiliation. Race is both a biological and social construct and is sometimes used to highlight biological differences and physical characteristics such as skin colour, bone structure, or blood group (Reich, 2018). The biological basis of race is frequently challenged. Children of mixed-­race couples can have varying degrees of skin pigmentation and physical characteristics and yet share similar genetic makeup and social culture. So, while there may be some genetic basis for biological differences based on gender and race, any attributions to race must be made with extreme caution (Reich, 2018). In recent years, language has shifted to ancestry. Rather than attributing increasing prevalence of illnesses such as sickle-­ cell anemia or cystic fibrosis to Black or White race, reference is made to ancestry or descent, such as “sub-­Saharan African” or “European” (Chou, 2017). As a social construct, race has been used to categorize people on the basis of physical characteristics and to denote superiority and inferiority. Racialization is the process of such categorization, which leads to discrimination. Racialized groups are people who are non-­White, visible minorities, or persons of colour (McKenzie et  al., 2016). The term racialized is often preferred because a racialized community in a particular area may not be a numerical “minority”; as well, it recognizes that barriers faced by people are reflective of historical social prejudice and not individual or group inadequacies. In a large and growing body of research, racism has been linked to poor health (Paradies et al., 2015). The effect of racism is multifaceted—it may be internalized, reflected in interpersonal relations with respect to how people are treated by others, or be systemic where social structures, processes, and policies lead to exclusion. Individuals experiencing racism may resort to high-­risk behaviours such as substance use or self-­harm or simply delay seeking health care. Physical health may be challenged by violence and injury or chronic, negative anxiety, depression, and diminished self-­esteem or identity, which, in turn, can have direct effects on biological processes such as the cardiovascular and compromised immune systems. Racism also influences health indirectly through differential exposures and opportunities related to other determinants of health such as education and employment (Paradies et al., 2015). Intersectionality is described as a framework for understanding how multiple social identities such as race, gender,

CHAPTER 2  Cultural Competence and Health Equity in Nursing Care

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EQUALITY VERSUS EQUITY

In the first image, it is assumed that everyone will benefit from the same supports. They are being treated equally.

In the second image, individuals are given different supports to make it possible for them to have equal access to the game. They are being treated equitably.

In the third image, all three can see the game without any supports or accommodations because the cause of the inequity was addressed. The systemic barrier has been removed.

FIG. 2.1  The difference between equity and equality. Source: City for All Women Initiative (CAWI). (2015). Advancing equality and inclusion: A guide for municipalities, p. 17. https://www.cawi-­ivtf.org/sites/default/files/publications/advancing-­equity-­inclusion-­web_0.pdf

sexual orientation, and economic status interact with each other to reflect interlocking systems of privilege and oppression. The multiple disadvantage locations cannot be simply added to one another, rather they interact with each other in ways that something new and specific is created with respect to exclusion and disadvantage (Henry et al., 2016). Think about the social inequality between White males and Black males; now also consider a Black man who may also be gay. While there are only two variables—skin colour and sexual orientation—the combination can drastically change one’s experience in different circumstances. In stereotyping, members of a specific culture, race, or ethnic group are automatically assumed to have associated characteristics that are imposed on individuals without further exploration of what the person is like. This oversimplified approach disregards individual differences, imposes a belief, and leads to false assumptions that can lead to poor care. Diversity is another term that is related to culture. For some people, the term simply refers to differences or variations across individuals and social groups; whereas for others, it represents a sum of differences, usually regarding unequal access to power, privilege, and resources. In the context of health care, diversity usually implies difference from the majority or dominant group that is assumed to be the norm. Diverse groups and communities, in this context, have marginalized status in society, and diversity initiatives often become synonymous with asserting human rights, freedom from discrimination, social justice, and, more recently, health equity (Began, 2015). When thinking about diversity or difference, it is important to recognize how differences matter and which differences matter more than others. Equity is the quality of being fair, just, or impartial. It is important to distinguish between equity and equality. The concept of equality refers to sameness in process (e.g., everyone gets the same treatment). Equity, on the other hand, focuses on sameness in outcomes. To achieve equality in outcomes, people need to be treated differently and in accordance of their needs.

Imagine three people of different heights trying to see over a 122-­cm (4-­ft) fence to watch a ball game. Kyle is an adult, 183 cm (6 ft) in height; Larry is a preteen, 122 cm (4 ft) in height; and Michael is a child who is 76 cm (2.5 ft) in height. As a way of providing support for onlookers, the park provides 12-­inch crates on which people can stand to see over the fence. In a system in which equality is the driving principle, each person gets one crate to stand on. As a result, Kyle, who is able to see over the fence with no difficulty, is even taller; Larry, who is able to see if he stands on tiptoe, can now stand on the crate and see the game more comfortably. But Michael, even with the crate, still reaches 15 cm (6 inches) below the top of the fence and therefore is still not able to see the game. The outcome is not much different than before the crates were provided, except for some benefit to Larry. The return on investment of crates is minimal, and the crate for both Kyle and Michael is a wasted resource. In a system in which equity is the driving force, the crates are distributed according to need. Kyle does not receive a crate to stand on, Larry gets one crate, and Michael gets two crates. The outcome is that all three individuals can see over the fence comfortably (Figure 2.1) and the desired goal is achieved. In the first scenario of resource distribution according to the principle of equality, everyone is assumed to be in the same situation and to have the same needs. This is simply not true. Differences in race, gender, income, and other factors means individuals vary in the strengths and needs they bring to every interaction. When these are recognized, interventions can be targeted on the basis of need. The result is optimal outcome with minimal waste. Another option would be to try to remove the barrier. If the wooden fence was removed or replaced by plexiglass or wire mesh that allowed people of all heights to see through the barrier, the supports would not be required. In this example the difference in height is attributed to age; however, if one were to consider the difference based on social or cultural identity, it is important to recognize that the reason people do not have equal access is not their limitation or shortcoming but rather because the ground they are standing on is not level. The tall person

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SECTION 1  Concepts in Nursing Practice

begins with considerable advantage and the person who appears “short” or needing support is actually starting from a place of considerable disadvantage created by society.

Health Equity There are many reasons why population groups may experience differences in health outcomes. These differences are referred to as health inequalities if the differences are based on genetics or developmental processes such as aging; however, when these differences are due to social factors such as income, race, or gender, they are identified as health inequities, as these factors are modifiable and therefore unfair or unjust. For example, Canadians who live in remote or northern regions do not have the same access to nutritious foods, such as fruits and vegetables, as do other Canadians, and this lack of access to healthy foods results in poor nutrition and poor health—this is an example of heath inequity. Health equity is an important concept in the pursuit of quality care for all individuals, regardless of their background and socioeconomic status. Health equity involves creating equal opportunities for good health for everyone in two ways: (1) by decreasing the negative effect of the social determinants of health, and (2) by improving services to enhance access and reduce exclusion. In Canada, health inequities are evident among Indigenous people, racial and sexual minorities, immigrants, and people living with disabilities (PHAC, 2018). Indigenous populations in Canada experience many health inequities, as evident from the significantly higher rates of illnesses such as tuberculosis, diabetes, and cardiovascular disease and by higher rates of suicide and self-­injury among these groups (PHAC, 2018). Living in remote or northern regions is one contributing factor; however the health of Indigenous Canadians is also affected by the loss of culture, including language and connection to land; racism and stigmatization; social exclusion; and loss of connection with Indigenous identity and spirituality (Fournier et al., 2019; Kim, 2019; Richmond & Cook, 2016). There is considerable evidence that sexual minority populations (lesbian, gay, bisexual, transgender, queer, intersex, asexual, and two spirited [LGBTQIA2]) experience significant inequities in health (Colpitts & Gahagan, 2016). In 2019, a study focusing on LGBTQIA2 health was undertaken by the Canadian House of Commons Standing Committee on Health. The study noted that while inequities are experienced differently by each of the LGBTQIA2 communities, the individuals overall are more likely to experience poorer mental health, have suicidal thoughts, and attempt suicide (House of Commons Standing Committee on Health, 2019). In particular, the transgender population has considerable vulnerability and unmet needs with respect to health (Giblon & Bauer, 2017). Racial minorities, immigrant, and refugee populations experience health inequities that can be attributed to lack of provider knowledge, stigmatization, and discrimination, including refusal to provide care or to seek care (McKenzie et al., 2016). Cain et  al. (2018) note that palliative care, considered a “gold standard of end-­of-­life care” continues to be used mainly by Whites and people of northern European descent. Even when the differences are attributed to choice, the researchers point out that it is important to take a nuanced look at factors behind the choice. People of color, of diverse sexual orientations, and who are disabled are less likely to receive care that aligns with their wishes than Whites, and these groups report lower levels of life satisfaction (Cain et al., 2019). Research from many countries, including Canada, indicates that immigrants report better physical and mental health when they first arrive in the country than their Canadian-­born

counterparts. This is known as the “healthy immigrant effect.” This health advantage is attributed to immigration criteria that favor healthy people; however, this advantage is usually lost as both physical and mental health deteriorates over time to “non-­ immigrant Canadian levels or worse” (Fung & Guzder, 2018, p. 5). Key factors that lead to this deterioration include social inequities such as poverty, underemployment, or unemployment; racism and discrimination; and inequitable access to services due to difficulties in navigation of the health system, communication challenges, or lack of culturally responsive services (Fung & Guzder, 2018; McKenzie et al., 2016). 

Social Justice and Equity in Nursing Care The growing evidence of health inequities across a variety of groups is challenging previous assumptions about how to provide quality health care for everyone in the context of a culturally diverse society. Without cultural competence, patients, families, and communities are at risk for no care or care that is ineffective or unsafe. A social justice approach requires awareness of and attention to inequities—where culture is understood as patterns but also as power; and racism and discrimination are recognized and challenged at the individual as well as organizational level (Small, 2019; Srivastava & Srivastava, 2019). The importance of health equity and the role that nurses can and must play is recognized by national and international nursing associations (Canadian Nurses Association, 2018; International Council of Nurses (ICN), 2018). The Truth and Reconciliation Commission of Canada (TRC) has also called for cultural competence education for health care providers to promote cultural safety for Indigenous people (TRC, 2015). Many national and local initiatives are underway to support health equity through research, policy, and in practice. The health equity impact assessment (HEIA) tool is an excellent example of how health care leaders can embed health equity considerations into decision making. When unintended potential effects are recognized, mitigating strategies can be put in place to reduce the negative and maximize the positive effects (Ontario Ministry of Health and Long Term Care, 2021). Nurses, by virtue of their role in the health care system, can promote health equity by recognizing cultural needs and expressions, removing unnecessary complexity in care, supporting informed choices, being sensitive to vulnerability, and drawing on cultural strengths to support and promote health.  Cultural Safety and Cultural Competence In Canada, both cultural safety and cultural competence are concepts used to guide the provision of safe, effective, equitable patient-­centred care. Frameworks for both concepts have different origins but have many similarities regarding key attributes and skills needed by health care providers. The concept of cultural safety is based on the notion of biculturalism and was initially developed in New Zealand to draw attention to the effects of colonization on the health of the Indigenous Maori people. Cultural safety focuses on the impact of colonialism and ongoing power imbalances that lead to a disregard for health and illness beliefs of the Indigenous people and to a privileging of the dominant cultural values. Some authors view cultural safety as an outcome from the process of cultural competence (Sharifi et al., 2019); others view it as a distinct approach that focuses on social and political power and redefines the provider–patient relationship with emphasis on self-­determination (Berg et  al., 2019). In Canada, the notion of cultural safety continues to be applied largely to health care for Indigenous people.

CHAPTER 2  Cultural Competence and Health Equity in Nursing Care Cultural competence is a process whereby practitioners recognize the need for the knowledge and skills to modify assessment and intervention strategies in order to achieve equity in health quality and outcomes. Cultural competence in nursing can be traced back to the 1960s, when Madeleine Leininger advocated for the use of culturally based health knowledge and care to ensure appropriate and effective care for individuals and groups with differences in values, beliefs, explanatory models of illness (discussed later in this chapter), and systems of healing (Sharifi et  al., 2019). One of the earliest and most widely cited definitions of cultural competence is a “set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-­cultural situations” (Cross et al., 1989). The International Council of Nurses describes it as care that “respects diversity in race, ethnicity, age, gender, sexual orientation, disability, social status, religious or spiritual beliefs, and nationality; recognizes populations at risk of discrimination; and supports differences in healthcare needs that may result in disparities in healthcare services” (ICN, 2018, p. 1). Both of these definitions denote action based on awareness and knowledge. Cultural competence is recognized as a critical attribute for the provision of safe, effective, quality care and has therefore been declared an entry-­to-­practice level competency for registered nurses in Canada (Canadian Nurses Association, 2018). A key difference between cultural competence and cultural safety is the role of cultural knowledge or information associated with specific groups. Because culture is a dynamic concept, the requisite knowledge is not about specific cultural groups but rather the patterns associated with groups and how these patterns may surface in health and illness. In this way, use of cultural knowledge is like the nurse’s use of clinical knowledge—to assess, understand, inquire, interpret, and ultimately validate the specific situation with patient, family, or community. Some argue that without knowledge health care providers are at risk for misunderstanding, missing critical information, and placing an undue burden on the patient to educate providers (Jongen et al., 2018). Both frameworks articulate the need for humility and inclusivity; respect for unique history, traditions, and beliefs of individuals and groups; communicating in culturally appropriate ways; and recognizing the effects of the broader social determinants of health on individuals, families, and communities. In this chapter, the term cultural competence is used, largely because the notion of competence implies acquisition and use of specific knowledge and skills, in an intentional way, to ensure the provision of quality care. The fundamental tenets underlying culturally competent care include awareness, knowledge, skills, commitment, and application of knowledge in decision making and actions (Table 2.2). Contrary to some interpretations in the literature, as stated earlier, cultural competence does not mean being an expert in or knowing everything about a particular culture; this is unrealistic and risks stereotyping. Rather, cultural competence is an evolving process that recognizes the dynamic nature of culture created through context and intersectionality and that is grounded in knowledge of a number of concepts, reflection, and action (Sharifi et al., 2019). Outcomes of culturally competent care can be described as culturally congruent care, culturally responsive care, or simply achieving health equity. 

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TABLE 2.2    FUNDAMENTAL TENETS OF

CULTURAL COMPETENCE

Awareness

Knowledge

Application in practice

Commitment to equity

Develop self-­awareness of one’s cultural identity, assumptions, biases, and beliefs and how these can impact others Purposefully seek out and examine similarities and differences between individuals and groups to understand and respect differences, what they mean, and how they impact individuals and communities Translate awareness and knowledge into actions and skills that include: • Building trust and partnerships • Assessment • Communication • Negotiation and advocacy Identify barriers, facilitators, and strengths in individuals and communities Challenge barriers within one’s sphere of influence; promote inclusion and self-­determination of goals for individuals and communities

ABCDE of Cultural Competence There are many frameworks and models of cultural competence, each highlighting a different aspect of culture, attributes of cultural competence, or approach to developing cultural competence (Berg et  al., 2019). However, three key domains are evident across these frameworks: (a) an affective domain, which reflects an awareness of and sensitivity to cultural values, needs, and biases; (b) a behavioural domain, which reflects skills necessary to be effective in cross-­cultural encounters; and (c) a cognitive domain, which involves cultural knowledge, as well as theory, research, and cross-­cultural approaches to care (Brown et al., 2016; Sharifi et al., 2019). Together, these domains can be considered the ABC’s of cultural competence (Srivastava, 2008). However, to fully understand the complexities of cultural competence and its relationship to health equity, two other domains must also be present. The dynamics of difference (D) highlights the fact that difference is not just about differing worldviews; it is also about discrimination and racism associated with minority group status and social power imbalances. The (E) domain involves the goal of equity in health care and also highlights the importance of the context of care, or the practice environment, which may or may not have necessary supports for individual clinicians (Srivastava, 2008). Understanding and actively addressing the dynamics of difference is consistent with nursing role expectations of social justice and advocacy. Challenging structural and systemic barriers within the care environments and leveraging supports and strengths are essential for effective care. Figure 2.2 shows the ABCDE framework for cultural competence. The framework can serve as road map or guide to developing competencies in each domain. Nurses need to develop and apply awareness and knowledge in ways that effectively navigate the downside of difference and utilize the strengths that come with difference to achieve the goal of equity and quality care. Table 2.3 presents examples of attributes that describe the ABC domains of cultural competence. The influence of the dynamics of difference and the environment is evident throughout the affective, behavioural, and cognitive domains and is thus not highlighted separately in the table.

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SECTION 1  Concepts in Nursing Practice

t en ts nm rs or ro ie p vi arr up En B g S in ck

La

En R vir e o Su so nm pp urc en o r es t ts

Affective

Dynamics of difference

og

ra

C

u io av

ni tiv e

eh

B l FIG. 2.2  The ABCDE’s of cultural competence. Source: Adapted from Srivastava, R. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 8(11), 25–31 (p. 31).

Affective Domain: Developing Cultural Awareness and Mindset.  The affective domain of cultural competence is concerned with both attitude and awareness. This is the first step toward developing cultural competence. Openness, a desire to learn, valuing differences, respect for others, and developing humility are characteristics of this domain (Brown et al., 2016; Sharifi et  al., 2019). Developing competencies in this domain means understanding the notion of multiple worldviews and norms, recognizing that no one way is universally superior and yet that we all have a bias toward things that are familiar. Every person is a cultural being; therefore any nurse–patient interaction is affected by the cultures of both the nurse and the patient. Each nurse is influenced by their own cultural identity, the culture of the nursing profession, the culture of the health care team, and the culture of the health care setting in which the interaction occurs. It is important to recognize that within the nursing profession there are different categories (registered nurse, registered/licensed practical nurse, registered psychiatric nurse, and nurse practitioner) and that there are variations in how each category may approach care. The same applies to different disciplines within the interprofessional team. Understanding these differences is critical for effective intra-­and interprofessional collaboration. Awareness can be subcategorized into three components: self-­ awareness, awareness of others, and awareness of the dynamics of difference (see the “Dynamics of Difference” section later in this chapter). Self-­awareness is a critical first step in developing cultural competence. This includes an examination of one’s conscious and unconscious biases toward others and exploring one’s own cultural identity—both with respect to how one views oneself and how one may be viewed by others (Srivastava, 2007a). Identifying how these views may influence the care encounter is a critical step in recognizing ethnocentrism, avoiding cultural imposition, and building trust. Development of self-­awareness requires nurses to engage in ongoing critical self-­reflection and being amenable to feedback from other people (see the “Nurse’s Self-­Assessment” section later in this chapter). Awareness of other people as cultural beings means understanding that people have different worldviews and norms. Cultural differences are not issues of right or wrong; they are simply about being different. Awareness also includes understanding that people have different historical legacies that have an impact on their health and well-­being,

including how they interact with the health care system. Understanding the dynamics of differences means going beyond acknowledging the inherent power dynamics that exist in any clinical encounter by recognizing that past experiences of discrimination and exclusion, communication difficulties, and differences in worldviews are also factors that need to be addressed to ensure that patient voice, perspectives, and rights are recognized.  Behavioural Domain: Adding a Cultural Lens to Clinical Skills.  The behavioural domain concerns the actual application of knowledge and awareness through interpersonal skills, assessment skills, and communication skills to specific clinical encounters and decisions. Demonstrating humility, intentionality, flexibility, and openness are critical attributes in this domain. Through the intentional use of interpersonal skills to build trust, nurses can partner with patients in performing a comprehensive assessment of not only patients’ concerns and symptoms but also their values, beliefs, and practices to develop mutual goals and interventions. Different cultural groups have different beliefs about the causes of illness and the appropriateness of various treatments. It is important for the nurse to try to determine the patient’s explanatory model (set of beliefs regarding what causes the disease or illness and the methods that would potentially treat the condition best). It is also important to determine how experiences and beliefs affect health-­seeking behaviours. Table 2.4 lists key questions that can be used to learn about the patient’s explanatory model of illness and care. These questions do not have to be asked in the order they are listed, and they can be adapted to the situation or incorporated into existing assessment approaches. Through these questions nurses can identify key values, beliefs, and issues that that are important to the patient in each situation (Brown et al., 2016; Jongen et al., 2018) Cross-­Cultural Communication.  Communication is foundational for every aspect of the clinical encounter; therefore cross-­cultural communication is a key area for cultural skill development (see Table 2.3). Cultural differences are often cited as a barrier to effective communication, leading to poor adherence to treatment regimens, dissatisfaction with care, and adverse health outcomes (Habadi et al., 2019; Ladha et al., 2018). Culturally safe communication that includes communication of cultural understanding and respect is an essential tool in forming a therapeutic relationship with the patient. It is critical for establishing trust, for informed consent, for decision making, for ability to partner in care, and for self-­management of chronic illnesses (Brown et  al., 2016; Minnican & O’Toole 2020).  Verbal and Nonverbal Communication.  Cultural influences on communication are evident in both verbal and nonverbal communication. Verbal communication includes not only the language or dialect but also the voice tone and volume, timing, and a person’s willingness to share thoughts and feelings. Nonverbal communication includes silence, eye contact, use of touch, body language, style of greeting, and the spatial arrangement taken up by the participants. Culture influences the ways that feelings are expressed, as well as which verbal and nonverbal expressions are appropriate in given situations, with norms varying across cultures. For example, many Indigenous people are comfortable with silence and interpret silence as essential for thinking and carefully considering a response. In these interactions,

CHAPTER 2  Cultural Competence and Health Equity in Nursing Care

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TABLE 2.3    THE ABC’S OF CULTURAL COMPETENCE Component

Description

Affective (Awareness) Domain Attitude

Awareness of self, others, and dynamics of difference

• Humility and a recognition of the need for ongoing learning and unlearning • Genuine curiosity and desire to learn; valuing differences • Nonjudgemental stance in encountering situations and perspectives that are different from those of self or the norm • Commitment to the goal of social justice, inclusivity, and equity • Self-­awareness of values, beliefs, and biases, including unconscious bias • Critical reflexivity to examine and critique own beliefs • Awareness of own social location and privilege • Awareness of challenges with cross-­cultural communication • Awareness of cultural influences on information seeking, conflict, and decision making • Recognition of the historical effects of racism and discrimination in society and health care

Behavioural (Skills) Domain Assessment

Cross-­cultural communication

Collaborative decision making Empowering and promoting patient choice Advocacy across differences

Development of resources (personal and organizational) to support practice

• Ask the correct questions in the correct way (knowing what and knowing how) • Establish trust and health care provider’s credibility • Elicit patient’s explanatory model of illness • Assess for the effect of social determinants on current situation • Determine patient’s values, strengths, and goals • Adapt own communication style to address cultural nuances and differences in information processing and decision making • Provide information in simple language and in ways that are consistent with patient’s language and culture • Become familiar with different communication styles and patterns • Recognize the need for and make use of interpreters for language support • Elicit patient’s values, preferences, and explanatory models of health and illness • Engage family and build trust • Accommodate values and preferences and negotiate approaches to obtain mutually agreed-­upon goals • Review cultural conflicts as opportunities to learn from differences • Reframe situations to mitigate biases that are held by the health care provider or patient • Acknowledge and support religious and spiritual beliefs • Facilitate participatory decision making and informed patient choices • Identify own privilege and use it appropriately to further goals of equity • Recognize and address the dynamics of difference at patient–clinician level and at patient–health care system level • Connect patients with resources within their community to promote greater autonomy and self-­ management • Explore opportunities to partner with and learn from colleagues, patients, and communities that are culturally different from self or own • Seek information on different cultural groups through the Internet, media, movies, and visits to cultural and community centres • Seek out the insider cultural perspectives and meanings of events and traditions • Develop relationship with service agencies that support health for specific cultural groups and communities

Cognitive (Knowledge) Domain Generic cultural knowledge

Specific cultural knowledge

• Understand the effect of culture on health and health-­seeking behaviours • Understand the difference between individualistic and collectivist cultures • Recognize dimensions of care that are likely to be influenced by culture in a particular setting (e.g., end-­of-­life care) • Identify biophysiological determinants of health and illness in minority groups • Identify social determinants of health: effects of race, culture, health status, employment, and so forth • Understand health disparities and health equity issues • Identify the effects of health policy on culturally diverse groups, particularly those whose members are economically disadvantaged • Understand the effect of diversity on team functioning • Develop contextual knowledge of communities served, including cultural strengths and resources; health inequities particular to the group or groups; and incidence and prevalence of major illnesses • Learn about commonly held worldviews and healing traditions • Identify the effect of life events such as migration, settlement, and racism • Review the care process for own clinical specialty and identify processes and treatments that are particularly susceptible to cultural differences • Do not make assumptions on the basis of cultural background; instead, use knowledge as a beginning point for further assessment and inquiry

Sources: Adapted from Srivastava, R. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 8(1), 25–31; and from Brown, O., Ham-­Baloyi, W., Van Rooyen, D., Aldous, C., & Marais, L. (2016). Culturally competent patient-­provider communication in the management of cancer: An integrative literature review. Global Health Action, 9(1), 33208.

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TABLE 2.4    QUESTIONS FOR DETERMINING THE

PATIENT’S EXPLANATORY MODEL OF ILLNESS AND CARE

1. What do you think has caused the problem? 2. Why do you think it started when it did? 3. What do you think the sickness or illness does to you? 4. How severe is the sickness? Will it have a long or short course? 5. What are the major problems or difficulties this sickness has caused in your life? 6. What have you done for this problem up to now? 7. What kind of treatment do you think you should receive? 8. What do you fear most about the sickness? 9. What do you fear most about the treatment? 10. Who else should be consulted or involved in your care? Source: From Srivastava, R. (2007). Culture care framework I: Overview and cultural sensitivity. In R. Srivastava (Ed.), The healthcare professional’s guide to clinical cultural competence (p. 89). Elsevier Canada. Adapted from Kleinman, A., Eisenberg, L., & Goode, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross cultural research. Annals of Internal Medicine, 88, 251–258.

silence shows respect for the other person and demonstrates the importance of the remarks. In traditional Japanese and Chinese cultures, the speaker may stop talking and leave a period of silence for the listener to think about what has been said before continuing. In other cultures (e.g., French, Spanish, and Russian), silence may be interpreted as meaning agreement. Differences in communication styles can lead to misinterpretations; what is considered normal and respectful in one culture may be interpreted as rudeness in another (Barker, 2016). Although nurses are often taught to maintain direct eye contact, patients of Asian or Arab descent or who are Indigenous may avoid direct eye contact and consider direct eye contact disrespectful or aggressive. Other factors to consider include the role of sex, age, status, or social position on what is considered as appropriate eye contact. For example, Muslim-­Arab women avoid eye contact with men other than their husbands in public situations to exhibit modesty. The degree of physical contact and touch, across gender and age, varies across cultures. In certain cultures (e.g., Muslim), health care providers may be prohibited from touching patients of the opposite sex (Marcus, 2016). Many Asians believe that touching a person’s head is a sign of disrespect, especially because the head is believed to be the source of a person’s strength. It is not sufficient for nurses to simply learn about cross-­ cultural communication issues; they must also develop and adapt their communication skills to connect with different individuals and cultural groups (see Table 2.3). Some groups may respond effectively to direct questions, whereas others respond more comfortably in interactions that are less direct. For example, instead of telling a person what to do, a nurse may phrase the teaching in a less directive way: “Many people who experience this illness find it helpful to do . . . .” Nurses must understand that when a patient says “yes,” it can have multiple interpretations, including “Go on,” “I hear you,” “I understand,” or “I agree.” Understanding and agreement must be validated through other means. Negotiation skills are also important in cultural competence because nurses are often required to negotiate interventions between mainstream and traditional ways of healing.  Providing Effective Language Support.  Effective communication is critical for patient safety. Providing effective

TABLE 2.5    WORKING EFFECTIVELY WITH

INTERPRETERS

General Considerations • Allow extra time for the session. • Use professionally trained bilingual–bicultural interpreters instead of the patient’s family or children. • Consider personal attributes of the interpreter such as age, gender, ethnicity, and dialect that may influence communication; use the services of an agency interpreter if possible. • Be aware of common issues such as words that cannot be translated, feeling rushed, interpreter answering for the patient, or conflicts between patient and interpreter. • Verify translations to avoid misunderstandings, mistakes, and distortions.

Before the Interpretation Session • Provide an overview of the situation (patient, goals, and procedures) to the interpreter. • Ask for concerns or issues from the interpreter’s perspective. • Remind the interpreter to interpret everything. • Ask the interpreter to share their cultural insights with you but to differentiate these from the interpretation itself.

During the Interpretation Session • Introduce everyone who is present. • Determine the most appropriate person to direct questions to (if relevant). • Face who you are speaking to and speak to them directly. • Describe the role of the interpreter, the interpreter service’s mandate, and the purpose of the session. • Use simple language and avoid jargon and technical terminology. • Speak in one-­ to two-­sentence bursts to allow for easier translation. • Allow the interpreter to ask open-­ended questions, if necessary, to clarify what the patient says. • Observe the patient for off-­target reactions (signalling challenges in interpretation).

After the Interpretation Session and Follow-­Up Strategies • Consider providing written instructions as appropriate. • Ask the patient whether they have anything to ask or convey. • Debrief with the interpreter.

language support through language aids, including interpreters, is essential for patient safety. Nurses and other health care providers often feel they can get by without interpreters by using a few words in the patient’s language and actions to demonstrate meaning. However, this is a fallacy and compromises quality care (Minnican & O’Toole, 2020). Health care providers must identify encounters where linguistic support is required through trained interpreters (Ladha et al., 2018). Table 2.5 lists strategies for working effectively with interpreters, and Table 2.6 lists strategies for communicating with patients with limited proficiency in English. It is important to recognize that, even though Canada is officially a bilingual country, the francophone community is a language minority in most of the country and requires additional support. Although in-­person interpretation by trained health care interpreters is considered optimal, organizations and individuals can often use technology-­aided solutions such as telephone or remote interpretation. Caution is needed for using smartphones and applications such as Google Translate. While these aids are useful in providing basic information, they can pose risks to accuracy and thus patient safety, and such translation must be carefully validated (Ladha et al., 2018). 

CHAPTER 2  Cultural Competence and Health Equity in Nursing Care TABLE 2.6    COMMUNICATING WITH

PATIENTS WITH LIMITED ENGLISH PROFICIENCY

1. Introduce yourself and, if possible, greet patient in the patient’s preferred language. This indicates that you are aware of and respect the patient’s culture. 2. Proceed in an unhurried manner. Pay attention to any effort by the patient or family to communicate. 3. Speak in a low, moderate voice. Avoid talking loudly. Remember that there is a tendency to raise the volume and pitch of your voice when the listener appears not to understand. The listener may perceive that you are shouting or angry, or both. 4. Use simple words, such as pain instead of discomfort. Avoid medical jargon, idioms, and slang. Avoid using contractions (e.g., “don’t,” “can’t,” “won’t”) and pronouns—refer to people by name or title. 5. Provide information in the proper sequence, outlining steps such as first, second … etc. 6. Focus on one question at a time. 7. Validate understanding by having the patient repeat instructions, demonstrate the procedure, or act out the meaning. Source: Srivastava, R. (2007). Culture care framework I: Overview and cultural sensitivity. In R. Srivastava (Ed.), The healthcare professional’s guide to clinical cultural competence (pp. 53–74). Elsevier Canada.

Cognitive Domain: Developing Cultural Knowledge.  Cultural knowledge is a crucial element of cultural competence. To provide culturally competent care, nurses must identify and seek out the cultural knowledge they need (see Table 2.3). Cultural knowledge can be divided into two categories: generic cultural knowledge and specific cultural knowledge (Brown et al., 2016; Srivastava, 2007b). Generic cultural knowledge is foundational knowledge that applies across a variety of cultural groups. The most fundamental aspect of generic cultural knowledge is understanding the effect of culture on health-­and illness-­ related behaviours. Generic knowledge can be broken down into several broad areas that nurses should be aware of, such as variations in worldviews and explanatory models of illness; beliefs about care, cure, caregivers, and healing systems; family roles and relationships; migration and settlement; norms about time and personal space; and spirituality and religion (Jongen et  al., 2018; Sharifi et  al., 2019). These areas are discussed in greater detail in the next section. Specific cultural knowledge focuses on learning about specific population(s) that the nurse is working with. Because of the number of cultural groups in Canada and the dynamic nature of culture, a detailed discussion of specific cultural knowledge is beyond the scope of this chapter. Nurses need to continually educate themselves (see Table 2.3) about specific cultures they encounter frequently in their practice and always be amenable to learning from patients and families. For example, if the nurse is working in a community with large numbers of South Asian and Chinese people, it is important to learn more about the beliefs and issues relevant to these communities. While all nurses need to acquire basic understanding of the legacy of residential schools, Sixties Scoop, and the associated trauma, nurses working with specific Indigenous communities need to acquire knowledge of the specific nation(s) or bands, including their history, current issues, strengths, and challenges, as there are many differences across different Indigenous groups. Other examples of specific cultural knowledge include focusing on specific health issues faced by particular populations, such as immigrant women or the transgender community, or people with a mental illness (Bhugra, 2016; Ferdous et al., 2019;

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Suphanchaimat et  al., 2015). Table 2.3 lists other attributes of this component of cultural competence. In addition to determining the kind of generic and specific knowledge that is needed, nurses must critically appraise how knowledge is developed and used. Culture is concerned with shared patterns, not universal truths. Therefore cultural knowledge should not be used to obscure individual differences. Individualized assessments are important to determine the extent to which the patient shares the beliefs and practices ascribed to the culture. Familiarity with cultural norms is helpful but should be used carefully so it does not lead to cultural stereotyping. It is important for nurses to reflect on how they acquired the knowledge and the extent to which the knowledge is unique to the individual, reflective of the broader cultural group, or reflective of cultural processes in general. Cultural knowledge must always be regarded as tentative hypotheses that need to be verified and expanded on by patients and their families. 

Generic Cultural Knowledge Care, Cure, Caregivers, and Healing Systems.  Cultural norms have a significant influence on how illness is understood, what remedies are deemed appropriate and desirable, and who provides the care. Whereas in some cultures patients seek professional help, others rely more on family, friends, or spiritual and religious leaders. It is important to ascertain a patient’s beliefs about the cause of illness, as well as perceptions of severity, expected treatment, prognosis, and effects (see Table 2.4). Canadian health care systems and health professions have a cultural basis in the dominant white, Eurocentric culture. The biomedical approach to health care, although regarded as the conventional treatment in North America, is one of several philosophical and scientifically based systems of healing. Other such systems include homeopathy, traditional Chinese medicine, Indigenous medicine, and Ayurvedic medicine (a form of traditional Hindu medicine). Although it is not possible for a health care provider to have expertise in all healing systems, familiarity with basic principles of major systems and traditions can be helpful. Individuals often use multiple healing systems, and a critical part of patient assessment is knowledge of what conventional treatments, as well as other traditional or herbal treatments, are being used. In addition, the use of complementary and alternative therapies continues to increase across Canada (Canizares et  al., 2017). Nurses need to understand their role in supporting and providing such therapy (College & Association of Registered Nurses of Alberta, 2018). Complementary and alternative therapies are further discussed in Chapter 12. Time Orientation.  Patient values regarding time orientation and personal space can affect the care delivery process. Health care providers in hospitals and clinics are often frustrated because many patients show up late for appointments and seem to have no regard for appointments and schedules. In reality, this may be a result of several factors, including issues of transportation, ability to navigate the health care system, and time orientation. The value of clock time and punctuality is different across cultures. In Western culture time is viewed as linear with a past–present–future orientation; however, for many people, including Indigenous people, time is structured with respect to cyclical events and associated with seasons or key events. In such an orientation, “when” things happen is not as important as “that” they happen (Janca & Bullen, 2003), thus “lateness” becomes a more relative concept. In collectivist cultures—that is, cultures in which the relationships and interconnectedness

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between people are valued over the needs of the individual—it is often more important to attend to a social role than to arrive on time for an appointment with a health care provider. Hence, the lack of adherence to the appointment time can be attributed to competing demands or a different time orientation and should not be interpreted as blatant disregard or disrespect for the health care providers or the system. Missed appointment times can also be reflective of a lack of resources, such as access to transportation or dependence on others to get to the appointment.  Biology, Physiology, and Pharmacology.  As discussed earlier, racial and ethnic influences on biological and physiological processes are often viewed as controversial because these influences are considered more to be social categories than scientific categories. However, clinical realities should not be ignored. Gender differences exist in the prevalence of illness, expression of illness, and response to pharmaceutical agents. The occurrence of certain diseases in different racial and ethnic populations also varies. Genetic predisposition varies across racial and ethnic lines. For example, sickle cell disease is a common genetic disorder among people of African descent. By being aware of such illness incidences, health care providers can perform a focused and thorough assessment and can avoid stereotypical assumptions. Having knowledge of increased vulnerability can enhance clinical decision making and prevent misdiagnosis or unnecessary delays that lead to poor care. There is some evidence that ethnicity influences responses to certain medications. These variations are a result of physiological and pathophysiological differences; pharmacogenetics and genetics; environmental factors such as diet, nutritional status, smoking, and alcohol use; and simultaneous use of herbal remedies (Ramamoorthy et al., 2015). Some European and African patients metabolize medications at a slower rate, which leads to high drug levels, whereas some Japanese and Indigenous patients metabolize medications more quickly. Differences in rates of metabolism mean that individuals from Japan, China, Thailand, and Malaysia require lower doses of medications such as codeine than does a European person. Differential response has also been documented for drug classifications such as antihypertensive, antipsychotic, and antianxiety agents. Studies note that Asians often require lower dosages of antipsychotic medications and Blacks have a less favorable response to many antihypertensive medications than that of Whites (Abuatiq, 2018). Although some medications may have population-­specific recommendations, it is important for nurses to be vigilant to variations in dosage response and adverse effects. For nurses working in specialty areas, it is important to learn about the ethnocultural variations in response to the classification of medications commonly taken by their clinical population.  Family Roles and Relationships.  Family structures and roles differ from one culture to another (Figure 2.3). For this reason, it is important for nurses to determine who should be involved in the communication and decision making related to health care. For example, individualistic cultures emphasize individual rights, goals, and needs, whereas collectivist cultures assign greater priority to the needs of the group (family or community) and there is an emphasis on interdependence rather than independence (Yi, 2018). The Eurocentric health care system is very individualistic focused and places a high value on autonomy; each adult individual is expected to make decisions and sign consent forms when receiving health care. In contrast, in Asian cultures, the head of the household or the eldest son is expected

FIG. 2.3  Family roles and relationships differ from one culture to another. Source: iStock.com/Image Source.

to make health care decisions. In collectivist cultures, including Indigenous communities, affiliation is valued over confrontation, and cooperation is preferred to competition. When the nurse encounters a family that values collectivity over individualism, conflicts may arise in how decisions are made. There may be a delay in treatment while the patient waits for significant family members to arrive before giving consent for a procedure or treatment. In other instances, the patient may make a decision that is best for the family but may have negative or adverse consequences for the patient. By being aware of such values, the nurse is better prepared to engage, advocate for, and support the patient.  Spirituality and Religion.  Spirituality and religion are aspects of culture that may affect a person’s beliefs and decisions about health and illness. Spirituality is related to a person’s efforts to find purpose, particularly in challenging situations, and to facilitate healing and wellness (Jiminez & Thal, 2020). Religion is a more formal and organized system of beliefs, including belief in or worship of God, and involves prayer and one or more rituals. Religious and spiritual beliefs have been shown to positively influence health, particularly in the care of patients with mental health and addiction issues (Jimenez & Thal, 2020; Vanderweele et al., 2017). Faith communities have been positively associated with health promotion (Kiger et al, 2017). Thus it is important for health care providers to understand the role of religion, spirituality, and culture in health and illness. For some ethnocultural groups, culture, spirituality, and religion are inseparable. For example, the Indigenous culture and way of life are intertwined with religious and spiritual beliefs, and these extend to health and wellness. Similarly, Hinduism is as much a way of life as it is a religion and is also associated with a healing system. Spiritual energy in various forms such as Qi, Kami, Prana, and “spirit helpers” is associated with many cultures and, in some instances, may be supported by objects that are protective or promote healing (Young & Pompana, 2017). Often these objects, such as sweetgrass, eagle feathers, beads, thread, pictures, or religious figurines and symbols, are placed on or near a person. Nurses can show respect for these beliefs by inquiring about, recognizing, and respecting sacred objects and by seeking permission before touching or removing them from where they are placed. Nurses can also support interventions such as healing ceremonies, prayer, scriptures, listening, and

CHAPTER 2  Cultural Competence and Health Equity in Nursing Care referral to meet a patient’s spiritual and religious needs (Drost, 2019; Giske & Cone, 2015). For many cultures hair is closely connected to spirituality and ancestry (Jahangir, 2015; Stensgar, 2019); it has also been used as an instrument of oppression. Students attending residential schools had their hair cut short. In other situations, athletes have been forced to cut their hair or people have been denied employment because of their long hair (Canadian Broadcasting Corporation, 2017; Johnston, 2018). In some instances, these were deliberate acts of oppression and in others, a lack of knowledge; however, the impact of such actions can be quite traumatic for the individuals concerned and their community.  Migration and Settlement Process.  As noted earlier, recent immigrants are at risk for health issues, for many reasons. The settlement process is associated with many losses and can cause physical and mental stress. New immigrants often experience challenges in areas of the social determinants such as employment, housing, social support, and access to services. They are also at risk for social exclusion through underemployment, workplace stress, and unemployment. Older immigrants and women are especially affected by changes in role, social position, and potentially social isolation in a new country. Factors such as fatigue, stress, and racism—and, for refugees, premigratory circumstances—can result in serious physical and psychological trauma. Children and adolescents may experience challenges in negotiating their identity in a new culture. Many newcomers face difficulties in accessing the health care system because of a lack of familiarity with the system, limited English-­ language proficiency, transportation difficulties, or inability to take time away from other responsibilities related to work and family (Delara, 2016; Kalich et al., 2015). Lack of permanent resident status may also influence if and how health care is accessed. It is important to recognize that while immigrant families face many challenges, they, like other groups, also have strengths such as resilience, optimism, and experience with dealing with challenges, which need to recognized and tapped into for health and wellness (Bonmati-­Tomas et al., 2016). 

Dynamics of Difference In the ABCDE framework, dynamics of difference is not a distinctly separate domain; rather, these are distinct processes evident across each of the ABC domains. The dynamics of difference must be understood at three levels: (1) the nurse– patient level, (2) the patient–health care organization/system level, and the (3) patient–society level. At the individual level, it is important to note that although power differences exist in all nurse–patient relationships, they are magnified, often through unconscious bias, when clinicians and patients belong to different cultural groups. To ensure that patients’ rights and autonomy are respected, it is important for health care providers to be aware of their own biases, to recognize that patients may have biases based on their past experiences, and to intentionally work to build trust while being vigilant in detecting processes that can be marginalizing or exclusionary. At the level of the health care system, factors to consider include the extent to which patients and families feel understood and supported. Are families included in care? Can patients access spiritual care and ceremonies based on their needs, or are there policies prohibiting or discouraging such practices? Are there safe, welcoming spaces for marginalized communities? Are services available at times when and in places where they can be readily accessed?

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Is there diversity in the staff and clinicians? Is patient or family voice present in decisions? These are just some of the questions to consider in assessing the dynamics of difference at the level of the organization or system. At the social level, understanding the dynamics of difference means understanding the effect of systemic oppression and institutional racism. Specific actions to address the dynamics of difference are outlined throughout Table 2.3. 

Culturally Competent Practice Environment It is well documented that the culture or context of the health care environment matters as much as the culture of the patient. Effective and equitable care requires that both the clinicians and the health care setting support cultural competence. Environment highlights the importance of understanding, developing, and utilizing resources at the individual and organizational levels for ongoing learning, consultation, and referral (Drost, 2019; Jongen et  al., 2018). Health care organizations that have policies and resources to support traditional healing practices such as smudging, have flexible hours of service provision, and use welcoming family presence guidelines can greatly facilitate the provision of culturally competent care. Patients and families are a critical resource for all clinicians to learn cultural needs as well as cultural strengths and resources that may exist within a family and community. Nurses need to be open to and inviting of this knowledge, while recognizing the strengths and limitations of their own expertise. Examples of other resources include colleagues who can share experience and expertise in cross-­cultural care, language support aids such as interpreters or telephonic services, hours of service that accommodate different work schedules, and access to spiritual and faith leaders and practices. There are many community and health care agencies that serve minority communities who can serve as a resource for referrals or partnership to better serve patients. 

THE NURSE’S SELF-­A SSESSMENT As stated earlier, developing an understanding of one’s own culture through reflection and self-­assessment is a crucial first step toward practising cultural competence in clinical care. Evidence indicates that health care providers’ attitudes, whether they are conscious of them or not, have a significant influence on their interactions with other people. Recognizing and taking conscious steps to address such biases or blind spots is an essential aspect of cultural competence (Srivastava, 2007b; White et al., 2018). This requires critical self-­reflection on one’s own privilege, identity, values, and beliefs, as well as on one’s motivation and the value that one places on cultural competence and social justice. It is also important to reflect on the history and culture of the professions and the health care systems to which nursing students are being socialized. For examples of specific activities that can be undertaken to support one’s cultural competence see Anderson-­Lain (2017), Rosen et al. (2017), and White et al. (2018). Another helpful tool is Harvard University’s Implicit Association Test (IAT), which measures attitudes and beliefs that people may not even know exist within themselves. This tool can be accessed online. 

CULTURALLY COMPETENT PATIENT ASSESSMENT A cultural assessment should be a fundamental part of all patient assessments. Conducting a cultural assessment means bringing

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SECTION 1  Concepts in Nursing Practice

TABLE 2.7    CULTURALLY COMPETENT HEALTH

TABLE 2.8    LEARN MODEL FOR CROSS-­

• Become aware of your own values, beliefs, and biases. • Develop humility and a critical awareness that your own expertise is probably ethnocentric. • Know that racism, heterosexism, classism, sexism, genderism, ageism, ableism, and so forth, are taught, not innate, and that the unlearning process is ongoing. • Perceive patients and clients as experts of their own realities. • Work to build trust. • Communicate in ways that are nonjudgemental and show respect for differences. • Use open-­ended questions to understand patients’ priorities and perceptions. • Pay attention to the economic and social contexts of patients’ and families’ lives. • Inquire about health beliefs, practices, and help-­seeking behaviours. • Inquire about the role of religion and spirituality in health and illness. • Identify sources of cultural support (friends, family, community). • Advocate with and for patients and learn how to be an ally across diversity and oppression. • Challenge discrimination, marginalization, and oppression. • Assist patients in becoming informed, knowledgeable, and empowered. • Embrace learning as an ongoing process.

Listen with sympathy and understanding to the patient’s perception of the problem. Explain your perception of the problem. Acknowledge and discuss the differences and similarities. Recommend treatment. Negotiate agreement.

ASSESSMENT

a lens of culture and equity to all processes and interactions and asking key questions with regard to language, diet, and religion and eliciting the patient’s explanatory model of health and illness (see Table 2.4). Assessments become culturally appropriate through the use of cultural knowledge and skill to determine when, how, and with whom to explore particular issues. It is critical to build trust by adopting an approach that conveys respect, a nonjudgemental attitude, and a genuine desire to understand the patient’s perspective. Issues concerning personal space and gender often surface during activities involving physical assessment and personal care. Health care providers can use their position to raise cultural issues, as patients may be hesitant to bring them up. Providers must also be vigilant and sensitive to patient responses and create an environment that facilitates patients being comfortable enough to express their needs and preferences. Table 2.7 summarizes nursing actions that are part of a culturally competent health assessment. 

BRIDGING CULTURAL DISTANCES Key characteristics of cultural competence are the ability to effectively apply the ABCDEs of cultural competence—cultural awareness, knowledge, and skills in clinical situations; keep in mind the dynamics of difference; access supports available through the practice environment; and continually assess for the goal of equity. Throughout this chapter, strategies that can be used to bridge gaps and differences across cultures have been discussed. One model useful for summarizing this discussion is the LEARN (listen, explain, acknowledge, recommend, and negotiate) model (Table 2.8), which offers simple but comprehensive guidelines for cross-­ cultural health care (Ladha et al., 2018). The LEARN model enables the nurse to reveal and acknowledge patients’ values and perspectives and practise in a professional manner by sharing the nurse’s expertise. By listening first, the nurse is

CULTURAL CARE

Source: Ladha, T., Zubairi, M., Hunter, A., Audcent, T., & Johnstone, J. (2018). Cross-­ cultural communication: Tools for working with families and children. Pediatrics & Child Health, 23(1), 66–69. https://doi.org/10.1093/pch/pxxl26

FIG. 2.4  Nurses working together in a multicultural health environment. Source: iStock.com/FatCamera.

less likely to give the impression of being hurried or too busy and will be able to tailor explanations in ways that are relevant for the patient. Another approach discussed in the Culture Care Framework (Srivastava 2007b) highlights the importance of acknowledging and validating patient values and beliefs; accommodating and negotiating treatments and approaches to care; and challenging perceptions through reframing interpretations associated with certain practices based on evidence. For example, many collectivist cultures focus on caring for others, thus care that is self-­focused may initially be viewed as a self-­centred; however, reframing self-­care as the ability to have capacity to care for others makes it more acceptable. Throughout this text, special “Culturally Competent Care” sections highlight knowledge and skills relevant to providing culturally competent health care. 

WORKING IN DIVERSE TEAMS Interactions between patients and health care providers are not the only situations in which cross-­cultural issues and challenges can arise. The increasing diversity in society also affects the makeup of the health care team (Figure 2.4). In general, workforce diversity is viewed as a positive attribute and a valuable resource to support the development of cultural competence and the provision of culturally relevant care. A diverse working team creates opportunities for cultural encounters and interactions that can result in greater cultural understanding and better delivery of care. However, diversity in the workforce has its challenges. Although culturally diverse

CHAPTER 2  Cultural Competence and Health Equity in Nursing Care groups have more potential to generate a greater variety of ideas and other resources than do culturally homogeneous groups, racially and ethnically mixed groups can experience more conflict and miscommunication than homogeneous groups. When health care providers from different cultures and countries work together as members of the health care team, opportunities for miscommunication and conflict naturally arise (Adeniranet al., 2015). These challenges can be minimized through the same principles of respect, empathy, and learning from difference that apply to nurse–patient interactions. 

CONCLUSION The need for cultural competence is a fundamental issue of health care quality and patient safety, and achieving it requires a commitment to principles of inclusiveness and equity. Cultural awareness and knowledge must be translated into action. Developing cultural competence is a journey in which nurses begin with strengthening their self-­awareness. They develop a generic knowledge base and, with time and experience, acquire additional knowledge specific to populations and aspects of care. They become aware of and sensitively address the dynamics of differences and tap into resources within the practice environment. It is important for nurses to combine the use of this information and knowledge with critical reflection and critical thinking. A commitment to health equity requires that nurses understand vulnerabilities as well as the strengths that exist within individuals and communities. This approach adds both

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CASE STUDY Communication Patient Profile M. J., 45 years old (pronouns she/her), is admitted to the hospital for investigation of a tumour. M. J.’s husband is also present. The healthcare provider explains to the couple that the prognosis is excellent and the treatment involves radiation. She plans to schedule the first treatment the following week. M. J. and her husband have been in Canada for approximately 3 years, and both speak English, albeit with an accent. There have been no difficulties in communicating in English with either M. J. or M. J.’s husband, although her husband tends to do most of the talking. While the healthcare provider is explaining the diagnosis, they listen intently, nod periodically, and do not raise any questions or objections to the plan. The healthcare provider assumes that the patient is in agreement with her plan. 

Discussion Questions 1. S  hould the nurse who is present for this discussion agree with the healthcare provider’s assessment? 2. What factors may be influencing the couple’s silence? 3. What actions could be taken by the nurse who is present for this discussion or the doctor that would reflect cultural competence?

Answers available at http://evolve.elsevier.com/Canada/Lewis/medsurg.

depth and breadth to the nurse’s clinical competence and ability to provide care that is truly patient-centred.

 REVIEW QUESTIONS

The number of the question corresponds to the same-­numbered objective at the beginning of the chapter. 1. Which of the following is an example of forcing one’s own cultural beliefs and practices on another person? a. Stereotyping b. Ethnocentrism c. Cultural relativity d. Cultural imposition 2. Which of the following most accurately describes cultural factors that may affect health? a. Diabetes and cancer rates differ by cultural and ethnic groups. b. Most clients find that religious rituals help them during times of illness. c. There is limited ethnic variation in physiological responses to medications. d. Silence during a nurse–client interaction usually means that the client understands the instructions. 3. Which of the following is true about inequities between Indigenous health and the health of the general population? (Select all that apply.) a. They result from lifestyle choices. b. They result from differences in living conditions, such as housing and education. c. They result from conflict between systems of Indigenous medicine and Western health care concepts. d. They result from bias and discrimination from the mainstream system. 4. Why is it important for the nurse to develop cultural self-­awareness? (Select all that apply.)

a. This enables the nurse to clearly articulate the nurse’s own values to the client. b. This enables the nurse to prevent ethnocentrism. c. This enables the nurse to prevent cultural imposition. d. This enables the nurse to challenge their own assumptions and stereotypes. 5. In communications with a client who speaks a language different from the nurse’s, which of the following interventions is important? a. Have a family member translate. b. Use a trained medical interpreter. c. Use specific medical terminology so that there will be no mistakes in the information communicated. d. Focus on the translation rather than the nonverbal communication. 6. Which of the following strategies are appropriate for demonstrating cultural competence in clinical care? (Select all that apply.) a. Explaining to the client and family how the Canadian health care system works b. Exploring economic and social factors affecting the client and family c. Pairing the client with a provider from the client’s own cultural community d. Exploring the client’s explanatory model of illness 7. How does a diverse workforce influence a nurse’s ability to provide care? a. It facilitates matching clients with health care providers of the same ethnicity.

SECTION 1  Concepts in Nursing Practice

b. It exposes the nurse to different values, beliefs, and worldviews. c. It leads to greater creativity and innovation and to the development of appropriate interventions for diverse clients. d. It meets mandated objectives of the federal and provincial governments.

For even more review questions, visit http://evolve.elsevier.com/Cana 1. d; 2. a, d; 3. c, d; 4. c, d; 5. c; 6. b; 7. b.

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da/Lewis/medsurg.

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first rapid review on this concept. BMC Health Services Research, 20, 20. https://doi.org/10.1186/s12913-­019-­4859-­6 Morency, J.-­D., Malenfant, E. C., & MacIsaac, S. (2017). Immigration and diversity: Population projections for Canada and its regions, 2011 to 2036. Statistics Canada Catalogue no. 91-­551-­X. https:// www150.statcan.gc.ca/n1/pub/91-­551-­x/91-­551-­x2017001-­eng.htm Murray, H., & Kulckhohn, C. (1953). Personality in Nature, Society, and Culture. www.panarchy.org/kluckhohn/personality.1953.html. (Seminal). Ontario Ministry of Health and Long-­Term Care. (2021). Health equity impact assessment. http://www.health.gov.on.ca/en/pro/pro grams/heia/ Paradies, Y., Ben, J., Denson, N., et al. (2015). Racism as a determinant of health: A systematic review and meta-­analysis. PLoS ONE, 10(9), 1–48. https://doi.org/10.1371/journal.pone.0138511 Public Health Agency of Canada. (2018). Key health inequities in Canada: A national portrait. Pan-­Canadian Health Inequities Reporting Initiative. https://www.canada.ca/content/dam/phac-­asp c/documents/services/publications/science-­research/key-­health-­ inequalities-­canada-­national-­portrait-­executive-­summary/hir-­full-­ report-­eng.pdf Ramamoorthy, A., Pacanowski, M. A., Bull, J., et al. (2015). Racial/ ethnic differences in drug disposition and response: Review of recently approved drugs. Clinical Pharmacology & Therapeutics, 97(3), 263–273. https://doi.org/10.1002/cpt.61 Reich, D. (2018, March 23). How genetics is changing our understanding of ‘race’. The New York Times. https://www.nytimes.com/ 2018/03/23/opinion/sunday/genetics-­race.html Richmond, C. A. M., & Cook, C. (2016). Creating conditions for Canadian Aboriginal health equity: The promise of healthy public policy. Public Health Reviews, 37(2), 1–16. https://doi.org/10.1186/ s40985-­016-­0016-­5. (Seminal). Rosen, D., McCall, J., & Goodkind, S. (2017). Teaching critical self reflection through the lens of cultural humility: an assignment in a social work diversity course. Social Work Education, 36(3), 289–298. https://doi.org/10.1080/02615479.2017.1287260 Sharifi, N., Adib-­Haijbaghery, M., & Najafi, M. (2019). Cultural competence in nursing: A concept analysis. International Journal of Nursing Studies, 99, 1–8. https://doi.org/10.1016/j.ijnurstu.2019.103386 Small, P. M. (2019). Structural justice and nursing: Inpatient nurses’ obligation to address social justice needs of patients. Nursing Ethics, 26(7-­8), 1928–1935. https://doi. org/10.1177/0969733018810764 Srivastava, R. (2007a). Culture care framework I: Overview and cultural sensitivity. In R. Srivastava (Ed.), The healthcare professional’s guide to clinical cultural competence (pp. 53–74). Elsevier Canada (Seminal). Srivastava, R. (2007b). Culture care framework II: Culture knowledge, resources, and bridging the gap. In R. Srivastava (Ed.), The healthcare professional’s guide to clinical cultural competence (pp. 75–100). Elsevier Canada (Seminal). Srivastava, R. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 8(1), 25–31 (Seminal). Srivastava, R., & Srivastava, R. (2019). Impact of cultural identity on mental health in post-­secondary students. International Journal of Mental Health and Addiction, 17, 520–530. https://doi.org/10.1007/ s11469-­018-­0025-­3 Smith, M. A. (2019). The promotion of social justice. Nursing Made Incredibly Easy, 17(2), 26-­32. https://doi.org/10.1097/01.NME.000 0553091.78584.a9

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Statistics Canada. (2017a). Aboriginal peoples in Canada: Key results from the 2016 Census (Updated 2019). https://www150.statcan.gc. ca/n1/daily-­quotidien/171025/dq171025a-­eng.htm Statistics Canada. (2017b). Immigration and ethnocultural diversity: Key results from the 2016 Census. https://www150.statcan.gc.ca/n1/ daily-­quotidien/171025/dq171025b-­eng.htm Statistics Canada. (2019). Diversity of the Black population in Canada: An overview. Statistics Canada Catalogue no. 89-­657-­X. Statistics Canada, Ethnicity, Language and Immigration Thematic Series. http s://www150.statcan.gc.ca/n1/en/pub/89-­657-­x/89-­657-­x2019002-­ eng.pdf?st=p4nh4jOc Stensgar, B. (2019). The significance of hair in Native American culture. https://sistersky.com/blogs/sister-­sky/the-­significance-­of-­hair-­in-­ native-­american-­culture Suphanchaimat, R., Kantamaturapoj, K., Putthasri, W., et al. (2015). Challenges in the provision of healthcare services for migrants: A systematic review through providers’ lens. BMC Health Services Research, 15(1), 1–14. https://doi.org/10.1186/s12913-­015-­1065-­z Truth and Reconciliation Commission of Canada (TRC). (2015). Truth and Reconciliation Commission of Canada: Calls to action. Truth and Reconciliation Commission of Canada. VanderWeele, T., Balboni, T., & Koh, H. (2017). Health and Spirituality. JAMA, 318(6), 519–520. https://doi.org/10.1001/ jama.2017.8136 White, A. A., Logghe, H. J., Goodenough, D. A., et al. (2018). Journal of Racial and Ethnic Disparities, 5, 34–49. https://doi.org/10.1007/ s40615-­017-­0340-­6 Yi, J. S. (2018). Revisiting individualism-­collectivism: A cross cultural comparison among college students in four countries. Journal of Intercultural Communication, 47, 1404–1634. Young, D., Pompana, C., & Willier, R. (2017). The concept of spiritual power in East Asian and Canadian Aboriginal thought. Social Compass, 64(3), 376–387. https://doi. org/10.1177/0037768617713657

RESOURCES Canadian Institute of Health Research: Pathways to Health Equity for Aboriginal Peoples: Overview https://www.cihr-­irsc.gc.ca/e/43630.html Canadian Psychological Association: Culturally Competent Care for Diverse Groups https://cpa.ca/practice/cultural/

Caring for Kids New to Canada: Cultural Competence for Child and Youth Health Professionals https://www.kidsnewtocanada.ca/culture/competence Cultural Competence: A Guide to Organizational Change https://albertahumanrights.ab.ca/Documents/ CulturalCompetencyGuide.pdf First Nations Health Authority: Cultural Safety and Humility https://www.fnha.ca/wellness/cultural-­humility Multicultural Mental Health Resource Centre: Cultural Competence: Tools & Resources https://multiculturalmentalhealth.ca/cultural-­competence-­tools­and-­resources/ National Aboriginal Health Organization https://www.naho.ca/ SickKids Cultural Competence E-­Learning Modules Series https://www.sickkids.ca/tclhinculturalcompetence/index.html Dimensions of Culture: Cross Cultural Communications for Health Professionals http://www.dimensionsofculture.com/ Ethnicity Online http://www.ethnicityonline.net/ National Center for Cultural Competence at Georgetown University https://nccc.georgetown.edu/ Project Implicit: Harvard University Implicit Association Test https://implicit.harvard.edu/implicit/ The Disparities Solutions Center https://mghdisparitiessolutions.org/ Think Cultural Health https://www.thinkculturalhealth.hhs.gov/ US Department of Health & Human Services, Office of Minority Health: Cultural and Linguistic Competence http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=1&lvlid=6

For additional Internet resources, see the website for this book at http: //evolve.elsevier.com/Canada/Lewis/medsurg.

CHAPTER

3

Health History and Physical Examination Mary Ann Fegan Originating US chapter by Courtney Reinisch

WEBSITE http://evolve.elsevier.com/Canada/Lewis/medsurg • R  eview Questions (Online Only) • Key Points • Conceptual Care Map Creator

• A  udio Glossary • Content Updates

LEARNING OBJECTIVES 1. Describe the purpose, components, and techniques of gathering a patient’s health history and performing a physical examination. 2. Discuss the functional health pattern framework used for obtaining a nursing history.

3. Explain how the techniques of inspection, palpation, percussion, and auscultation are used during the physical examination of a patient. 4. Differentiate among comprehensive, focused, and emergency types of assessment in terms of indications, purposes, and components.

KEY TERMS auscultation database general survey statement inspection

  

nursing history objective data palpation percussion

During the assessment phase of the nursing process, the nurse documents a patient’s health history and performs a physical examination. The findings of this assessment (a) contribute to a database that identifies the patient’s current and past health status and (b) provide a baseline against which future changes can be evaluated. The purpose of the nursing assessment is to enable the nurse to make clinical judgements or nursing diagnoses about the patient’s health status (Jarvis et al., 2019). While assessment is the first step of the nursing process, it is performed continuously throughout the nursing process to validate nursing diagnoses, evaluate nursing interventions, and determine whether patient outcomes and goals have been met. Note: This chapter provides a basic overview and review of health assessment and physical examination. A detailed health assessment textbook will provide more information and direction regarding how to perform a physical examination and how to identify and document abnormal findings.

DATA COLLECTION In the broadest sense, the database is all the health information about a patient. This includes the data from the nursing history and physical examination, the data from the medical history and

physical examination subjective data

physical examination, results of laboratory and diagnostic tests, and information contributed by other health care providers. The focus of nursing care is the diagnosis and treatment of human responses to actual or potential health concerns or life processes. The information obtained from the nursing history and physical examination is used to determine the patient’s strengths and responses to a health condition. For example, for a patient with a diagnosis of diabetes, the patient’s responses may include anxiety or a lack of knowledge about self-­management of the condition. The patient may also experience the physical response of fluid volume deficit because of the abnormal fluid loss caused by hyperglycemia. These human responses to the condition of diabetes are diagnosed and treated by nurses. During the nursing history interview and physical examination, the nurse obtains and records the data to support the identification of nursing diagnoses (Figure 3.1). The purpose of the health history is to collect both subjective and objective data. Subjective data, also known as symptoms, are collected in an interview with the patient (primary source) or caregiver (secondary source), or both, during the nursing history. This type of data includes information that can be described or verified only by the patient or caregiver. It is what the person tells the nurse either spontaneously or in response to a direct question.

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FIG. 3.1  Obtaining a nursing history is an important role of the nurse. Source: iStock.com/monkeybusinessimages.

Objective data, also known as signs, are data that can be observed and measured. The nurse obtains this type of data by using inspection, palpation, percussion, and auscultation during the physical examination. Objective data are also acquired by diagnostic testing. Patients often provide subjective data while the nurse is performing the physical examination. The nurse also observes objective signs while interviewing the patient. All findings related to a specific health issue, whether subjective or objective, are known as clinical manifestations of that issue.

Interviewing Considerations The purpose of the patient interview is to obtain a complete health history (e.g., subjective data) about the patient’s past and present health status. Effective communication is a key factor in the interview process. Creating a climate of trust and respect is crucial for establishing a therapeutic relationship, as is the nurse’s ability to engage in reflective practice. This ability includes the required capacities of self-­awareness, self-­knowledge, empathy, and awareness of boundaries and limits of the professional role (Registered Nurses’ Association of Ontario, 2006). The nurse needs to communicate acceptance of the patient as an individual by using an open, responsive, nonjudgemental approach. Nurses and patients communicate not only through language but also in their manner of dress, gestures, and body language. An awareness of culturally accepted nonverbal communication is important. For example, simple eyebrow-­raising indicates a positive response or “yes” answer for the Inuit population. Modes of communication are learned through one’s culture and influence—not only the words, gestures, and posture one uses but also the nature of the information that is shared with others (see Chapter 2 for discussion on culture). The amount of time needed to complete a nursing history may vary with the format used and the experience of the nurse. The nursing history may be completed in one or several sessions, depending on the setting and the patient. For example, several short sessions might be needed for an older patient with a low energy level to allow time for the patient to provide the needed information. The nurse must also make a judgement about the amount of information collected on initial contact with the patient. In interviews with patients with chronic disease, patients in pain, and patients in emergency situations, the nurse should ask only questions that are pertinent to a specific problem. The nurse can complete the health history interview at a more appropriate time.

Before beginning the nursing history, the nurse should explain to the patient that the purpose of a detailed history is to collect information that will provide a health profile for comprehensive health care, including health promotion. This detailed information is collected during the patient’s entry into the health care system, and subsequently, only updates are needed. The nurse should explain that personal and social data are needed to individualize the plan of care. This explanation is necessary because the patient may not be accustomed to sharing personal information and may need to know the purpose of such questioning. The nurse should assure the patient that all information will be kept confidential. The Canadian Nurses Association (CNA) requires that nurses protect the confidentiality of all information obtained in the context of the professional relationship and practise within the bounds of relevant laws governing privacy and confidentiality of personal health information. The CNA Code of Ethics for Registered Nurses provides helpful guidelines for ensuring confidentiality in nursing practice (CNA, 2017). To obtain factual, easily categorized information, a direct interview technique can be used. Closed-­ended questions such as “Have you had surgery before?” that require brief, specific responses are used. When asking sensitive personal and social questions, the nurse can communicate the acceptance or normality of behaviours by prefacing questions with phrases such as “most people” or “frequently.” For example, stating, “Many people taking antihypertensive drugs have concerns about sexual functioning; do you have any you would like to discuss?” shows the patient that a particular situation may not be unique to that patient. The nurse must judge the reliability of the patient as a historian. An older person may give a false impression about their mental status because of prolonged response time or visual and hearing impairment. The complexity and long duration of health issues may make it difficult for an older person or a chronically ill younger patient to be an accurate historian. It is important for the nurse to determine the patient’s priority concerns and expectations because the nurse’s priorities may be different from the patient’s. For example, the nurse’s priority may be to complete the health history, whereas the patient is interested only in relief from symptoms. Until the patient’s priority need is met, the nurse will probably be unsuccessful in obtaining complete and accurate data. 

Teamwork and Collaboration Ongoing data collection is expected of all members of the health care team. In acute-care settings, the initial (admission) nursing assessment must be completed by a registered nurse (RN) and within the time frame determined by the employer. A registered/licensed practical nurse (PN) will often be responsible for collecting and documenting specific patient data as delegated by the RN, after the RN has developed the plan of care on the basis of the admission assessment findings.  Data Organization Assessment data must be systematically obtained and organized so that the nurse can readily analyze and make judgements about the patient’s health status and any health concerns. Information about the patient in various health care settings can be gathered in numerous approaches and formats. The format used in this chapter for obtaining a nursing history includes the following sequence of categories, similar to those outlined by Jarvis et al.

CHAPTER 3  Health History and Physical Examination

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TABLE 3.1    INVESTIGATION OF PATIENT-­REPORTED SYMPTOM Factor

Questions for Patient and Caregiver

Record

Precipitating and palliative

Were there any events that came before the symptom? What makes it better? Worse? What have you done for the symptom? Did this help? Tell me what the symptom feels like (e.g., aching, dull, pressure, burning, stabbing). Where do you feel the symptom? Does it move to other areas?

Influence of physical and emotional activities Patient’s attempts to alleviate (or treat) the symptom

Quality Radiation Severity

Timing

Understanding

On a scale of 0–10, with 0 meaning no pain and 10 being the worst pain you could imagine, what number would you give your symptom? When did the symptom start? Was it sudden or gradual? Any particular time of day, week, month, or year? Has the symptom changed over time? Where are you, and what are you doing when the symptom occurs? Understand the patient’s perception of the symptom: What do you think it means?

(2019). These assessment data provide a generic database for all health care providers: 1. Biographical data 2. Reason for seeking care 3. Current health status or history of current illness 4. Past health history 5. Family health history 6. Review of systems 7. Functional assessment CULTURALLY COMPETENT CARE ASSESSMENT

The process of obtaining a health history and performing a physical examination is an intimate experience for the nurse and the patient. As noted earlier in the chapter, a person’s culture influences patterns of communication and what information is shared with others. During the interview and physical examination, the nurse must be sensitive to issues of eye contact, space, modesty, and touching, as discussed in Chapter 2. Knowing the cultural norms related to male–female relationships is especially important during the physical examination. To avoid violating any culturally based practices, the nurse can ask the patient about cultural values. The nurse should determine whether the patient would like to have someone else present during the history taking or physical examination or would prefer someone of the same gender to perform the history taking and physical examination (Jarvis et al., 2019). Note: Additional screening or focused assessments may be required during epidemics or pandemics. For example, during the COVID-­19 pandemic, advance screenings and assessments were required prior to entering health care facilities. 

NURSING HISTORY: SUBJECTIVE DATA Biographical Data The nurse records the patient’s name, address, contact information, age, birth date, marital status, partner or significant other, ethnocultural background, primary language, and current occupation. Advance care directives can be documented among these data (see Chapter 13). Also important to include here is the source of history: who is providing the information, how reliable the informant seems, and any special circumstances, such as the use of an interpreter (Jarvis et al., 2019). 

Patient’s own words (e.g., “Like a pinch or stabbing feeling”) Region of the body Local or radiating, superficial or deep Pain rating number (e.g., 5/10)

Time of onset, duration, periodicity, and frequency Course of symptoms Where the patient is and what the patient is doing when the symptom occurs Patient’s own words about what the problem means to them

Reason for Seeking Care The reason for seeking care is a brief statement in the patient’s own words describing the reason for the visit. This statement is documented in quotation marks to indicate the patient’s exact words (e.g., “My head has been aching for 3 days”; “My child has a fever and has been vomiting since last evening”).  Current Health or History of Current Illness This section is a chronological record of the reason for seeking care, beginning with the first time the symptom appeared until now. Symptoms experienced by the patient are not observed, so the symptoms must be explored. Table 3.1 shows a mnemonic (PQRSTU) to help remember the areas to explore if a symptom is reported. The information that is obtained may help determine the cause of the symptom. A common symptom assessed is pain (see Chapter 10). For example, if a patient states that he has “pain in his leg at times,” the nurse would assess and record the data with the use of PQRSTU: Has right midcalf pain that usually occurs at work when climbing stairs after lunch (P). Pain is alleviated by stopping and resting for 2 to 3 minutes. Patient thinks this pain is a “muscle cramp” and states he has been “eating a banana every day for extra potassium” but “it hasn’t helped” (U, P). Pain is described as “stabbing” and is nonradiating (Q, R). Pain is so severe (rating 9 on 0–10 scale) that patient cannot continue activity (S). Onset is abrupt, occurring once or twice daily. It last occurred yesterday while he was cutting the lawn (T). 

Past Health History The past health history provides information about the patient’s prior state of health. The patient is asked specifically about major childhood and adult illnesses, injuries, hospitalizations, surgeries, obstetrical history (if relevant), immunizations, and allergies. This documentation should include questions about any infectious diseases such as human immunodeficiency virus (HIV) infection, hepatitis, methicillin-­resistant Staphylococcus aureus (MRSA) infection, and vancomycin-­resistant enterococcal (VRE) infection. Specific questions are more effective than simple questions of whether the patient has had any illness or health issues in the past. For example, the question “Do you have a history of diabetes?” elicits better information than does “Do you have any chronic health problems?”

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Medications.  The nurse should obtain specific details related to past and current medications, including prescription, medical recreational (e.g., cannabis), and over-­the-­counter drugs; vitamins; herbs; traditional medicines; nutritional supplements; and illegal substance use. The brown-­bag technique encourages patients to bring all of their medications, herbs, and supplements with them and is effective in determining what medications the patient is taking and how they are taking them. Indigenous patients should feel safe and respected when asked to share any traditional medicines they are using. It’s important for the nurse to ask about all types of medicines because they can interact adversely with existing or newly prescribed medications (see Chapter 12, Table 12.5). Older patients and chronically ill patients should be questioned about medication routines; for these patients, polypharmacy, changes in absorption, distribution, metabolism, and elimination of and reaction to medications can pose serious potential problems (Touhy et al., 2018). 

Family Health History The nurse should ask about the health of family members, as well as the ages at and cause of death of blood relatives, such as parents, siblings, and grandparents. Common questions include those about any family history of heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sickle cell disease, arthritis, allergies, obesity, alcoholism, mental health issues or illness, seizure disorder, kidney disease, and tuberculosis (Jarvis et al., 2019). A genogram or family tree will help the nurse accurately document this information. Family health histories may be difficult to obtain from some Indigenous people for a variety of reasons, such as being separated from their families during the Sixties Scoop and relocation to residential schools, not understanding medical terminology, not being aware of relatives’ illnesses and hospitalizations, experiencing fragmented care in remote communities, and lacking trust in the health care system.  Review of Systems The nurse should use a head-­to-­toe approach to inquire about past and current health states of each body system. This part of the nursing history records subjective data only and provides an opportunity to collect data that may have been omitted in previous categories as well as health promotion practices. System-­specific assessment questions are included in the assessment chapters of this text (see, for example, Chapter 34, Table 34.2 for health history of the cardiovascular system). Detailed health assessment textbooks will provide additional information, formats, and examples of completed review of systems documentation.  Functional Health Assessment The nurse assesses the patient’s overall self-­care ability, including activities of daily living (ADLs) such as bathing, dressing, toileting, eating, and walking, as well as instrumental activities of daily living (IADLs), or activities needed for independent living such as housekeeping, shopping, cooking, doing laundry, using the telephone, and managing finances; getting adequate nutrition; having social relationships and resources; promoting self-­concept; and coping and maintaining a home environment (Jarvis et  al., 2019). Assessing functional health enables the nurse to identify positive, dysfunctional, and potentially dysfunctional patterns. Dysfunctional health patterns result in

nursing diagnoses, and potential dysfunctional patterns identify risk conditions for health concerns. Gordon’s (2014) functional health pattern framework for assessment can assist the nurse in differentiating between areas for independent nursing intervention and areas necessitating collaboration or referral. The nurse may identify patients with effective health functions who express a desire for a higher level of wellness. It is also important to consider the social determinants of health to ensure a complete and relevant health history assessment. The nurse should explore the patient’s living conditions by asking about employment, working conditions, well-­being, health and social services received, and the ability to obtain a quality education, food, and housing, among other factors (Mikkonen & Raphael, 2010). Health Perception–Health Management.  Assessment of the patient’s health perception and health management focuses on the patient’s perceived level of health and well-­being and on personal practices for maintaining health. The nurse should ask the patient to describe their personal health and any concerns they might have. The patient’s opinions about the effectiveness of health maintenance practices can be explored with questions about what helps and what hinders their well-­being. The nurse should ask the patient to rate their health as excellent, good, fair, or poor. When possible, this information is best recorded in the patient’s own words. Asking about the type of health care providers that the patient uses is also important. For example, if the patient is an Indigenous Canadian, a traditional healer may be considered the primary health care provider. If the patient is of Chinese origin, a Chinese healer who practices traditional Chinese medicine may be the primary health care provider. Other questions are used to identify risk factors, by obtaining a thorough family history (e.g., cardiac disease, cancer, genetic disorders), history of personal health habits (e.g., tobacco, alcohol, drug use), and history of exposure to environmental hazards (e.g., asbestos). If the patient is hospitalized, the nurse should ask about their expectations for this experience. The patient can be asked to describe their understanding of the current health issue, including its onset, course, and treatment. These questions elicit information about a patient’s knowledge of their health issue and their ability to use appropriate resources to manage it.  Nutrition–Metabolic.  The nurse must assess the patient’s processes of ingestion, digestion, absorption, and metabolism. A 24-­hour dietary recall should be obtained from the patient to evaluate the quantity and quality of foods and fluids consumed. If a problem is identified, the nurse may ask the patient to keep a 3-­day food diary for a more careful analysis of dietary intake. The effect of psychological factors such as depression, anxiety, stress, and self-­concept on nutrition should be assessed. In addition, socioeconomic and cultural factors such as food budget, who prepares the meals, and food preferences are also recorded. To determine whether the patient’s present condition has interfered with eating and appetite, the nurse can explore any symptoms of nausea, intestinal gas, or pain. Food allergies should be differentiated from food intolerances, such as lactose or gluten intolerance.  Elimination.  To assess bowel, bladder, and skin function, the nurse should ask the patient about the frequency of bowel and bladder activity, including laxative and diuretic use. The skin is assessed again in the elimination pattern in terms of its excretory function. 

CHAPTER 3  Health History and Physical Examination Activity–Exercise.  The nurse assesses the patient’s usual pattern of exercise, work activity, leisure, and recreation. The patient should be questioned about their ability to perform ADLs and any specific problems identified.  Sleep–Rest.  It is important for the nurse to describe the patient’s perception of their pattern of sleep, rest, and relaxation in a 24-­hour period. This information can be elicited by asking, “Do you feel rested when you wake up?”  Cognitive–Perceptual.  Assessment of this area involves a description of all of the senses and cognitive functions. Pain is assessed as a sensory perception in this pattern. (See Chapter 10 for details on pain assessment.) The patient should be asked about any sensory deficits that affect their ability to perform ADLs. Ways in which the patient compensates for any sensory-­ perceptual problems should be recorded. To plan for patient teaching, the nurse can ask the patient how they learn and communicate best and what they understand about the illness and treatment plan. (See Chapter 4 for details on patient teaching.)  Self-­Perception–Self-­Concept.  The nurse should explore the patient’s self-­concept, which is crucial for determining the way the person interacts with others. Included are attitudes about self, perception of personal abilities, body image, and a general sense of worth. The nurse should ask the patient for a self-­description and about how their health condition affects self-­concept. A patient’s expressions of helplessness or loss of control frequently reflect an inability to care for themselves.  Role–Relationship.  The nurse should explore the patient’s roles and relationships, including major responsibilities. The patient should be asked to describe family, social, and work roles and relationships and to rate their performance of the expected behaviours related to these. The nurse should determine whether patterns in these roles and relationships are satisfactory or whether strain is evident. The nurse should note the patient’s feelings about how the current condition affects their roles and relationships.  Sexuality–Reproductive.  The nurse needs to evaluate the patient’s satisfaction or dissatisfaction with personal sexuality, sexual identity, and potential reproductive issues. Assessing these aspects is important because many illnesses, surgical procedures, and medications affect sexual function. A patient’s sexual and reproductive concerns may be expressed, and teaching needs may be identified through information obtained in this assessment. The interview should be appropriate for the patient’s developmental stage as well as their self-­identified gender, sexuality, and expression. The nurse should screen for sexual function and dysfunction in a nonjudgemental way and provide information as appropriate or refer the patient to a more experienced health care provider. It is important to acknowledge that discussing sexual health may be difficult for some patients, especially those who have experienced trauma. Some Indigenous people feel humiliated by a discussion about sexuality, as a result of residential school impacts on sexual health through imposed religious beliefs and Western values, sexual abuse, and shaming about sexuality (O’Brien et al., 2009; Wiebe et al., 2015).  Coping–Stress Tolerance.  The nurse should describe the patient’s general coping pattern and the effectiveness of the coping mechanisms. Assessment of this pattern involves analyzing the specific stressors or problems that confront the patient, the patient’s perception of the stressors, and the patient’s response to the stressors. The nurse should document any major losses or stressors experienced by the patient in the previous year.

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Strategies used by the patient to deal with stressors and relieve tension should be noted. The nurse should ask about individuals and groups that make up the patient’s social support networks.  Value–Belief.  The nurse should describe the values, goals, and beliefs (including spiritual) that guide health-­ related choices. The patient’s ethnic background and the effects of culture and beliefs on health practices should be documented. The patient’s wishes about the continuation of religious or spiritual practices and the use of religious articles should be noted and respected. 

PHYSICAL EXAMINATION: OBJECTIVE DATA General Survey After the nursing history, the nurse makes a general survey statement. This reflects a general impression of a patient, including behavioural observations. This initial survey begins with the nurse’s first encounter with the patient and continues during the health history interview. The major areas included in the general survey statement are (a) body features, (b) mental state, (c) speech, (d) body movements, (e) obvious physical signs, (f) nutritional status, and (g) behaviour. Vital signs, height, and weight or body mass index (BMI) (calculated from height and weight [kg/m2]) may be included. The following is a sample of a general survey statement: A.H. is a 34-­year-­old Italian woman, BP 130/84, P 88, R 18. No distinguishing body features. Alert but anxious. Speech is rapid, with trailing thoughts. Wringing hands and shuffling feet during the interview. Skin flushed, hands clammy. Overweight relative to height (BMI = 28.3 kg/m2). Sits with eyes downcast, shoulders slumped, and avoids eye contact. 

Physical Examination The physical examination is the systematic assessment of a patient’s physical status. Throughout the physical examination, the nurse explores any positive findings, using the same criteria as those used during the investigation of a symptom in the nursing history (see Table 3.1). A positive finding indicates that the patient has or had a particular health issue or sign under discussion (e.g., if the patient with jaundice has an enlarged liver, it is a positive finding). Relevant information about this health issue should then be gathered. Negative findings may also be significant. A negative finding is the absence of a sign or symptom usually associated with a health issue. For example, peripheral edema is common with advanced liver disease. If edema is not present in a patient with advanced liver disease, this should be specifically documented as “no peripheral edema.” Techniques.  Four major techniques are used in performing the physical examination: inspection, palpation, percussion, and auscultation. The techniques are usually performed in this sequence, except for the abdominal examination (inspection, auscultation, percussion, and palpation). Performing palpation and percussion of the abdomen before auscultation can alter bowel sounds and produce false findings. Not every assessment area requires the use of all four assessment techniques (e.g., for the musculoskeletal system, only inspection and palpation are required). Inspection.  Inspection is the visual examination of a part or region of the body to assess normal and abnormal conditions. Inspection is more than just looking. This technique is

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SECTION 1  Concepts in Nursing Practice

FIG. 3.2  Palpation is the examination of the body using touch. Source:

FIG. 3.3  Percussion technique: tapping the interphalangeal joint. Only the

deliberate, systematic, and focused. The nurse must compare what is seen with the known, generally visible characteristics of the body part being inspected. For example, most 30-­year-­old men have hair on their legs. Absence of hair may indicate a vascular issue and signals the need for further investigation, or it may be normal for a patient of a particular ethnicity (e.g., First Nations men have little body hair).  Palpation.  Palpation is the examination of the body through the use of touch. Using light and deep palpation can yield information about masses, pulsations, organ enlargement, tenderness or pain, swelling, muscular spasm or rigidity, elasticity, vibration of voice sounds, crepitus, moisture, and texture. Different parts of the hand are more sensitive for specific assessments. For example, the palmar surface (base of fingers) should be used to feel vibrations; the dorsa (back) of the hands and fingers, to assess skin temperature; and tips of the fingers, to palpate the abdomen (Jarvis et al., 2019) (Figure 3.2).  Percussion.  Percussion is a technique of tapping the body directly or indirectly with the fingertips to produce a sound and vibration to obtain information about the underlying area (Figure 3.3). The sounds and the vibrations are specific to the underlying structures. A change from an expected sound may indicate a problem. For example, dullness in the right lower quadrant instead of the normal tympany should be explored. (Specific percussion sounds of various body parts and regions are discussed in the appropriate assessment chapters.)  Auscultation.  Auscultation involves using a stethoscope to listen to sounds produced by the body to assess normal and abnormal conditions. This technique is particularly useful in evaluating sounds from the heart, lungs, abdomen, and vascular system. The bell of the stethoscope is more sensitive to low-­pitched sounds (e.g., heart murmurs). The diaphragm of the stethoscope is more sensitive to high-­pitched sounds (e.g., bowel sounds). Some stethoscopes have only a diaphragm, designed to transmit low-­and high-­pitched sounds. To listen

for low-­pitched sounds, the examiner holds the diaphragm lightly on the patient’s skin. For high-­pitched sounds, the examiner presses the diaphragm firmly on the skin (Jarvis et al., 2018; Figure 3.4). (Specific auscultatory sounds and techniques are discussed in the appropriate assessment chapters.)  Equipment.  The nurse should collect the equipment needed for the physical examination before beginning (Table 3.2). This saves time and energy for the nurse and the patient. (The uses of specific equipment are discussed in the appropriate assessment chapters.)  Organization of the Examination.  The physical examination should be performed systematically and efficiently. Explanations should be given to the patient as the examination proceeds, and the patient’s comfort, safety, and privacy should be considered. By being confident and self-­assured, considerate, and unhurried, the nurse will help reduce any anxiety the patient may be feeling about the examination (Jarvis et al., 2019). Following the same sequence every time helps ensure that the nurse does not forget a procedure, a step in the sequence, or a part of the body. Table 3.3 presents a comprehensive and organized physical examination outline. Adaptations of the physical examination often are useful for older patients, who may have age-­related issues such as decreased mobility, limited energy, and perceptual changes.  Recording Physical Examination.  At the conclusion of the examination, the nurse records the normal and abnormal findings in the patient’s record. Table 3.4 provides an example of how to record the findings of a physical examination of a healthy adult. See Chapter 7, Table 7.2, and the age-­related assessment findings in each assessment chapter for helpful references in recording age-­related assessment differences. 

© CanStock Photo Inc. / Bialasiewicz.

middle finger of the nondominant hand should be in contact with the skin surface. Normal percussion sounds for lung tissue are resonant; for air-­filled viscus (e.g., intestines), tympany; for dense organs (e.g., liver), dull; and for areas with no air present (e.g., bone, muscle), flat. Source: © CanStock Photo Inc. / obencem.

CHAPTER 3  Health History and Physical Examination

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musculoskeletal, neurological, and head and neck examinations. See examples of focused assessments in the appropriate assessment chapters. 

Emergency Assessment In an emergency or a critical care situation, an emergency assessment may be performed. This involves a rapid history and examination of a patient while supporting vital functions. 

FIG. 3.4  Auscultation is listening to sounds produced by the body to assess

normal conditions and deviations from normal. Source: © CanStock Photo Inc. / obencem.

TABLE 3.2    COMMON PHYSICAL EXAMINATION

EQUIPMENT

• Alcohol swabs • Blood pressure cuff • Cotton balls • Examining table or bed • Eye chart (e.g., Snellen eye chart) • Paper cup with water • Patient gown • Pocket flashlight • Reflex hammer • Stethoscope (with bell and diaphragm or a dual-­purpose diaphragm; 38-­ to 46-­cm tubing) • Tongue blades • Watch (with second hand or digital)

TYPES OF ASSESSMENT Various types of assessment are used to obtain information about a patient. These approaches can be divided into three types: comprehensive, focused, and emergency (Table 3.5). The nurse must decide what type of assessment to perform according to the clinical situation. Sometimes the health care employer provides guidelines, and other times it is a nursing judgement.

Comprehensive Assessment A comprehensive assessment includes detailed documentation of the health history and a physical examination of all body systems. This is typically performed on the patient’s admission to the hospital or onset of care in a primary care setting.  Focused Assessment A focused assessment is an abbreviated health history and examination. It is used to evaluate the status of previously identified issues and monitor for signs and symptoms of new issues. It can be performed when a specific condition (e.g., pneumonia) is identified. The patient’s clinical manifestations guide a focused assessment. For example, abdominal pain indicates the need for a focused assessment of the abdomen. Some conditions need a focused assessment of more than one body system. A patient with a headache may need

Using Assessment Approaches Assessment in an inpatient, acute-care hospital setting can be markedly different from assessments in other settings. Focused assessment of the hospitalized patient is frequent and performed by many different people. An interprofessional team approach demands a high degree of consistency among health care providers. While providing ongoing care for a patient, the nurse constantly refines their mental image of the patient. With experience, the nurse will derive a mental image of a patient’s status from a few very basic details, such as “85-­year-­old Black woman admitted for COPD [chronic obstructive pulmonary disease] exacerbation.” Details from a complete verbal report, including the length of stay, laboratory results, physical findings, and vital signs, will help the nurse make a clearer picture. Next, the nurse will perform their own assessment, using a focused approach. During this assessment, the nurse confirms or revises the findings that were read in the medical record and received from other health care providers. The process does not end once the nurse has completed their first assessment of a patient; rather, the nurse will have to continue to gather information about their patients throughout the shift. Everything that the nurse learned previously about each patient is considered in light of new information. For example, while the nurse is performing a respiratory assessment on a patient with COPD, crackles are heard in the lungs. This finding should lead the nurse to perform a cardiovascular assessment because cardiac issues (e.g., heart failure) can also cause crackles. As the nurse gains experience, the importance of new findings will be more obvious. (See assessment case studies in the appropriate assessment chapters.) Table 3.6 shows how the nurse can perform different types of assessments on the basis of a patient’s progress through a given hospitalization. When a patient arrives at the emergency department with a life-­threatening condition, the nurse performs an emergency assessment on the basis of the elements of a primary survey (e.g., airway, breathing, circulation, disability; see Chapter 71, Table 71.5). Once the patient is stabilized, the nurse can begin a focused assessment of the respiratory and related body systems. After the patient is admitted, a comprehensive assessment of all body systems is completed. 

PROBLEM IDENTIFICATION AND NURSING DIAGNOSES After completing the history and physical examination, the nurse analyzes the data and develops a list of nursing diagnoses and collaborative problems. See Chapter 1 for a description of the nursing process, including the identification of nursing diagnoses and collaborative problems.

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SECTION 1  Concepts in Nursing Practice

TABLE 3.3    OUTLINE FOR PHYSICAL EXAMINATION 1. General Survey Observe general state of health (patient is seated): • Body features • Mental state and level of orientation • Speech • Body movements • Physical appearance • Nutritional status • Behaviour

2. Vital Signs Record vital signs: • Blood pressure—both arms for comparison • Apical/radial pulse • Respiration • Temperature • Oxygen saturation • Pain score Record height and weight; calculate body mass index (BMI)

3. Integument Inspect and palpate skin for the following: • Colour • Integrity (e.g., lesions, breakdown, lacerations) • Scars, tattoos, piercings • Bruises, rash • Edema • Moisture • Texture • Temperature • Turgor • Vascularity Inspect and palpate nails for the following: • Colour • Lesions • Size • Shape • Angle • Capillary refill time

4. Head and Neck Inspect and palpate head for the following: • Shape and symmetry of skull • Masses • Tenderness • Condition of hair and scalp • Temporal arteries • Temporomandibular joint • Sensory (CN V; light touch, pain) • Motor (CN VII; shows teeth, purses lips, raises eyebrows) • Facial expression (CN VII; looks up, wrinkles forehead) • Strength (CN XI; raises shoulders against resistance) Inspect and palpate (occasionally auscultate) neck for the following: • Skin (vascularity and visible pulsations) • Symmetry • Range of motion • Pulses and bruits (carotid) • Midline structure (trachea, thyroid gland, cartilage) • Lymph nodes (preauricular, postauricular, occipital, mandibular, tonsillar, submental, anterior and posterior cervical, infraclavicular, supraclavicular) Test visual acuity. Inspect and palpate eyes/eyebrows for the following: • Position and movement of eyelids (CN VII) • Visual fields (CN II) • Extraocular movements (CN III, IV, VI) • Cornea, sclera, conjunctiva • Pupillary response (CN III) • Retinal (red) reflex Inspect and palpate nose and sinuses for the following: • External nose: shape, blockage • Internal nose: patency of nasal passages, shape, turbinates or polyps, discharge • Frontal and maxillary sinuses

Inspect and palpate ears for the following: • Placement • Pinna • Auditory acuity (CN VIII; whispered voice, ticking watch) • Mastoid process • Auditory canal • Tympanic membrane Inspect and palpate mouth for the following: • Lips (symmetry, lesions, colour) • Buccal mucosa (Stensen’s and Wharton’s ducts) • Teeth (absence, state of repair, colour) • Gums (colour, receding from teeth) • Tongue for strength (CN XII; asymmetry, ability to stick out tongue, move side to side, fasciculations) • Palates • Tonsils and pillars • Uvular elevation (CN IX) • Posterior pharynx • Gag reflex (CN IX and X) • Jaw strength (CN V) • Moisture • Colour • Floor of mouth

5. Extremities Observe size and shape, symmetry and deformity, involuntary movements. Inspect and palpate arms, fingers, wrists, elbows, shoulders for the following: • Strength • Range of motion • Joint pain • Swelling • Pulses (radial, brachial) • Sensation (light tough, pain, temperature) • Test reflexes: triceps, biceps, brachioradialis Inspect and palpate legs for the following: • Strength • Range of motion • Joint pain • Swelling, edema • Hair distribution • Sensation (light touch, pain, temperature) • Pulses (dorsalis pedis, posterior tibialis) • Test reflexes: patellar, Achilles, plantar

6. Posterior Thorax • Inspect for muscular development, scoliosis, respiratory movement, an approximation of AP diameter. • P  alpate for symmetry of respiratory movement, tenderness of CVA, spinous processes, tumours or swelling, tactile fremitus • P  ercuss for pulmonary resonance • A  uscultate for breath sounds • A  uscultate for egophony, bronchophony, whispered pectoriloquy

7. Anterior Thorax • A  ssess breasts for configuration, symmetry, dimpling of skin • A  ssess nipples for rash, direction, inversion, retraction • Inspect for apical impulse, other precordial pulsations • P  alpate the apical impulse and the precordium for thrills, lifts, heaves, tenderness • Inspect neck for venous distension, pulsations, waves • P  alpate lymph nodes in the subclavian, axillary, and brachial areas • P  alpate breasts • A  uscultate for rate and rhythm, character of S1 and S2 in the aortic, pulmonic, Erb’s point, tricuspid, and mitral areas; bruits at carotid, epigastrium

8. Abdomen • Inspect for scars, shape, symmetry, bulging, muscular position and condition of umbilicus, movements (respiratory, pulsations, presence of peristaltic waves) • A  uscultate for peristalsis (e.g., bowel sounds), bruits • P  ercuss then palpate to confirm positive findings: check liver (size, tenderness), spleen, kidney (size, tenderness), urinary bladder (distension) • P  alpate femoral pulses, inguinofemoral nodes, and abdominal aorta

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CHAPTER 3  Health History and Physical Examination TABLE 3.3    OUTLINE FOR PHYSICAL EXAMINATION—cont’d 9. Neurological Observe motor status. • Gait • Toe walk • Heel walk • Drift Observe coordination. • Finger to nose • Romberg sign • Heel to opposite shin Observe the following: • Proprioception (position sense of great toe)

10. Genitalia Male External Genitalia • Inspect penis, noting hair distribution, prepuce, glans, urethral meatus, scars, ulcers, eruptions, structural alterations, discharge • Inspect epidermis of perineum, rectum • Inspect skin of scrotum; palpate for descended testes, masses, pain

Female External Genitalia • Inspect hair distribution; mons pubis, labia (minora and majora); urethral meatus; Bartholin’s, urethral, Skene’s glands (may be palpated, if indicated); introitus; any discharge • A  ssess for presence of cystocele, prolapse • Inspect perineum, rectum

AP, anteroposterior; CN, cranial nerve; CVA, costovertebral angle; S1 and S2, first and second heart sounds.

TABLE 3.4    FINDINGS FROM A PHYSICAL EXAMINATION OF A HEALTHY ADULT Example Patient’s Name: _______________________________________ Age: General Status

Breasts

Well-­nourished, well-­hydrated, well-­developed White [woman or man] in NAD, appears stated age, speech clear and evenly paced; is alert and oriented × 3; cooperative, calm; BMI 23.8

Axilla

Skin

Respiratory rate 18, regular rhythm, oxygen saturation 98% on room air; AP < transverse diameter, no ↑ in tactile fremitus, no tenderness, lungs resonant throughout, diaphragmatic excursion 4 cm bilaterally, chest expansion symmetric, lung fields clear throughout

Clear S lesions, warm and dry, trunk warmer than extremities, normal skin turgor, no ↑ vascularity, no varicose veins

Nails Well-­groomed, round 160-­degree angle S lesions, nail beds pink, capillary refill 35 kg/m2), age older than 50 years, neck circumference greater than 43 cm (17 inches), craniofacial abnormalities that affect the upper airway, and acromegaly. People who smoke are more likely to have OSA than are those who do not smoke. OSA is twice as common in men as in women until after menopause, when the prevalence is similar. The STOP-­BANG (snore, tired, obstruction, pressure– BMI, age, neck, gender) questionnaire summarizes the key risk factors and is increasingly used as a quick and reliable screening tool for OSA (Chung et al., 2016 ) (Table 9.9). In the BANG portion, the more questions that a patient answers “yes,” the greater is the patient’s risk of having moderate to severe OSA. 

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CHAPTER 9  Sleep and Sleep Disorders Open airway—awake

Closed airway—asleep Nasal CPAP Tongue Epiglottis

A

C

B

Oropharynx Soft palate FIG. 9.4  How sleep apnea occurs. A, The patient predisposed to obstructive sleep apnea (OSA) has a small pharyngeal airway. B, During sleep, the pharyngeal muscles relax, allowing the airway to close. Lack of airflow results in repeated apneic episodes. C, With continuous positive airway pressure (CPAP), the airway is splinted open, which prevents airflow obstruction. Source: Modified from LaFleur Brooks, M. (2012). Exploring medical language: A student-­directed approach (8th ed.). Mosby.

TABLE 9.9    STOP-­BANG STOP Yes No S (Snore): Have you ever been told that you snore? Yes No T (Tired): Are you often tired during the day? Yes No O (Obstruction): Do you know if you stop breathing, or has anyone witnessed you stop breathing while you are asleep? P (Pressure): Do you have high blood pressure, or are Yes No you on medication to control high blood pressure? If the person answers “yes” to two or more of the STOP questions, they are at risk for OSA and should contact their primary care provider. The second component of this questionnaire (BANG) provides risk assessment of moderate to severe risk of OSA.

BANG B (BMI): Is your body mass index (BMI) greater than 28? A (Age): Are you 50 years or older? N (Neck): Are you a male with a neck circumference greater than 43 cm or a female with a neck circumference greater than 41 cm? G (Gender): Are you a male?

Yes

No

Yes Yes

No No

Yes

No

OSA, obstructive sleep apnea. Source: Chung, F., Yegneswaran, B., Liao, P., et al. (2008). STOP questionnaire: A tool to screen patients for obstructive sleep apnea. Anesthesiology, 108, 812–821. https ://doi.org/10.1097/ALN.0b013e31816d83e4.

Clinical Manifestations and Diagnostic Studies.  Clinical manifestations of sleep apnea include frequent arousals during sleep, insomnia, excessive daytime sleepiness, and witnessed apneic episodes. The patient’s bed partner may complain about the patient’s loud snoring. Other symptoms include morning headaches (from hypercapnia or increased blood pressure that causes vasodilation of cerebral blood vessels), personality changes, and irritability. Women with OSA have higher rates of mortality from the disorder than do men. Hypoxemia associated with OSA is worse in patients with chronic obstructive pulmonary disease (COPD) than in those without COPD. Complications that can result from untreated sleep apnea include hypertension, right-­sided heart failure from pulmonary hypertension caused by chronic nocturnal hypoxemia, and cardiac dysrhythmias, and the risk for stroke is increased. Symptoms of sleep apnea alter many aspects of the patient’s life. If problems are identified, appropriate referrals need to be made. Cessation of breathing reported by the bed partner is usually a source of great anxiety because of the fear that breathing may not resume.

Assessment of the patient with OSA includes thorough documentation of sleep and medical histories. The previously mentioned clinical manifestations of OSA should be assessed, as should less obvious symptoms, which may include cardiovascular symptoms, muscle pain, and mood changes. A diagnosis of sleep apnea is made on the basis of PSG findings. This diagnosis requires documentation of apneic events (no airflow with respiratory effort) or hypopnea (airflow diminished 30% to 50% with respiratory effort) of at least 10 seconds’ duration. OSA is defined as more than five apnea/hypopnea events per hour accompanied by a 3% to 4% decrease in oxygen saturation. In severe cases of apnea, apneic events may number more than 30 to 50 per hour of sleep. Typically, PSG studies are performed in a sleep laboratory with technicians monitoring the patient. In some instances, portable sleep studies are conducted in the home setting (see the Informatics in Practice box on sleep apnea diagnosis and monitoring). Overnight pulse oximetry assessment may be an alternative to determine whether nocturnal oxygen supplementation is indicated. 

INFORMATICS IN PRACTICE Sleep Apnea Diagnosis and Monitoring • H  ome respiratory monitoring is a cost-­effective alternative for diagnosing sleep-­related breathing disorders that allows some patients the convenience of sleeping in their own home. Home respiratory monitoring is used as part of a comprehensive •  sleep evaluation and in patients likely to have moderate to severe obstructive sleep apnea but who do not have heart failure, obstructive lung disease, or neuromuscular disease. • Home respiratory monitoring is used to monitor the effectiveness of non-­CPAP therapies for patients with sleep-­related breathing disorders. • Wireless monitors can detect changes in vital signs and pulse oximetry, raising an alarm if values fall outside of set parameters. • A patient may benefit from telehealth to diagnose and monitor for sleep apnea in the home. CPAP, continuous positive airway pressure.

NURSING AND INTERPROFESSIONAL MANAGEMENT SLEEP APNEA Mild sleep apnea (5 to 10 apneic/hypopneic events per hour) may respond to simple measures. Conservative treatment at home begins with simply sleeping on the side rather than on the back. The patient is instructed to avoid sedatives and consuming

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SECTION 1  Concepts in Nursing Practice are carefully selected for these surgeries, inasmuch as there has been no conclusive evidence that they are actually beneficial for treating sleep apnea. The most common procedure is uvulo-­ palato-­pharyngoplasty, which involves excision of the tonsillar pillars, the uvula, and the posterior soft palate with the goal of removing the obstructing tissue. Septoplasty is another effective surgical procedure which straighten the bone and cartilage of a deviated septum. 

A

B

C

FIG. 9.5  Examples of positive airwave pressure devices for sleep apnea. A,

Patient wearing a nasal mask and headgear (positive pressure only to nose). B, Patient wearing nasal pillows (positive pressure only to nose). C, Patient wearing a full face mask (positive pressure to both nose and mouth). Source: Goldman, I., & Schafer, A. I. (2012). Goldman’s Cecil medicine (24th ed.). Saunders.

alcoholic beverages for 3 to 4 hours before sleep. Sleep medications often make OSA worse. Because excessive weight worsens and weight loss reduces sleep apnea, referral to a weight loss program may be indicated. Bariatric surgery reduces incidence of OSA (Peromaa-­Haavisto et al., 2017). It is essential to instruct the patient on the dangers of driving or using heavy equipment as insomnia is commonly experienced by individuals with OSA. Symptoms may resolve in up to half of patients with OSA who use a special mouth guard, also called an oral appliance, during sleep to prevent airflow obstruction. Oral appliances bring the mandible and tongue forward to enlarge the airway space, thereby preventing airway occlusion. Some individuals find beneficial a support group in which concerns and feelings can be expressed and strategies for resolving problems can be discussed. In patients with more severe symptoms (>15 apneic/hypopneic events per hour), continuous positive airway pressure (CPAP) by mask is the treatment of choice. With CPAP, the patient applies a nasal mask that is attached to a high-­flow blower (Figure 9.5). The blower is adjusted to maintain sufficient positive pressure (5 to 25 cm H2O) in the airway during inspiration and expiration to prevent airway collapse. Some patients cannot adjust to wearing a mask over the nose or mouth or to exhaling against the high pressure. With a technologically more sophisticated therapy, bilevel positive airway pressure (BiPAP), a higher inspiration pressure and a lower pressure during expiration can be delivered. With BiPAP, the apnea can be relieved with a lower mean pressure and may be better tolerated. CPAP is highly effective in reducing apnea, daytime sleepiness, and fatigue. It improves perceived quality of life and returns cognitive functioning to normal. Benefits of CPAP are dose dependent based on how long the device is used at night. It must be used a minimum of 4 hours each night to reduce or reverse the negative cardiovascular effects of OSA (Abuzaid et al., 2017). Approximately two-thirds of patients using CPAP report adverse effects such as nasal stuffiness. Regular cleaning of the mask, tubing, and water chamber should be performed daily with liquid dish soap and hot water or a commercially available CPAP sanitizer.

Surgical Interventions Tonsillectomy (removal of tonsillar glands) is used if a patient with OSA has large tonsils. If other measures fail, surgical interventions may be attempted to help manage the airway. Patients

Special Concerns for Hospitalization of Patients With Obstructive Sleep Apnea CPAP treatment should be maintained throughout a hospitalization stay. When patients with a history of OSA are hospitalized, health care staff must be aware that the administration of opioid analgesics and sedating medications (benzodiazepines, barbiturates, hypnotics) may worsen OSA symptoms by depressing respiration. This will necessitate that the patient wear the CPAP or BiPAP mask when resting or sleeping (Marshansky et al., 2018). Perioperative concerns include an increased risk for difficult endotracheal intubation and a need for increased monitoring during the postoperative period. In patients with sleep-­disordered breathing, OSA may be exacerbated in the postoperative period in relation to medications they receive during anaesthesia. All patients with OSA should be monitored for pulse oximetry after surgery, and those at increased risk for cardiac events should also receive cardiac monitoring postoperatively.  Sleep Movement Disorders In sleep movement disorders, involuntary movement during sleep disrupts sleep and leads to daytime sleepiness. Periodic limb movement disorder (PLMD) is a type of sleep movement disorder characterized by involuntary, periodic movement of the legs, arms, or both that affects people only during sleep. Sometimes abdominal, oral, and nasal movement accompanies PLMD. Movements typically occur for 0.5 to 10 seconds, in intervals separated by 5 to 90 seconds. PLMD causes poor-­ quality sleep, which may lead to sleep maintenance insomnia, excessive daytime sleepiness, or both. PLMD and restless legs syndrome often occur simultaneously, but they are distinct disorders. (Restless legs syndrome is discussed in Chapter 61.) PLMD is diagnosed on the basis of a detailed history from the patient or bed partner, or both, and PSG findings. PLMD is treated by medications aimed at reducing or eliminating the limb movements or the arousals. Dopaminergic medications (pramipexole [Mirapex] and ropinirole [Requip]) are preferred. Parasomnias.  Parasomnias are defined as unusual and often undesirable behaviours that occur during sleep or during arousal from sleep. They can include abnormal movements and dream-­related behaviours, emotions, and perceptions. They are divided into three clusters: NREM, REM, and “other.” Rapid Eye Movement Parasomnias.  Parasomnias that occur during REM sleep include REM sleep behaviour disorder, nightmare disorder, and recurrent isolated sleep paralysis (Stefani, 2019). Parasomnias may result in fragmented sleep and fatigue. Nightmare disorder is a parasomnia characterized by recurrent awakening with recall of the frightful or disturbing dream. Nightmares are extended dysphoric dreams that usually involve efforts to avoid threats to survival, security, or physical integrity (Thorpy, 2017). These normally occur during the final third of sleep and in association with REM sleep. In critically ill patients, nightmares are common and likely due to medications.

CHAPTER 9  Sleep and Sleep Disorders Drug classes most likely to cause nightmares are sedative– hypnotics, β-­adrenergic antagonists, dopamine agonists, and amphetamines. Treatments for nightmare disorder include psychological interventions such as imagery rehearsal therapy and exposure treatment. Nabilone (a synthetic cannabinoid) has shown promise in people experiencing nightmares related to post-­traumatic stress disorder (Babson et al., 2017).  Non–Rapid Eye Movement Parasomnias.  NREM parasomnias include sleepwalking, sleep terrors, sleep-­related eating disorder, and confusional arousal. Sleepwalking behaviours can range from sitting up in bed, moving objects, walking around the room, to driving a car. During a sleepwalking event, the affected individual does not speak and may have limited or no awareness of the event. On awakening, the individual does not remember the event. In the CCU, a parasomnia may be misinterpreted as CCU psychosis. In addition, sedated CCU patients can exhibit manifestations of an NREM parasomnia. Sleep terrors (night terrors) are characterized by a sudden awakening from sleep along with a loud cry and signs of panic. There is an intense autonomic response, including increased heart rate, increased respiration, and diaphoresis. Factors in the CCU such as sleep disruption and deprivation, fever, stress (physical or emotional), and exposure to noise and light can contribute to sleep terrors. 

AGE-­R ELATED CONSIDERATIONS Sleep Sleep, like many physiological functions, changes as people age. Even with healthy aging, there are expected changes in sleep patterns, including a decrease in the amount of deep sleep, overall shorter total sleep time at night, decreased sleep efficiency, more awakenings, and increased napping (Christie et  al., 2016). Sleep requirements for older persons are 7 to 8 hours per 24-­hour cycle (Centers for Disease Control and Prevention, 2017). Despite these expected changes, the incidence of sleep disturbances and disorders is also increased in older persons (Figure 9.6). Insomnia, OSA, restless leg syndrome, and PLMD in particular are increased in prevalence among older persons, especially among Indigenous people of Canada (Gulia & Kumar, 2018; Yiallourou et al., 2019). A key issue is that multiple factors impair the ability of older persons to obtain quality sleep. Chronic conditions that are more common in older persons—including COPD, diabetes, dementia, chronic pain, and cancer—can affect sleep quality and increase the prevalence of insomnia (Gulia & Kumar, 2018). Prescribed and OTC medications used to treat these conditions can contribute to sleep problems. Daily stress and poor social support have also been linked to insomnia in older persons. Insomnia may have detrimental effects on cognitive function in healthy older persons. Chronic disturbed sleep in an older person can result in disorientation, delirium, impairment of intellect, disturbances in cognition, and increased risk of accidents and injury (see precipitating factors for delirium in Chapter 62). Getting out of bed during the night to use the bathroom increases the risk for falls. Older persons may use OTC medications or alcohol as a sleep aid (see Chapter 11), which can further increase the risk of falls at night.

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FIG. 9.6  Many older people have sleep difficulties. Source: iStock.com/ Studio-­Annika.

Because many older persons may not tell their health care providers about their sleep problems, a sleeping assessment (see Table 9.6) can be used to detect sleep disturbances. Napping during the day should not be considered problematic unless the person is reporting insomnia or excessive daytime sleepiness. In the case of insomnia, daytime napping should be restricted. Screening for sleep disorders is important because of their higher prevalence among older persons. Sleep hygiene education and CBT-­i are useful interventions for insomnia in older persons. Pharmacological therapies are more challenging for older persons. Whenever possible, long-­acting benzodiazepines should be avoided. Older persons receiving benzodiazepines are at increased risk for daytime sedation, falls, and cognitive and psychomotor impairment (see Chapter 62). They also have increased sensitivity to hypnotic and sedative medications. For this reason, medication therapies for sleep disturbances are started at low doses and monitored carefully. Hypnotic drugs should be used for as brief a period as possible, in most cases not exceeding 2 to 3 weeks of treatment. 

SPECIAL SLEEP NEEDS OF NURSES Nursing is one of several professions that necessitate night shift and rotating shift schedules. In many acute-care and long-­term care settings, nurses volunteer or are asked to work a variety of day and night shifts, often alternating and rotating them. Unfortunately, many nurses who do shift work report less job satisfaction and more job-­related stress (Tahghighi, 2017) than those who do not. Nurses on permanent night or rapidly rotating shifts are at increased risk of experiencing shift work sleep disorder, characterized by insomnia, sleepiness, and fatigue. Nurses on rotating shifts get the least amount of sleep. With repeated periods of inadequate sleep, the sleep debt grows. Poor sleep is the strongest predictor of chronic fatigue in nurses doing shift work. As a result, rotating and night shift schedules pose specific challenges for the individual nurse’s health and for patients’ safety. Shift work alters the synchrony between circadian rhythms and the environment, which leads to sleep disruption. Nurses working the night shift are often too sleepy to be fully alert at work and too alert to sleep soundly the next day. Sustained alterations in circadian rhythms such as that imposed by rotating shift work have been linked to negative health outcomes, including increased risk of morbidity and mortality in association with

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cardiovascular issues. In addition, mood disorders such as anxiety are more severe in nurses who work rotating shifts. Gastrointestinal disturbances are also more common in nurses who do shift work than in those who do not. From a patient safety perspective, disturbed sleep and subsequent fatigue can make for a workplace hazard (errors and accidents) for nurses, as well as for their patients (Thompson, 2019). Fatigue can result in diminished memory or distortions in perceptual skills, judgement, and decision-­making capabilities. Lack of sleep affects the ability to cope and handle stress. Subsequently, the reduced ability to handle stress may result in physical, mental, and emotional exhaustion. The problem of sleep disruption is one that is critically important in nursing. Workplace policy and nursing education programs have a significant role to play in helping nurses access

strategies to ensure adequate sleep. Several strategies may help reduce the distress associated with rotating shift work. These include brief scheduled periods of on-­site napping. Napping during shift has been found to improve recovery time from night shift and to enhance safety on the job of shift workers. Maintaining a consistent sleep–wake schedule even on days off is optimal but perhaps unrealistic. For night shift work, scheduling the sleep period for just before going to work increases alertness and vigilance, improves reaction times, and decreases accidents during night shift work. It is important that nurses self-­manage the effect of sleep disruption through the use of sleep hygiene practice. Sleep hygiene skills and self-­care practices could be considered as required learning for nursing students because sleep quality has been found to decrease as nurses transition from school to workplace (James et al., 2019).

CASE STUDY Insomnia Patient Profile D. P., 49 years old (pronouns she/her), is seen in the preoperative clinic. D. P. is scheduled for a right shoulder (rotator cuff) repair. She tore her rotator cuff while playing tennis 1 year ago. It is no longer painful, but her range of motion is limited. During the preoperative screening, D. P. reports chronic fatigue. She is postmenopausal, according to her self-­report. In the past year, since the end of her periods, D. P. has experienced daily hot flashes and sleep problems. She denies any other health problems. On a usual workday, D. P. drinks two cups of hot tea and one can of diet cola. Currently, she is taking OTC diphenhydramine for sleep. Her partner, who has accompanied her to the clinic, states that D. P.’s snoring has gotten worse and is interfering with his sleep. 

Subjective Data • R  eports hot flashes and nighttime sweating • Reports daytime tiredness and fatigue • States trouble with getting to sleep and staying asleep 

Objective Data Physical Examination • L  aboratory evaluations within normal limits • Overweight (20% over ideal body weight for height) • Blood pressure (BP): 155/92 mm Hg

• Limited lateral and posterior rotation of right shoulder 

Diagnostic Studies • N  ighttime polysomnography study reveals episodes of obstructive sleep apnea 

Interprofessional Care • C  ontinuous positive airway pressure (CPAP) nightly • Referred for weight reduction counselling 

Discussion Questions . W 1  hat are D. P.’s risk factors for sleep apnea? 2. What specific sleep hygiene practices could D. P. use to improve the quality of her sleep? 3. How does CPAP work? 4. What are the potential health risks associated with sleep apnea? 5. Priority decision: According to the assessment data provided, what are the priority nursing diagnoses? Are there any interprofessional problems? 6. Priority decision: For the day of surgery, what are the priority nursing interventions for D. P.?

Answers are available at http://evolve.elsevier.com/Canada/Lewis/medsurg.

 REVIEW QUESTIONS The number of the question corresponds to the same-­numbered outcome at the beginning of the chapter. 1. Sleep is best described as a a. Loosely organized state similar to coma b. State in which pain sensitivity decreases c. Quiet state in which there is little brain activity d. State in which an individual lacks conscious awareness of the environment 2. Which statement is true regarding rapid eye movement (REM) sleep? (Select all that apply.) a. The EEG pattern is quiescent. b. Muscle tone is greatly reduced. c. It only occurs once in the night d. It is separated by distinct physiological stages. e. The most vivid dreaming occurs during this phase.

3. Sleep loss is associated with which of the following symptoms? (Select all that apply.) a. Increased body mass index b. Increased insulin resistance c. Enhanced cognitive functioning d. Increased immune responsiveness 4. Which of the following points should the nurse emphasize when providing education to the client with insomnia? a. The importance of daytime naps b. The need to exercise before bedtime c. The need for long-­term use of hypnotics d. Avoidance of caffeine-­containing beverages before bedtime

CHAPTER 9  Sleep and Sleep Disorders

REFERENCES Abuzaid, A. S., Al Ashry, H. S., Elbadawi, A., et al. (2017). Meta-­ analysis of cardiovascular outcomes with continuous positive airway pressure therapy in patients with obstructive sleep apnea. American Journal of Cardiology, 120(4), 693–699. https://doi. org/10.1016/j.amjcard.2017.05.042 Asnis, G. M., Thomas, M., & Henderson, M. A. (2016). Pharmacotherapy treatment options for insomnia: a primer for clinicians. International journal of molecular sciences, 17(1), 50. https://doi. org/10.3390/ijms17010050 Babson, K., Sottile, J., & Morabito, D. (2017). Cannabis, cannabinoids, and sleep: A review of the literature. Current Psychiatry Reports, 19(4), 23. https://doi.org/10.1007/s11920-­017-­0775-­9 Bassetti, C., Adamantidis, A., Burdakov, D., et al. (2019). Narcolepsy— clinical spectrum, aetiopathophysiology, diagnosis and treatment. Nature Reviews Neurology, 15, 519–539. https://doi.org/10.1038/ s41582-­019-­0226-­9 Berry, R. B., Albertario, C. L., Harding, S. M., et al. (2017). The American Academy of Sleep Medicine: The AASM scoring manual updates for 2017 (version 2.4). Journal of Clinical Sleep Medicine, 13(5), 655–666. https://doi.org/10.5664/jcsm.6576 Bollu, P., & Kaur, H. (2019). Sleep medicine: insomnia and sleep. Missouri Medicine, 116(1), 68–75. Canadian Geriatrics Society. (2019). Choosing wisely Canada. https://c hoosingwiselycanada.org/geriatrics/ Centers for Disease Control and Prevention. (2017). How much sleep do I need?. https://www.cdc.gov/sleep/about_sleep/how_much_sl eep.html Chaput, J. P., Wong, S. L., & Michaud, I. (2017). Duration and quality of sleep among Canadians aged 18 to 79. https://www150.statcan.gc .ca/n1/pub/82-­003-­x/2017009/article/54857-­eng.htm Chattu, V., Manzar, M., Kumary, S., et al. (2018). The global problem of insufficient sleep and its serious public health implications. Healthcare, 7(1), 1. https://doi.org/10.3390/healthcare7010001 Chow, M., & Cao, M. (2016). The hypocretin/orexin system in sleep disorders: preclinical insights and clinical progress. Nature and Science of Sleep, 8, 81–86. https://doi.org/10.2147/NSS.S76711 Christie, A. D., Seery, E., & Kent, J. A. (2016). Physical activity, sleep quality, and self-­reported fatigue across the adult lifespan. Experiential Gerontology, 77, 7–11. https://doi.org/10.1016/j. exger.2016.02.001 Chung, F., Abdullah, H., & Liao, P. (2016). STOP-­BANG Questionnaire: A practical approach to screen for obstructive sleep apnea. Chest, 149(3), 631–638. https://doi.org/10.1378/chest.15-­0903

7. Which of the following strategies would reduce sleepiness during nighttime work? a. Exercising before work b. Sleeping for at least 2 hours before work time c. Taking melatonin before working the night shift d. Walking for 10 minutes every 4 hours during the night shift 1. d; 2. b, e; 3. a, b; 4. d; 5. a; 6. b; 7. b.

5. A client with sleep apnea would like to avoid using a nasal CPAP device if possible. Which of the following suggestions should the nurse make to help him reach his goal? a. Lose excess weight. b. Take a nap during the day. c. Eat a high-­protein snack at bedtime. d. Use mild sedatives or alcohol at bedtime. 6. A client on the surgical unit has a history of parasomnia (sleepwalking). Which of the following is true with regard to parasomnia? a. Hypnotic medications reduce the risk of sleepwalking. b. The client is often unaware of the activity on awakening. c. The client should be restrained at night to prevent personal harm. d. The potential for sleepwalking is reduced by exercise before sleep.

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For even more review questions, visit http://evolve.elsevier.com/Cana da/Lewis/medsurg.

Davidson, J. R., Dawson, S., & Krsmanovic, A. (2019). Effectiveness of group cognitive behavioral therapy for insomnia (CBT-­I) in a primary care setting. Behavioral Sleep Medicine, 17(2), 192–201. https://doi.org/10.1080/15402002.2017.1318753 Feng, F., Zhang, Y., Hou, J., et al. (2018). Can music improve sleep quality in adults with primary insomnia? A systematic review and network meta-­analysis. International Journal of Nursing Studies, 77, 189–196. https://doi.org/10.1016/j.ijnurstu.2017.10.011 Garland, S. N., Rowe, H., Repa, L. M., et al. (2018). A decade’s difference: 10-­year change in insomnia symptom prevalence in Canada depends on sociodemographics and health status. Sleep Health, 4(2), 160–165. https://doi.org/10.1016/j.sleh.2018.01.003 Gros, P., & Videnovic, A. (2020). Overview of sleep and circadian rhythm disorders in Parkinson disease. Clinics in Geriatric Medicine, 36(1), 119–130. https://doi.org/10.1016/j. cger.2019.09.005 Gulia, K., & Kumar, V. (2018). Sleep disorders in the elderly: a growing challenge. Psychogeriatrics, 18(3), 155–165. https://doi. org/10.1111/psyg.12319 Health Canada. (2017). Health Canada is advising Canadians about safe levels of caffeine consumption. https://healthycanadians.gc.ca/r ecall-­alert-­rappel-­avis/hc-­sc/2017/63362a-­eng.php Hieu, T. H., Dibas, M., Surya Dila, K. A., et al. (2019). Therapeutic efficacy and safety of chamomile for state anxiety, generalized anxiety disorder, insomnia, and sleep quality: A systematic review and meta-­analysis of randomized trials and quasi-­randomized trial. Phytotherapy research: PTR, 33(6), 1604–1615. https://doi. org/10.1002/ptr.6349 Hirshkowitz, M., Whiton, K., Albert, S. M., et al. (2015). National Sleep Foundation’s updated sleep duration recommendations. Sleep Health, 1(4), 233–243. https://doi.org/10.1016/j. sleh.2015.10.004 Iggena, D., Winter, Y., & Steiner, B. (2017). Melatonin restores hippocampal neural precursor cell proliferation and prevents cognitive deficits induced by jet lag simulation in adult mice. Journal of Pineal Research, 62(4), e12397. https://doi-­ org.proxy.queensu.ca/10.1111/jpi.12397 James, L., Butterfield, P., & Tuell, E. (2019). Nursing students’ sleep patterns and perceptions of safe practice during their entrée to shift work. Workplace Health & Safety, 67(11), 547–553. https:// doi.org/10.1177/2165079919867714 Javaheri, S., & Redline, S. (2017). Insomnia and risk of cardiovascular disease. Chest, 152(2), 435–444. https://doi.org/10.1016/j. chest.2017.01.026

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Locihová, H., Axmann, K., Padyšáková, H., et al. (2018). Effect of the use of earplugs and eye mask on the quality of sleep in intensive care patients: a systematic review. Journal of Sleep Research, 27(3), e12607. https://doi.org/10.1111/jsr.12607 Mahoney, C., Cogswell, A., Koralnik, I., et al. (2019). The neurobiological basis of narcolepsy. Nature Reviews Neuroscience, 20, 83–93. https://doi.org/10.1038/s41583-­018-­0097-­x Maich, K., Lachowski, A., & Carney, C. (2018). Psychometric properties of the consensus sleep diary in those with insomnia disorder. Behavioral Sleep Medicine, 16(2), 117–134. https://doi.org/10.1080/ 15402002.2016.1173556 Marshansky, S., Mayer, P., Rizzo, D., et al. (2018). Sleep, chronic pain, and opioid risk for apnea. Progress in Neuro-­Psychopharmacology and Biological Psychiatry, 87(20), 234–244. https://doi. org/10.1016/j.pnpbp.2017.07.014 Matheson, E. M., & Hainer, B. L. (2017). Insomnia: pharmacologic therapy. American Family Physician, 96(1), 29–35 Mathias, J., Cant, M., & Burke, A. (2018). Sleep disturbances and sleep disorders in adults living with chronic pain: a meta-­analysis. Sleep Medicine Reviews, 52, 198–210. https://doi.org/10.1016/j. sleep.2018.05.023 Murphy, Y., Wilson, E., Goldner, E., et al. (2016). Benzodiazepine use, misuse, and harm at the population level in Canada: a comprehensive narrative review of data and developments since 1995. Clinical Drug Investigation, 36(7), 519–530. https://doi.org/10.1007/ s40261-­016-­0397-­8 National Highway Traffic Safety Administration (NHTSA). (2020). Drowsy Driving. https://www.nhtsa.gov/risky-­driving/drowsy-­ driving#2271 National Institute of Neurological Disorders and Stroke (NINDS). (2020). Narcolepsy Fact Sheet. https://www.ninds.nih.gov/Disor ders/Patient-­Caregiver-­Education/Fact-­Sheets/Narcolepsy-­Fact-­ Sheet Nesbitt, A. (2018). Delayed sleep-­wake phase disorder. Journal of Thoracic Disease, 10(1), 103–111. https://doi.org/10.21037/ jtd.2018.01.11 Ostrin, L. (2019). Ocular and systemic melatonin and the influence of light exposure. Clinical and Experimental Optometry, 102(2), 99–108. https://doi.org/10.1111/cxo.12824 Pavlova, M., & Latreille, V. (2019). Sleep disorders. The American Journal of Medicine, 132(3), 292–299. https://doi.org/10.1016/j. amjmed.2018.09.021 Peromaa-­Haavisto, P., Tuomilehto, H., Kössi, J., et al. (2017). Obstructive sleep apnea: the effect of bariatric surgery after 12 months. A prospective multicenter trial. Sleep Medicine, 35, 85–90. https:// doi.org/10.1016/j.sleep.2016.12.017 Pilcher, J., & Morris, D. (2020). Sleep and organizational behavior: implications for workplace productivity and safety. Frontiers in Psychology, 11(45). https://doi.org/10.3389/fpsyg.2020.00045 Public Health Agency of Canada (PHAC). (2019). Are Canadian’s adults getting enough sleep?. https://www.canada.ca/en/public-­healt h/services/publications/healthy-­living/canadian-­adults-­getting-­ enough-­sleep-­infographic.html Rash, J. A., Kavanagh, V. A., & Garland, S. N. (2019). A meta-­analysis of mindfulness-­based therapies for insomnia and sleep disturbance: moving towards processes of change. Sleep medicine clinics, 14(2), 209–233. https://doi.org/10.1016/j.jsmc.2019.01.004 Riemann, D., Baglioni, C., Bassetti, C., et al. (2017). European guideline for the diagnosis and treatment of insomnia. Journal of Sleep Research, 26(6), 675–700. https://doi.org/10.1111/jsr.12594 Sateia, M. J. (2014). International Classification of Sleep Disorders— Third Edition: Highlights and recommendations. Chest, 146(5), 1387–1394. https://doi.org/10.1378/chest.14-­0970. (Seminal).

Statistics Canada. (2018). Health Fact Sheet: Sleep Apnea in Canada, 2016 and 2017. https://www150.statcan.gc.ca/n1/en/pub/82-­625-­ x/2018001/article/54979-­eng.pdf?st=xwDO0mKB Stefani, A., Holzknecht, E., & Högl, B. (2019). Clinical neurophysiology of REM parasomnias. Handbook of Clinical Neurology, 161, 381–396. https://doi.org/10.1016/B978-­0-­444-­64142-­7.00062-­X Suh, S., Cho, N., & Zhang, J. (2018). Sex differences in insomnia: from epidemiology and etiology to intervention. Current Psychiatry Reports, 20(9), 69. https://doi.org/10.1007/s11920-­018-­0940-­9 Szabo, S., Thorpy, M., Mayer, G., et al. (2019). Neurobiological and immunogenetic aspects of narcolepsy: implications for pharmacotherapy. Sleep Medicine Reviews, 43, 23–36. https://doi. org/10.1016/j.smrv.2018.09.006 Tahghighi, M., Rees, C. S., Brown, J. A., et al. (2017). What is the impact of shift work on the psychological functioning and resilience of nurses? An integrative review. Journal of Advanced Nursing, 73(9), 2065–2083. https://doi.org/10.1111/jan.13283 Thompson, B. (2019). Does work-­induced fatigue accumulate across three compressed 12 hour shifts in hospital nurses and aides? PloS One, 14(2), e0211715. https://doi.org/10.1371/journal.pone.0211715 Thorpy, M. (2017). International classification of sleep disorders. In Sleep Disorders Medicine (pp. 475–484). Springer. Wilt, T. J., MacDonald, R., Brasure, M., et al. (2016). Pharmacologic treatment of insomnia disorder: an evidence report for a clinical practice guideline by the American College of Physicians. Annals of Internal Medicine, 165(2), 103–112. https://doi.org/10.7326/ M15-­1781 Xie, Z., Chen, F., Li, W., et al. (2017). A review of sleep disorders and melatonin. Neurological Research, 39(6), 559–565. https://doi.org/1 0.1080/01616412.2017.1315864 Yiallourou, S. R., Maguire, G. P., Eades, S., et al. (2019). Sleep influences on cardio-­metabolic health in Indigenous populations. Sleep Medicine, 59, 78–87. https://doi.org/10.1016/j.sleep.2018.10.011 Zisapel, N. (2018). New perspectives on the role of melatonin in human sleep, circadian rhythms and their regulation. British Journal of Pharmacology, 175(16), 3190–3199. https://doi.org/10.1111/ bph.14116

RESOURCES Canadian Lung Association: Sleep Disordered Breathing https://www.lung.ca/research/sleep-­disordered-­breathing Canadian Sleep Society https://css-­scs.ca American Academy of Sleep Medicine https://www.aasmnet.org Better Sleep Council https://www.bettersleep.org Centers for Disease Control and Prevention: Sleep and Sleep Disorders https://www.cdc.gov/sleep/index.html Epworth Sleepiness Scale https://healthysleep.med.harvard.edu/narcolepsy/diagnosing-narc olepsy/epworth-sleepiness-scale Narcolepsy Network https://www.narcolepsynetwork.org Pittsburgh Sleep Quality Index http://www.opapc.com/uploads/documents/PSQI.pdf Sleep Foundation https://www.sleepfoundation.org For additional Internet resources, see the website for this book at http: //evolve.elsevier.com/canada/lewis/medsurg.

CHAPTER

10

Pain Natasha Fulford  Originating US chapter by Debra Miller-­Saultz

WEBSITE http://evolve.elsevier.com/Canada/Lewis/medsurg • R  eview Questions (Online Only) • Key Points • Answer Guidelines for Case Study

• C  onceptual Care Map Creator • Student Case Study • Pain

• A  udio Glossary • Content Updates

LEARNING OBJECTIVES 1. Define pain. 2. Describe the neural mechanisms of pain and pain modulation. 3. Differentiate between nociceptive, neuropathic, somatic, and visceral types of pain. 4. Explain the physical and psychological effects of unrelieved pain. 5. Describe the components of a comprehensive pain assessment. 6. Describe effective pain management techniques used across many professional disciplines.

7. Describe pharmacological and nonpharmacological methods of pain relief. 8. Explain the nurse’s role and responsibility in pain management. 9. Discuss ethical issues related to pain and pain management. 10. Evaluate the influence of one’s own knowledge, beliefs, and attitudes about pain assessment and management.

KEY TERMS analgesic ceiling breakthrough pain ceiling effect dermatomes equianalgesic dose modulation neuropathic pain

  

nociception nociceptive pain pain pain perception patient-­controlled analgesia (PCA) physical dependence suffering

PAIN Pain is a complex experience with sensory-­ discriminative, motivational–affective, and cognitive–evaluative dimensions. For many people, it is a major problem that causes suffering and reduces quality of life. Pain is one of the major reasons that people seek health care, and effective pain relief is a basic human right (Canadian Pain Task Force, 2019). A thorough understanding of the multiple dimensions of pain is important for effective assessment and management of patients with pain. Nurses have a central role in pain assessment and management. Components of the nursing role include (a) assessing pain and documenting and communicating this information to other health care providers, (b) ensuring delivery of effective pain relief measures, (c) evaluating the effectiveness of these

titration transduction transmission trigger point windup

interventions, (d) monitoring ongoing effectiveness of pain management strategies, and (e) providing education to patients and their families regarding pain management approaches and possible adverse effects. This chapter presents current knowledge about pain and pain management to enable the nurse to assess and manage pain successfully in collaboration with other health care providers. 

MAGNITUDE OF THE PAIN PROBLEM Unrelieved, persistent pain is an epidemic in Canada and the United States. More than 50 million people are affected with musculoskeletal pain, such as back pain and arthritis, that goes unrelieved for 5 years or more (Gaskin & Richard, 2012). In Canada, pain is one of the four most common causes of disability

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among working-­age adults aged 25–64 years. The Canadian Survey on Disability (2017) indicates that pain-­related disabilities affect over 4 million Canadians and account for 15% of the total of disabilities in Canada (Clouter et al., 2018). In Canada, 17% of women and 12% of men have a pain-­related disability (Clouter et al., 2018). The global prevalence of pain has a major negative economic impact, with estimated annual values of lost productivity ranging from $297.4 billion to $335.5 billion (2010 US dollars). These values include days of work missed (ranging from $11.6 to $12.7 billion), hours of work lost ($95.2 to $96.5 billion), and reduction in wages ($190.6 billion to $226.3 billion) (Institutes of Medicine, 2011). The direct and indirect costs of chronic pain in Canada are estimated to be $60 billion per year (Canadian Pain Task Force, 2019). In Canada, 36% of unemployed Canadians with a pain-­related disability have employment potential (Clouter et al., 2018). Unfortunately, cumulative evidence indicates that, across the lifespan, people in a variety of settings continue to experience considerable acute and persistent pain despite the availability of treatment options (Choinière et al., 2014; McGillion & Watt-­Watson, 2015). It has been reported that Indigenous children experience a higher number of pain occurrences than non-­Indigenous children (Latimer et  al., 2018). Despite management standards and directives from nongovernmental organizations such as the Canadian Pain Society (CPS) and the Registered Nurses’ Association of Ontario (RNAO), more than four decades’ worth of evidence documents inadequate pain management practices as the norm across health care settings and patient populations. For example, alarming numbers of Canadians are still left in pain after surgery, even in top hospitals. Evidence suggests that up to 50% of patients report pain in the moderate-­to-­severe range following surgical procedures (Huang et al., 2016). The prevalence of chronic pain increases with age, with estimates of as many as 65% of community-­dwelling older persons and up to 80% of older people in long-­term care facilities experiencing chronic pain. Chronic pain in these populations is underrecognized and undertreated. People living with cancer—whether the disease is newly diagnosed, is being actively treated, or is in a more advanced stage—also consistently receive inadequate pain treatment. The prevalence of moderate to severe pain among people with metastatic disease is 66% and 51%, respectively, of all cancer patients, regardless of cancer type and stage (Asthana et al., 2019). It is important to note that Indigenous populations in Canada have the highest prevalence of chronic pain (Canadian Pain Task Force, 2019). Consequences of untreated pain include unnecessary suffering, physical dysfunction, psychosocial distress (which manifests in such forms as anxiety or depression), impairment in recovery from acute illness and surgery, immunosuppression, and sleep disturbances. In the acutely ill patient, unrelieved pain can result in increased morbidity as a result of respiratory dysfunction, increased heart rate and cardiac workload, increased muscular contraction and spasm, decreased gastrointestinal (GI) motility, and increased catabolism (Table 10.1). Screening for the presence of pain is recommended as an institutional priority. In general, pain should be assessed—in all clinical care settings for all patients—at least once per day (RNAO, 2013). When left untreated, acute pain can also progress to persistent pain. Common surgical procedures have resulted in

TABLE 10.1    CONSEQUENCES OF

UNRELIEVED PAIN

System

Responses

Endocrine

↑ Adrenocorticotrophic hormone (ACTH), ↑ cortisol, ↑ antidiuretic hormone (ADH), ↑ epinephrine, ↑ norepinephrine, ↑ growth hormone, ↑ renin, ↑ aldosterone levels; ↓ insulin, ↓ testosterone levels Gluconeogenesis, glycogenolysis, hyperglycemia, glucose intolerance, insulin resistance, muscle protein catabolism, ↑ lipolysis ↑ Heart rate, ↑ cardiac output, ↑ peripheral vascular resistance, hypertension, ↑ myocardial oxygen consumption, ↑ coagulation ↓ Tidal volume, atelectasis, shunting, hypoxemia, ↓ cough, sputum retention, infection ↓ Urinary output, urinary retention ↓ Gastric and bowel motility Muscle spasm, impaired muscle function, fatigue, immobility ↓ Cognitive function; mental confusion ↓ Immune response

Metabolic

Cardiovascular

Respiratory Genitourinary Gastrointestinal Musculoskeletal Neurological Immunological

Source: Adapted from McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual for nursing practice (2nd ed.). Mosby.

patients experiencing persistent pain after surgery in 5% to 50% of cases; for some (2% to 10%), this pain is moderate to severe (Pergolizzi et al., 2014). Rationales for the undertreatment of pain vary. Among health care providers, frequently cited reasons include a lack of knowledge and skills to adequately assess and treat pain; misconceptions about pain; and inaccurate and inadequate information regarding addiction, tolerance, respiratory depression, and other adverse effects of opioids (Hroch et al., 2019). These reasons are indeed common among nurses, who routinely administer the lowest prescribed analgesic dose when a range of doses is prescribed (McGillion & Watt-­Watson, 2015). Such practices do little to provide relief from unremitting pain and are not consistent with current pain management guidelines (RNAO, 2013). The need to improve prelicensure pain education for health care providers in Canada is dire. One national study revealed that the majority of graduate nursing students lack adequate knowledge of pain and how to conduct a thorough pain assessment (Hroch et al., 2019). 

DEFINITIONS OF PAIN McCaffery and Pasero’s seminal definition that pain is “whatever and whenever the person says it is” changed practice by focusing health care providers’ attention on the subjectivity of pain (McCaffery & Pasero, 1999). Patients’ self-­reports about their pain are key to effective pain management. This definition at the simplest level may cause problems because patients do not always admit to pain or use the word pain. The International Association for the Study of Pain (IASP) has defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (Raja et al., 2020). Pain is multidimensional and subjective, as the IASP definition emphasizes. The patient’s self-­report, therefore, is the most valid means of assessment. A person’s inability to communicate verbally does not negate the possibility of that individual’s

CHAPTER 10  Pain Affective (emotions, suffering)

Physiological (transmission of nociceptive stimuli)

Behavioural (behavioural responses)

PAIN Sensory (pain perception)

Cognitive (beliefs, attitudes, evaluations, goals)

FIG. 10.1  Multidimensional nature of pain. Source: Developed by M. Mc-

Caffery, C. Pasero, and J. A. Paice. Modified from McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual for nursing practice (2nd ed.). Mosby.

experiencing pain or the need for appropriate pain-­relieving treatment. For patients who are nonverbal or cognitively unable to rate pain, gathering nonverbal information is critical for pain assessment. The IASP definition of pain underscores the fact that pain can be experienced in the absence of identifiable tissue damage. It is important to differentiate pain that involves perception of a noxious (tissue-­damaging) stimulus from pain involving nociception, which may not be perceived as painful. Nociception is the activation of the primary afferent nociceptors (PANs) with peripheral terminals (free nerve endings) that respond differently to noxious stimuli. Nociceptors function primarily to sense and transmit pain signals. If nociceptive stimuli are blocked, pain is not perceived. Pain is not synonymous with suffering, although pain can cause substantial suffering. Suffering has been defined as “the state of severe distress associated with events that threaten the intactness (biopsychosocial integrity) of the person” (Cassell, 1982, p. 32). Suffering can occur in the presence or absence of pain, and pain can occur with or without suffering. For example, the woman awaiting breast biopsy may suffer emotionally because of anticipated loss of her breast. She may have acute pain in the breast after the biopsy (due to the procedure itself) without emotional suffering if the biopsy result is negative for malignancy. Conversely, she may have biopsy-­related pain with emotional suffering if the biopsy result is positive for malignancy. 

DIMENSIONS OF PAIN AND THE PAIN PROCESS Pain is a complex experience involving several dimensions: physiological, sensory-­discriminative (i.e., the perception of pain by the individual that addresses the pain location, intensity, pattern, and quality), motivational–affective, behavioural, cognitive–evaluative, and sociocultural (Figure 10.1). In 1965, Melzack and Wall built on prior understanding of pain mechanisms in order to develop their gate control theory of pain (Melzack & Wall, 1987). Although the gate control theory is limited to providing a basic understanding of acute pain mechanisms, it is seminal work that remains critical to the

137

understanding of the pain process, including transduction, transmission, perception, and modulation of pain. Pain experience and response result from complex interactions among these dimensions. In the following discussion, each dimension and the ways in which different dimensions influence pain are described.

Physiological Dimension of Pain Understanding the physiological dimension of pain requires knowledge of neural anatomy and physiology. The neural mechanism by which pain is perceived consists of four major steps: transduction, transmission, perception, and modulation (Fields, 1987). Figure 10.2 outlines these four steps. Transduction.  Transduction is the conversion of a mechanical, thermal, or chemical stimulus to a neuronal action potential. Transduction occurs at the level of the peripheral nerves, particularly the free nerve endings, or PANs. Noxious (tissue-­ damaging) stimuli can include thermal damage (e.g., sunburn), mechanical damage (e.g., surgical incision, pressure from swelling), or chemical damage (e.g., from toxic substances). These stimuli cause the release of numerous chemicals into the peripheral microenvironment of the PAN. Some of these chemicals— such as histamines, bradykinin, prostaglandins, nerve growth factor, and arachidonic acid—activate or sensitize the PAN to excitation. If the PAN is activated or excited, it fires an action potential to the spinal cord. An action potential is necessary to convert the noxious stimulus to an impulse and move the impulse from the periphery to the spinal cord. A pain action potential can result from two sources: (a) a release of the sensitizing and activating chemicals (nociceptive pain) or (b) abnormal processing of stimuli by the nervous system (neuropathic pain). Both of these sources produce a change in the charge along the neuronal membrane. In other words, when the PAN terminal is transduced, the PAN membrane becomes depolarized. Sodium enters the cell, and potassium exits the cell, thereby generating an action potential. The action potential is then transmitted along the entire length of the neuron to cells in the spinal cord. Inflammation and the subsequent release of the chemical mediators listed above lower the excitation threshold of PANs and increase the likelihood of transduction. This increased susceptibility is called sensitization. Several chemicals, such as leukotrienes, prostaglandins, and substance P, are probably involved in this process of sensitization. It is known that the release of substance P, a chemical stored in the distal terminals of the PAN, sensitizes the PAN and dilates nearby blood vessels, resulting in subsequent development of edema and release of histamine from mast cells (Pelletier et al., 2015). Therapies directed at altering either the PAN environment or the sensitivity of the PAN are used to prevent the transduction and initiation of an action potential. Decreasing the effects of chemicals released at the periphery is the basis of several pharmacological approaches to pain relief. For example, nonsteroidal anti-­inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin) and naproxen (Naprosyn, Aleve), and corticosteroids, such as dexamethasone (Decadron), exert their analgesic effects by blocking pain-­producing chemicals. NSAIDs block the action of cyclo-­oxygenase, and corticosteroids block the action of phospholipase, thereby interfering with the production of prostaglandins. 

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SECTION 1  Concepts in Nursing Practice 1

1

3

Site of pain 2 Transmission

2

3

on ulati Mod

Transduction 1. Noxious stimuli cause cell damage with the release of sensitizing chemicals • Prostaglandins • Bradykinin • Serotonin • Substance P • Histamine 2. These substances activate nociceptors and lead to generation of action potential

Perception Conscious experience of pain

4 2 4

Transmission Action potential continues from • Site of injury to spinal cord • Spinal cord to brainstem and thalamus • Thalamus to cortex for processing

Modulation • Neurons originating in the brainstem descend to the spinal cord and release substances (e.g., endogenous opioids) that inhibit nociceptive impulses

FIG. 10.2  Nociceptive pain originates when the tissue is injured. Transduction (1) occurs when chemical mediators are released. Transmission (2) involves the

conduct of the action potential (short-­term change in the electrical potential travelling along a cell) from the periphery (injury site) to the spinal cord and then to the brainstem, thalamus, and cerebral cortex. Perception (3) is the conscious awareness of pain. Modulation (4) involves signals from the brain going back down the spinal cord to modify incoming impulses. Source: Developed by M. McCaffery, C. Pasero, & J. A. Paice. Modified from McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual for nursing practice (2nd ed.). Mosby.

Transmission.  Transmission is the movement of pain impulses from the site of transduction to the brain (see Figure 10.2). Three segments are involved in nociceptive signal transmission: (1) transmission along the nociceptor fibres to the level of the spinal cord, (2) processing in the dorsal horn, and (3) transmission to the thalamus and the cortex. Each step in the transmission process is important in pain perception. Transmission to the Spinal Cord.  One nerve cell extends the entire distance from the periphery to the dorsal horn of the spinal cord with no synapses. For example, an afferent fibre from the great toe travels from the toe through the fifth lumbar nerve root into the spinal cord; it is one cell. Once generated, an action potential travels all the way to the spinal cord unless it is blocked by a sodium channel inhibitor or disrupted by a lesion at the central terminal of the fibre (e.g., by a dorsal root entry zone lesion). Two types of peripheral nerve fibres are responsible for the transmission of pain impulses from the site of transduction to the level of the spinal cord: the A fibres (A-­alpha, A-­beta, and A-­delta) and the C fibres. Neurons that project from the periphery to the spinal cord are also referred to as first-­order neurons. Each type of fibre has different characteristics that determine its conduction rate (Table 10.2). A-­alpha and A-­beta fibres are large fibres enclosed within myelin sheaths that allow them to conduct impulses at a rapid rate. A-­delta fibres are smaller with thinly myelinated sheaths. Because of their smaller size, however, they conduct at a slower rate than the larger A-­alpha and A-­beta fibres. C fibres are the smallest fibres and are unmyelinated. They conduct at the slowest rate. The conduction rates have important implications for the modulation of noxious information from A-­delta and C fibres. Stimulation of different fibres results in different sensations. Stimulation of A-­delta fibres results in pain described as

TABLE 10.2    CHARACTERISTICS OF PERIPHERAL

NERVE FIBRES

Type of Fibre

Size

Myelinization

Conduction Velocity*

A-­alpha A-­beta A-­delta C

Large Large Small Smallest

Myelinated Myelinated Myelinated Not myelinated

Rapid Rapid Medium Slow

*The conduction rates are important because information carried to the spinal cord by the more rapidly conducting nerve fibres reaches dorsal horn cells sooner than does information carried by the fibres that conduct more slowly.

pricking, sharp, well localized, and short in duration. C-­fibre activation pain is described as a dull, aching, burning sensation and is characterized by its diffuse nature, slow onset, and relatively long duration. The A-­alpha (sensory muscle) and A-­beta (sensory skin) fibres typically transmit nonpainful sensations such as light pressure to deep muscles, soft touch to skin, and vibration. All of these fibres extend from the peripheral tissues through the dorsal root ganglia to the dorsal horn of the spinal cord. The manner in which nerve fibres enter the spinal cord is central to the notion of spinal dermatomes. Dermatomes are areas on the skin that are innervated primarily by a single spinal cord segment. Figure 10.3 illustrates different dermatomes and their innervations.  Dorsal Horn Processing.  Once the nociceptive signal arrives in the central nervous system (CNS), it is processed within the dorsal horn of the spinal cord. This processing includes the release of neurotransmitters from the afferent fibre into the synaptic cleft. These neurotransmitters bind to receptors on nearby cell bodies and dendrites of cells that may be located elsewhere in the dorsal horn. Some of these neurotransmitters (e.g., aspartate, glutamate, substance P) produce activation of

CHAPTER 10  Pain

C2 C3 C4 C5 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 S2-S4 L2 L3 C6 C7 C8 L4 L5 S1

C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S4 S3 S2 S1 L3 L5

L4

L5

FIG. 10.3  Spinal dermatomes representing organized sensory input carried via specific spinal nerve roots. C, cervical; L, lumbar; S, sacral; T, thoracic.

nearby cells, whereas others (e.g., γ-­aminobutyric acid, serotonin, norepinephrine) inhibit such activation. In turn, these nearby cells release other neurotransmitters. The effects of the complex neurochemistry can facilitate or modulate (i.e., inhibit) transmission of noxious stimuli. In this area, exogenous and endogenous opioids also play an important role by binding to opioid receptors and blocking the release of neurotransmitters, particularly substance P. Endogenous opioids, which include enkephalins and β-­endorphins, are chemicals that are synthesized and secreted by the body. They are capable of producing effects that are similar to those of exogenous opioids such as morphine. The dorsal horn of the spinal cord contains specialized cells called wide dynamic range neurons. These neurons receive input from noxious stimuli primarily carried by A-­delta and C-­fibre afferent pathways (especially from viscera) and from non-­noxious stimuli from A-­beta fibres; they also receive indirect input from dendritic projections (Mifflin & Kerr, 2014). These stimuli come from distant areas, providing a neural explanation for referred pain. Inputs from both nociceptive fibres and A-­beta fibres converge on the wide dynamic range neuron, and when the message is transmitted to the brain, pain in the originating area of the body becomes poorly localized. The concept of referred pain must be considered when a person with injury to or disease involving visceral organs

139

Anterior

Posterior Lungs and diaphragm Heart Liver Gallbladder Heart Liver Stomach Liver Ovaries Appendix Kidneys Ureters Kidney

Bladder FIG. 10.4  Typical areas of referred pain.

reports pain in a certain location. The location of a tumour, for instance, may be distant from the pain location reported by the patient (Figure 10.4). Liver disease is located in the right upper abdominal quadrant, but pain frequently is referred to the anterior and posterior neck region and to a posterior flank area. If referred pain is not considered in the evaluation of a pain location report, diagnostic tests and therapy could be misdirected. Sensitization, or enhanced excitability, can also occur at the level of the spinal neurons, known as central sensitization (Pelletier et al., 2015). Peripheral tissue damage or nerve injury can cause central sensitization, and continued nociceptive input from the periphery is necessary to maintain it. With ongoing stimulation of the slowly conducting, unmyelinated C-­fibre nociceptors, firing of specialized dorsal horn neurons gradually increases. This process is known as windup and is dependent on the activation of N-­methyl-­d-­aspartate (NMDA) receptors. NMDA receptors produce alterations in neural processing of afferent stimuli that can persist for long periods. For this reason, an important goal of therapy is to prevent persistent pain by avoiding central sensitization. Currently, the NMDA antagonist most commonly used is the anaesthetic medication ketamine (Ketalar). Unfortunately, intolerable adverse effects, such as hallucinations, limit its usefulness. Development of newer NMDA-­antagonist medications is ongoing and shows promise for potentially blocking central sensitization with fewer adverse effects.  Transmission to the Thalamus and the Cortex.  From the dorsal horn, nociceptive stimuli are communicated to the third-­order neurons, primarily in the thalamus, and several other areas of the brain. Fibres of dorsal horn projection cells enter the brain through several pathways, including the spinothalamic tract and the spinoreticular tract. Distinct thalamic nuclei receive nociceptive input from the spinal cord and have projections to several regions in the cerebral cortex, where the perception of pain is believed to occur. 

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SECTION 1  Concepts in Nursing Practice

Perception.  Pain perception is the recognition of, definition of, and response to pain by the individual experiencing it. In the brain, nociceptive input is perceived as pain. There is no single, precise location where pain perception occurs. Instead, pain perception involves several brain structures. For example, it is believed that the reticular activating system is responsible for the autonomic response of warning the individual to attend to the pain stimulus; the somatosensory system is responsible for localization and characterization of pain; and the limbic system is responsible for the emotional and behavioural responses to pain. Cortical structures are also thought to be crucial to constructing the meaning of the pain. Therefore, behavioural strategies such as distraction, relaxation, and guided imagery (distraction and relaxation are discussed later in this chapter; guided imagery is discussed in Chapter 8) are effective pain-­ reducing therapies for many people. By directing attention away from the pain sensation, patients can reduce the sensory and affective components of pain. For example, blood flow to the anterior central gyrus, an area intimately involved with the perception of the unpleasantness of pain, can be altered by hypnosis.  Modulation.  Modulation involves the activation of descending pathways that exert inhibitory or facilitatory effects on the transmission of pain. Depending on the type and degree of modulation, the nociceptive stimuli may or may not be perceived as pain. Modulation of pain signals can occur at the level of the periphery, the spinal cord, the brainstem, and the cerebral cortex. Centrally, modulation of nociceptive impulses occurs via descending fibres that influence dorsal horn neuronal activity. Complex neurochemistry involving excitatory and inhibitory neurotransmitters such as enkephalin, γ-­aminobutyric acid (GABA), serotonin, and norepinephrine is involved in this nociceptive modulation; as a result, pain transmission is inhibited (Salter, 2014). A number of pain management medications exert their effects through the modulatory systems. For example, tricyclic antidepressants, such as amitriptyline (Elavil), are used in the management of persistent noncancer pain and cancer pain. These medications interfere with the reuptake of serotonin and norepinephrine, thereby increasing their availability to inhibit noxious stimuli and produce analgesia. Baclofen (Lioresal), an analogue of the inhibitory neurotransmitter GABA, can interfere with the transmission of nociceptive impulses and thus produce analgesia for many chronic conditions, particularly those accompanied by muscle spasms. Table 10.3 briefly summarizes how pain-­relieving medications can affect pain transduction, transmission, perception, and modulation. 

Sensory–Discriminative, Motivational–Affective, Behavioural, Cognitive–Evaluative, and Sociocultural Dimensions of Pain Pain is subjective; the experience of pain and related responses vary from person to person. Because of the complex neural mechanisms of nociceptive processing, pain is a multidimensional sensory and affective experience that has cognitive, behavioural, and sociocultural aspects. The sensory–discriminative component of pain is the recognition of the sensation as painful. Elements of sensory pain include pattern, area, intensity, and nature (PAIN). Information about these elements and knowledge about the pain process are indispensable to clinical decision making and appropriate pain therapy. The motivational–affective component of pain encompasses the emotional responses to the pain experience. These affective

TABLE 10.3    MEDICATION THERAPY Interrupting the Pain Pathway Pain Mechanism

Mechanism of Action

Transduction NSAIDs Local anaesthetics Antiseizure medications (e.g., gabapentin [Neurontin]) Corticosteroids

Block prostaglandin production Block action potential initiation Block action potential initiation Block action potential initiation

Transmission Opioids Cannabinoids

Block release of substance P Inhibit mast cell degranulation and response of nociceptive neurons

Perception Opioids NSAIDs Adjuvants (e.g., antidepressants)

Decrease conscious experience of pain Inhibit cyclo-­oxygenase action Dependent on specific adjuvant

Modulation Tricyclic antidepressants (e.g., amitriptyline [Elavil])

Interfere with reuptake of serotonin and norepinephrine

NSAIDs, nonsteroidal anti-­inflammatory drugs.

responses include anger, fear, depression, and anxiety, negative emotions that impair the patient’s quality of life. They become part of a vicious cycle in which pain leads to negative emotions such as depression, which in turn intensifies pain perception, leading to more depression and impairment of function. It is important for nurses to recognize this cycle and intervene appropriately. The behavioural component of pain comprises the observable actions used to express or control the pain. For example, facial expressions such as grimacing may reflect pain or discomfort. Posturing may be used to decrease pain associated with specific movements. A person often adjusts their daily physical and social activities in response to the pain. In this way, pain, especially persistent pain, has profound effects on functioning (RNAO, 2013). The cognitive–evaluative component of pain consists of beliefs, attitudes, memories, and the meaning of the pain for the individual. The meaning of the pain stimulus can contribute to the pain experience. For example, a woman in labour may experience severe pain, but for her it is associated with a joyful event; moreover, she may feel control over her pain because of training she received in prenatal classes and the knowledge that the pain is self-­limited. In contrast, a woman with persistent, nonspecific musculoskeletal pain may be plagued by thoughts that the pain is “not real.” Many people with persistent pain like this experience challenges from health care providers and others who question whether their pain is a legitimate experience (McGillion & Watt-­Watson, 2015). Such anxieties, fears, and stressors have been identified as potential intensifiers of perceived pain and related burden (O’Keefe-­McCarthy et  al., 2015). The meaning of pain and related responses are critical aspects of nursing pain assessment. The cognitive dimension also includes pain-­related beliefs and the cognitive coping strategies that people use. For example, some people cope with pain by distracting themselves, whereas others struggle with feelings that the pain is untreatable and overwhelming. People who believe their pain is uncontrolled

CHAPTER 10  Pain

141

TABLE 10.4    COMPARISON OF NOCICEPTIVE AND NEUROPATHIC PAIN Definition Treatment Types

Nociceptive Pain

Neuropathic Pain*

Normal processing of stimulus that damages normal tissue or has the potential to do so if prolonged Usually responsive to nonopioid and/or opioid medications Superficial Somatic Pain Pain arising from skin, mucous membranes, subcutaneous tissue. Tends to be well localized Examples: Sunburn, skin contusions Deep Somatic Pain Pain arising from muscles, fasciae, bones, tendons. Localized or diffuse and radiating Examples: Arthritis, tendonitis, myofascial pain Visceral Pain Pain arising from visceral organs, such as the gastrointestinal tract and bladder. Well or poorly localized. Often referred to cutaneous sites Examples: Appendicitis, pancreatitis, cancer affecting internal organs, irritable bowel and bladder syndromes

Abnormal processing of sensory input by the peripheral or central nervous system Usually includes adjuvant analgesics Central Pain Caused by primary lesion or dysfunction in the central nervous system Examples: Poststroke pain, pain associated with multiple sclerosis Peripheral Neuropathies Pain felt along the distribution of one or many peripheral nerves caused by damage to the nerve Examples: Diabetic neuropathy, alcohol-­nutritional neuropathy, trigeminal neuralgia, postherpetic neuralgia Deafferentation Pain Pain resulting from a loss of or altered afferent input Examples: Phantom limb pain, postmastectomy pain, spinal cord injury pain Sympathetically Maintained Pain Pain that persists secondary to autonomic nervous system dysfunction Examples: Phantom limb pain, complex regional pain syndrome

*Some types of neuropathic pain (e.g., postherpetic neuralgia) are caused by more than one neuropathological mechanism.

TABLE 10.5    DIFFERENCES BETWEEN ACUTE AND PERSISTENT PAIN Characteristic

Acute Pain

Persistent Pain

Onset Duration

Sudden Usually within the normal time for healing

Severity Cause of pain

Mild to severe In general, a precipitating illness or event (e.g., surgery) can be identified ↓ Over time and goes away as recovery occurs

Gradual or sudden May start as acute injury but continues past the normal time for healing to occur Mild to severe May not be known; original cause of pain may differ from mechanisms that maintain the pain Typically, pain persists and may be ongoing, episodic, or both Predominantly behavioural manifestations: • Changes in affect • ↓ Physical movement and activity • Fatigue • Withdrawal from other people and social interaction

Course of pain Typical physical and behavioural manifestations

Usual goals of treatment

Manifestations reflect sympathetic nervous system activation: • ↑ Heart rate • ↑ Respiratory rate • ↑ Blood pressure • Diaphoresis, pallor • Anxiety, agitation, confusion Note: Responses normalize quickly owing to adaptation Pain control with eventual elimination

and overwhelming are more likely to have poor outcomes (Jensen et  al., 2017). Cognitions about the pain contribute to patients’ goals for and expectations of pain relief and treatment outcomes. The sociocultural dimension of pain encompasses factors such as demographic features (e.g., age, sex, education, socioeconomic status), support systems, social roles, past pain experiences, and cultural aspects that contribute to the pain experience [Yoshikawa et al., 2020]). Female sex, for example, has been found to influence nociceptive processes and the acceptability and usage of and response to analgesics such as NSAIDs and opioids (O’Keefe-­McCarthy et al., 2015). 

Minimizing pain to the extent possible; focusing on enhancing function and quality of life

persistent; some people may experience both, depending on the situation (Table 10.5).

CAUSES AND TYPES OF PAIN

Nociceptive Pain Nociceptive pain is caused by damage to somatic or visceral tissue. Somatic pain, characterized as aching or throbbing that is well localized, arises from bone, joint, muscle, skin, or connective tissue. Visceral pain, which may result from stimuli such as tumour involvement or obstruction, arises from internal organs such as the intestines and the bladder. Examples of nociceptive pain include pain from a surgical incision or a broken bone, arthritis, or cardiac ischemia. Nociceptive pain is usually responsive to both nonopioid and opioid medications. 

Pain is generally classified as nociceptive, neuropathic, or both, according to the underlying pathological process. Nociceptive pain and neuropathic pain have different characteristics (Table 10.4). Because of its temporal nature, pain may be acute or

Neuropathic Pain Neuropathic pain is caused by damage to nerve cells or changes in the CNS. Typically described as burning, shooting, stabbing, or electrical in nature, neuropathic pain can be sudden,

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SECTION 1  Concepts in Nursing Practice

intense, short-­lived, or lingering. Neuropathic pain is difficult to treat, and management includes opioids, antiseizure medications, and antidepressants. Neuropathic pain can be either central or peripheral in origin. Although challenging to determine the global burden of neuropathic pain, it is estimated that around 8% of the general population has pain with neuropathic characteristics (Blythe, 2018). Common causes of neuropathic pain include trauma, inflammation, metabolic diseases (e.g., diabetes), alcoholism, nervous system infections (e.g., herpes zoster, human immunodeficiency virus), tumors, toxins, and neurological diseases (e.g., multiple sclerosis). Examples of neuropathic pain conditions include phantom limb sensation, diabetic neuropathy, and trigeminal neuralgia. No single sign or symptom is diagnostic for neuropathic pain. Neuropathic pain is often not well controlled by opioid analgesics alone. Treatment often requires a multimodal approach combining various adjuvant analgesics from different drug classes. These include tricyclic antidepressants (e.g., amitriptyline), serotonin–norepinephrine reuptake inhibitors (SNRIs) (e.g., bupropion [Wellbutrin, Zyban]), antiseizure medications (e.g., gabapentin [Neurontin]; pregabalin [Lyrica]), transdermal lidocaine, and α2-­adrenergic agonists (e.g., clonidine). NMDA receptor antagonists, such as ketamine, have shown promise in alleviating neuropathic pain refractory to other medications. 

Acute and Chronic Pain Acute pain and persistent pain have different causes, courses, manifestations, and treatment (see Table 10.5). Examples of acute pain include postoperative pain, labour pain, pain from trauma (e.g., lacerations, fractures, sprains) and infection (e.g., dysuria), and angina. For acute pain, treatment includes analgesics for symptom control treatment of the underlying cause (e.g., splinting for a fracture, antibiotic therapy for an infection). Normally, acute pain diminishes over time as healing occurs. Chronic pain or persistent pain continues beyond the normal time expected for healing, often longer than 3 months. The severity and functional impact of chronic pain often are disproportionate to objective findings because of changes in the nervous system not detectable with standard tests. Although acute pain functions as a signal, warning the person of potential or actual tissue damage, chronic pain does not appear to have an

adaptive role. Chronic pain can be disabling and often is accompanied by anxiety and depression. Cancer pain often is considered separately because its cause can be determined, its course differs from that of nonmalignant pain (cancer pain often worsens with documented disease progression), and the use of opioids in its treatment is more widely accepted than in the treatment of noncancer pain (von Gunten, 2011). Many older persons with advanced cancer experience daily cancer pain, especially at end of life (Booker et al., 2020). An adequate pain assessment for these patients is essential during palliative or end-­of-­life care (see Chapter 13). 

PAIN ASSESSMENT The goals of a nursing pain assessment are (a) to describe the patient’s sensory, affective, behavioural, and sociocultural pain experience for the purpose of implementing pain management techniques and (b) to identify the patient’s goal for therapy and resources and strategies for effective self-­ management. The nurse is responsible for conducting an accurate pain assessment. To conduct an accurate pain assessment, the nurse should consider the principles of pain assessment (Table 10.6). The following sections describe key components in pain assessment.

Initial Pain Assessment Nurses need to complete an initial pain assessment. The initial pain assessment provides the nurse with a comprehensive overview of the patient’s perception of their pain as well as provide a foundation to determine a plan of care and treatment for a patient. The initial pain assessment (Table 10.7) focuses on eight areas, using the acronym OPQRSTUV: onset, provocative/palliative, quality of the pain, region of the body/radiation, severity of pain, treatment/timing, understanding of pain, and values (Jarvis, 2019).  Sensory–­Discriminative Component Every pain assessment should include evaluation of the sensory–­ discriminative component: pattern, area, intensity, and nature (PAIN) of the pain. Information about these elements is essential to identifying appropriate therapy for the type and severity of the pain (RNAO, 2013).

TABLE 10.6    PRINCIPLES OF PAIN ASSESSMENT Principles

Nursing Implications

1. Patients have the right to appropriate assessment and management of pain. 2. Pain is always subjective.

• Assess pain in all patients.

3. Physiological and behavioral signs of pain (e.g., tachycardia, grimacing) are not reliable or specific for pain. 4. Pain is an unpleasant sensory and emotional experience. 5. Assessment approaches, including tools, must be appropriate for the patient population. 6. Pain can exist even when no physical cause can be found. 7. Different patients have different levels of pain in response to comparable stimuli. 8. Patients with chronic pain may be more sensitive to pain and other stimuli. 9. Unrelieved pain has adverse consequences. Acute pain that is not adequately controlled can result in physiological changes that increase the chance of developing persistent pain.

• Patient’s self-­report of pain is the single most reliable indicator of pain. • Accept and respect this self-­report unless there are clear reasons for doubt. • Do not rely primarily on observations and objective signs of pain unless the patient is unable to self-­report pain. • Address physical and psychological aspects of pain when assessing pain. • Special considerations are needed for assessing pain in patients with difficulty communicating. • Include family members in the assessment process (when appropriate). • Do not attribute pain that does not have an identifiable cause to psychological causes. • A uniform pain threshold does not exist. • Pain tolerance varies among and within persons depending on several factors (e.g., genetics, energy level, coping skills, prior experience with pain). • Encourage patients to report pain, especially patients who are reluctant to discuss pain, deny pain when it is probably present, or fail to follow through on prescribed treatments.

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TABLE 10.7    INITIAL PAIN ASSESSMENT Initial Pain Assessment (OPQRSTUV) O: onset • When did the pain start? P: provocative/palliative • Does your pain increase with movement or activity? • Are the symptoms relieved with rest? • Were any previous treatments effective? Q: quality of the pain • What does your pain feel like? • What words describe your pain? R: region of the body/radiation • Where is your pain? • Does the pain radiate, or move to other areas? S: severity of pain • How would you rate your pain on an intensity scale? T: treatment/timing • What treatments have worked for you in the past? • Is it a constant, dull, or intermittent pain? U: understanding of pain • To understand patient history of pain. What is your past experience(s) of pain? V: values • What is your acceptable level for this pain? • Is there anything else that you would like to say about your pain? • Are there any other symptoms related to the pain?

To identify onset of pain (when active, or resting) or whether pain is acute or chronic To identify quality of pain and differentiate between nociceptive and neuropathic pain mechanisms To identify alleviating and aggravating factors To evaluate effectiveness of current treatment To identify mechanism of pain (terms such as throbbing, aching, shooting, and dull may provide clues) To identify one or more areas of the body that are affected by pain, inasmuch as there may be several To identify intensity (refer to various intensity scales) To identify degree of impairment and effect on quality of life or ability to perform activities of daily living (ADLs) To identify treatments that have been successful in the past To identify timing of the pain so that treatment can be focused on spikes in pain To understand patient history of pain To be able to set achievable pain and function goals when reviewing the plan of care To understand and discuss other stressors, spiritual pain

Source: Jarvis, C. (2019). Physical examination and health assessment (3rd ed. p. 188). Elsevier.

Before beginning any assessment, the nurse must recognize that patients may use words other than pain (Table 10.8). For example, older persons may deny that they have pain but respond positively when asked if they have discomfort, soreness, or aching. For these patients, repeatedly using open-­ended questions including descriptors to understand pain may elicit more information than closed-­ended questions. The words that the patient uses in describing pain must be documented, and when the patient is asked about pain, the patient’s words should be used consistently. Pattern of Pain.  Pain onset (when it starts) and duration (how long it lasts) are components of the pain pattern. Acute pain typically increases during wound care, ambulation, coughing, and deep breathing. Acute pain associated with surgery or injury tends to diminish over time, with recovery as tissues heal. In contrast, persistent pain may be ongoing, episodic, or both. For example, a person with persistent osteoarthritis pain may experience increased stiffness and pain on arising in the morning. As the joint is gently mobilized, the pain often decreases. A patient may have constant, round-­the-­clock pain or discrete periods of intermittent pain. Breakthrough pain is moderate to severe pain that occurs despite treatment. Many patients with cancer experience breakthrough pain. It is usually rapid in onset and brief in duration, with highly variable intensity and frequency of occurrence. Episodic, procedural, or incident pain is a transient increase in pain that is caused by a specific activity or event that precipitates the pain (e.g., dressing changes, movement, eating, position changes, and certain procedures such as catheterization).  Area of Pain.  The area or location of pain assists in identifying possible causes of the pain and in determining treatment. Some patients may be able to specify one or more precise locations of their pain, whereas others may describe very general areas or comment that they “hurt all over.” The location of the pain may also be referred from its origin to another site (see Figure 10.4), as described earlier in the chapter. Pain may also radiate from its origin to another site. For example, angina pectoris

TABLE 10.8    SOME WORDS USED TO DESCRIBE

PAIN

• Pressure • Cramping • Tender • Aching • Burning

• Discomfort • Squeezing • Stabbing • Soreness

is known to radiate from the chest to the jaw, to the shoulders, or down the left arm. Sciatica is pain that originates from compression or damage to the sciatic nerve or its roots within the spinal cord. The pain is projected along the course of the peripheral nerve, causing painful shooting sensations down the back of the thigh and the inside of the leg. Typically, information about the location of pain is elicited by asking the patient to (a) describe the site or sites of pain, (b) point to painful areas on the body, or (c) mark painful areas on a body diagram (Figure 10.5). Because many patients have more than one site of pain, it is important to make certain that the patient describes every location and identifies which one is most problematic.  Intensity of Pain.  An assessment of the severity, or intensity of pain provides a reliable measurement for determining the type of treatment as well as for evaluating the effectiveness of therapy. Pain scales are useful in helping the patient communicate the intensity of pain and in guiding treatment. Scales must be adjusted to age and level of cognitive development. Numerical scales (e.g., 0 = “no pain” and 10 = “the worst pain”), verbal descriptor scales (e.g., none, a little [1–3], moderate [4–6], and severe [7–10]), or visual analogue scales (a 10-­cm line with one end labelled “no pain” and the other end labelled “worst possible pain”) can be used by most adults to rate the intensity of their pain (Figure 10.6). For patients who are unable to respond to other pain intensity scales, a series of faces ranging from “smiling” to “crying” can be used. These scales have been investigated

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SECTION 1  Concepts in Nursing Practice Initial Pain Assessment Tool Date Client’s Name

Age

Diagnosis

Room

Physician Nurse

1. LOCATION: Patient or nurse marks drawing.

Right Right

Left

Left

Right

Left

Left

L

R

L

R

Right

LEFT

RIGHT

Right

Left Left

Right

2. INTENSITY: Client rates the pain. Scale used: Present: Worst pain gets: Best pain gets: Acceptable level of pain: 3. QUALITY: (Use client’s own words, e.g., prick, ache, burn, throb, pull, sharp) 4. ONSET, DURATION, VARIATIONS, RHYTHMS: 5. MANNER OF EXPRESSING PAIN:

6. WHAT RELIEVES THE PAIN?

7. WHAT CAUSES OR INCREASES THE PAIN?

8. EFFECTS OF PAIN: (Note decreased function, decreased quality of life) Accompanying symptoms (e.g., nausea) Sleep Appetite Physical activity Relationship with others (e.g., irritability) Emotions (e.g., anger, suicidal thoughts and behaviours, crying) Concentration Other 9. OTHER COMMENTS: 10. PLAN:

May be duplicated for use in clinical practice. From McCaffery, M., Pasero, C. Pain: Clinical manual, p. 60. Copyright © 1999, Mosby. FIG. 10.5  Initial pain assessment tool (may be duplicated for use in clinical practice). Source: McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual for nursing practice (2nd ed., p. 60). Mosby.

CHAPTER 10  Pain

0

1

2

3

4

5

6

7

8

145

9 10 Worst possible pain

No pain

A No pain

Worst possible pain

B 0

C

No pain

1

2

3

4

5

Mild pain

Moderate pain

Severe pain

Very severe pain

Unbearable pain

FIG. 10.6  Pain intensity scales. A, 0 to 10 numeric scale. B, Visual

D for use in a variety of patient populations, including young children and older persons. Although intensity is an important factor in determining analgesic approaches, patients should not be dosed with opioids solely on the basis of reported pain scores (Drew et al., 2018). Opioid “dosing by numbers” without considering a patient’s sedation level and respiratory status can lead to unsafe practices and serious adverse events. Safer analgesic administration can be achieved by balancing an amount of pain relief with analgesic adverse effects. Adjustments in therapy can be made to promote better pain control and minimize adverse outcomes. 

Nature of Pain The subjective nature of pain refers to the self-­reported quality or characteristics of the pain. Many commonly used words to describe the nature of pain are included in the McGill Pain Questionnaire (MPQ; see the Resources at the end of this chapter). The MPQ is a widely used measure of subjective pain experience with well-­established reliability, validity, sensitivity, and discriminative capacity in divergent acute and chronic pain populations (Main, 2016). Two major strengths of the MPQ are that (1) it provides a comprehensive assessment of the nature of pain problems in a short time frame (5 to 10 minutes), and (2) it includes subsets of verbal pain descriptors associated with both nociceptive and neuropathic pain.  Motivational–Affective, Behavioural, Cognitive–Evaluative, and Sociocultural Components Comprehensive pain assessment includes evaluation of all pain dimensions and should be completed upon a patient’s admission to a facility and repeated at regular intervals to evaluate response to treatment. In an acute care setting, time limitations may dictate an abbreviated assessment of the affective, behavioural, cognitive, and sociocultural dimensions of pain. At a minimum, patients’ expression of pain and the effect of pain on sleep, daily activities, relationships, physical activity, and emotional well-­being should be assessed. Strategies that the patient has used or tried to control the pain (effective or not) should also be documented.

analogue scale. C, Descriptive scale. D, Faces Pain Scale. Modified from Baird, M. (2015). Manual of critical care nursing: Nursing interventions and collaborative management (2nd ed.). Elsevier.

When possible and relevant, assessment should also include examination of the psychological and social factors associated with patients’ subjective experience of pain and, in particular, the meaning of the pain experience; pain meaning may often feature prominently in patients’ treatment progress. Data related to meaning may be particularly useful in care planning for patients who exhibit high levels of pain-­related behaviour, functional impairment, or pain-­related distress. For example, as stated earlier, a woman in labor may have severe pain but can manage it without analgesics because for her it is associated with a joyful event. Moreover, she may feel control over her pain because of the training she received in prenatal classes and the knowledge that the pain is time limited. This may be in contrast to an individual experiencing chronic, undefined musculoskeletal pain who may be stressed by thoughts that the pain is “not real,” is uncontrollable, or is caused by their own actions. Perceptions influence the ways in which an individual responds to pain and must be included in a comprehensive treatment plan. For clinical assessment purposes, key areas of inquiry with patients about the meaning of pain and related beliefs should include effective pain control in relation to current intervention strategies, pain-­related disability, value placed on comfort and solace from other people, and the effect of emotions on the experience of pain. Comprehensive assessment information is necessary to ensure effective treatment, as shown in Table 10.9. 

Indigenous Considerations Indigenous populations in Canada are experiencing high rates of chronic pain. These populations also continue to face many challenges to accessing culturally sensitive health care. It is important for health care providers to acknowledge these challenges, to ensure that Indigenous populations receive appropriate and effective treatment plans for pain. Many of the challenges faced by Indigenous people involve discrimination around the assumption of substance misuse; Indigenous people have expressed being considered a “drug seeker” when they are experiencing legitimate pain issues (Brown et al., 2016). Such discrimination can lead to inadequate treatments for pain experiences (Brown et  al., 2016). Health care providers need to acknowledge and

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SECTION 1  Concepts in Nursing Practice

TABLE 10.9    NURSING ASSESSMENT: Pain Subjective Data Important Health Information Health history: Pain history includes onset, location, intensity, quality, patterns, aggravating and alleviating factors, and expression of pain. Coping strategies. Past treatments and their effectiveness. Review health care use related to the pain problem (e.g., emergency department visits, treatment at pain clinics, visits to primary health care providers and specialists). Medications: Use of any prescription or over-­the-­counter, illicit, or herbal products for pain relief. Alcohol use Nonpharmacological measures: Use of therapies, such as massage, heat or ice, Reiki, aromatherapy, acupuncture, hypnosis, yoga, or meditation

Functional Health Patterns Health perception–health management: Social and work history, mental health history, smoking history. Effects of pain on emotions, relationships, sleep, and activities. Interviews with family members. Records from psychological/psychiatric treatment related to the pain Elimination: Constipation related to opioid medication use, other medication use, or pain related to elimination Activity-­exercise: Fatigue, limitations in ability to perform activities of daily living (ADLs), instrumental activities of daily living (IADLs), and pain related to use of muscles Sexuality-­reproductive: Decreased libido Coping–stress tolerance: Psychological evaluation using standardized measures to examine coping style, depression, anxiety

Objective Data Physical examination, including evaluation of functional limitations Psychosocial evaluation, including mood

understand the historical social issues experienced by Indigenous populations to ensure culturally sensitive care. 

PAIN TREATMENT Basic Principles All pain treatment is guided by the same underlying principles. Although treatment regimens range from short-­term management to multimodal, long-­term therapy for many persistent pain problems, all treatment should follow the same basic standards, as stated by the Canadian Pain Society (Watt-Watson et al., 1999) and the RNAO 2013 Pain Assessment and Management Best Practice Guidelines: • Routine assessment is essential for effective pain management. Pain is a subjective experience involving multiple characteristics, including biological and psychosocial factors, all of which must be considered for comprehensive assessment and management. • Unrelieved acute pain complicates recovery. Unrelieved pain after surgery or injury results in more complications, longer hospital stays, greater disability, and potentially long-­term pain. • Patients’ self-­report of pain should be used whenever possible. For patients unable to report pain, a nonverbal assessment method must be used. • Health care providers have a responsibility to assess pain routinely, to accept patients’ pain reports and document them, and to intervene in order to manage pain. • The best approach to pain management involves patients, families, and health care providers. Patients and families must be informed of their right to the best pain care possible and encouraged to communicate the severity of their pain. • Many patients—in particular, vulnerable populations including infants, children, adolescents, and older adults; individuals from diverse ethnic backgrounds who have limited ability to communicate; and patients with past or current substance use problems—are at high risk for suboptimal or inappropriate pain management. Health care providers must understand that adequate pain relief is a basic human right, must be aware of their own biases and misinformation, and must ensure that all patients

•

•

•

•

are treated respectfully. Patients with a history of opioid tolerance or addiction may have higher opioid requirements following a new episode of acute pain. Care should be taken that these patients do not experience withdrawal due to undermedication. Treatment must be based on the patient’s and family’s goals for pain treatment, which should be discussed upon initial pain assessment. Sometimes these goals can be described in terms of pain intensity (e.g., the desire for pain intensity to decrease from an “8 out of 10” to a “3 out of 10”). Other patients may express a functional goal (e.g., a person may want the pain to be relieved to an extent that allows them to perform daily activities). Over the course of prolonged therapy, these goals should be reassessed, and progress should be documented. If the patient has unrealistic goals for therapy, such as wanting to be completely rid of all persistent arthritis pain, the nurse should work with the patient to establish a more realistic goal. Treatment plans should involve a combination of pharmacological and nonpharmacological therapies. Although medications are often considered the mainstay of therapy, particularly for moderate to severe pain, nonpharmacological strategies should be incorporated to increase the overall effectiveness of the treatment plan and to allow for the reduction of medication dosages to minimize adverse effects. Examples of therapies are discussed later in the chapter. A multidimensional and interprofessional approach is necessary for optimal pain management. Multiple perspectives from all members of the interprofessional team, which can include physicians, registered nurses (RNs), registered practical nurses (RPNs), physiotherapy, pharmacy, occupational therapy, and other professional involved in the patient’s circle of care, should be incorporated. All therapies must be evaluated to ensure that they are meeting the patient’s goals. Therapy must be individualized for each patient, and, often, achieving an effective treatment plan requires trial and error. Medications, dosages, and routes are commonly adjusted to achieve maximal benefit while minimizing adverse effects. This trial-­and-­error process can become frustrating for the patient and family. They need to be

CHAPTER 10  Pain reassured that pain relief is possible and that the health care team will continue to work with them to achieve adequate pain relief. • Adverse effects of medications must be prevented or managed. Adverse effects are a major reason for treatment failure and nonadherence despite the fact that most patients’ pain can be effectively managed (RNAO, 2013). Adverse effects are managed in one of several ways, described in Table 10.10. The nurse plays a key role in monitoring for and treating adverse effects, as well as in teaching the patient and family how to minimize adverse effects. • Patient and caregiver teaching should be a cornerstone of the treatment plan. Content should include information about the cause or causes of the pain, pain assessment methods, treatment goals and options, expectations for pain management, instruction regarding the proper use of medications, management of adverse effects, and nonpharmacological and self-­help measures for pain relief (RNAO, 2013). Teaching should be documented, and the patient’s and caregiver’s comprehension of this teaching should be evaluated. 

Medication Therapy for Pain Although a physician or nurse practitioner prescribes the medications, it is the nurse’s responsibility to evaluate the effectiveness and adverse effects of what is prescribed. It is also a nursing responsibility to document and communicate the outcomes of analgesic therapy and to suggest changes when appropriate, using knowledge and skills related to several pharmacological and pain management concepts. These include calculating equianalgesic doses, scheduling analgesic TABLE 10.10    MEDICATION THERAPY Examples of Ways to Manage Adverse Effects of Opioids • Ensuring a schedule for the dosing regimen to maintain blood levels • Using stool softeners and stimulant laxatives to prevent constipation • Using an antiemetic to prevent nausea • Changing to a different medication in the same drug class • Using an administration route that minimizes drug concentrations at the site of the adverse effect (e.g., intraspinal administration of opioids is sometimes used to minimize high drug levels that produce sedation, nausea, and vomiting)

147

doses, titrating opioids, and selecting from the prescribed analgesic medications. Equianalgesic Dose.  The term equianalgesic dose refers to a dose of one analgesic that produces pain-­relieving effects equivalent to those of another analgesic. The concept of equivalence is important when substituting one analgesic for another in the event that a particular medication is ineffective or causes intolerable adverse effects and when the administration route of opioids is changed (e.g., from parenteral to oral). In general, opioids are administered in equianalgesic doses—which is important to know because no upper dosage limit has been established for many of these medications. Equianalgesic charts and conversion programs are widely available in textbooks, in clinical guidelines, in health care facility pain policies, and on the Internet. Table 10.11 provides an example of common equianalgesic dosages compared with 10 mg of parenteral morphine, which is the standard basis for comparison. Although equianalgesic charts are useful tools, health care providers must understand their limitations: Equianalgesic dosages are approximate, and individual patient response must be routinely assessed. In addition, discrepancies exist among different published equianalgesic charts. All changes in opioid therapy must be carefully monitored and adjusted for the individual patient. When possible, health care providers should use equianalgesic conversions that have been approved for their facility or clinic and should consult a pharmacist before making changes.  Scheduling Analgesics.  Appropriate analgesic scheduling should focus on prevention or ongoing control of pain rather than on providing analgesics only after the patient’s pain has become moderate to severe. A patient should receive medication before procedures and activities that are expected to produce pain. Similarly, a patient with constant pain should receive analgesics around the clock rather than on an as-­needed basis. These strategies control pain before it starts and usually result in lower analgesic requirements. Fast-­acting medications should be used for incident or breakthrough pain, whereas long-­acting analgesics are more effective for constant pain. Examples of fast-­acting and sustained-­release analgesics are described later in this section.  Titration.  Analgesic titration is dosage adjustment that is based on assessment of the adequacy of analgesic effect versus the adverse effects produced. The amount of analgesic needed to manage pain varies widely, and titration is an important

TABLE 10.11    EXAMPLES OF COMMON EQUIANALGESIC DOSES Medication

Approximate Equianalgesic Parenteral Dosage

Approximate Equianalgesic Oral Dosage

Morphine Hydromorphone (Dilaudid) Oxycodone Codeine Methadone and tramadol

10 mg 1–1.5 mg Not available 120 mg —

30 mg 4–7.5 mg 20 mg 200 mg —

Meperidine (Demerol)

75 mg

300 mg

Alert/Special Considerations

Methadone and tramadol conversion morphine dose equivalents have not been reliably established. Methadone conversion requires a licensed expert’s assessment based on the patient’s history of opioid consumption. Prolonged use may increase risk of toxicity (e.g., seizures) from accumulation of the meperidine metabolite, normeperidine.

Source: Adapted from National Opioid Use Guideline Group. (2010). Oral opioid analgesic conversion table. In Canadian guideline for safe and effective use of opioids for chronic non-­ cancer pain (p. 75). https://nationalpaincentre.mcmaster.ca/documents/opioid_guideline_part_b_v5_6.pdf.

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SECTION 1  Concepts in Nursing Practice

strategy in addressing this variability. An analgesic dosage can be titrated upward or downward, depending on the situation. For example, in a postoperative patient, the dosage of analgesic generally decreases over time as the acute pain resolves. On the other hand, opioids for persistent, severe chronic noncancer pain may be titrated upward over the course of therapy to maintain adequate pain control; this titration requires expert specialty care according to the 2017 Canadian Guidelines for Opioids for Chronic Non-­Cancer Pain (Busse et al., 2017). The goal of titration is to use the lowest dosage of opioid that provides effective pain control with the fewest adverse effects.  Analgesic Ladder.  Several national and international groups have published practice guidelines recommending a systematic plan for using analgesic medications. One widely used system is the analgesic ladder proposed by the World Health Organization (WHO) (Figure 10.7). The WHO treatment plan emphasizes that different medications are administered, depending on the severity of pain, by means of a three-­step ladder approach. Step 1 medications are used for mild pain; step 2, for mild to moderate pain; and step 3, for moderate to severe pain. If pain persists or increases, medications from the next higher step are introduced to control the pain. The steps are not meant to be sequential if someone has moderate to severe pain: for this person, the analgesics given would be the stronger analgesics listed in steps 2 and 3. Medication Therapy for Mild Pain.  When pain is mild (1 to 3 on a scale of 0 to 10), nonopioid analgesics (Aspirin and other salicylates, other NSAIDs, and acetaminophen) may be used (Table 10.12). These medications are characterized by the following: (a) their analgesic properties have a ceiling effect, that is, increasing the dose beyond an upper limit provides no greater analgesia; (b) they do not produce tolerance or physical dependence; and (c) many are available without a prescription. It is important to monitor over-­the-­counter analgesic use to avoid serious problems related to medication interactions, adverse effects, and overdosage. MEDICATION ALERT—NSAIDs

• NSAIDs (except Aspirin) have been linked to a higher risk for cardiovascular events, such as myocardial infarction, stroke, and heart failure.



• Patients who have just had heart surgery should not take NSAIDs.

A number of nonopioid analgesics such as acetylsalicylic acid (ASA, Aspirin) and NSAIDs inhibit the chemicals that activate the PAN (Figure 10.8). Thus when these medications are used, the PAN is transduced less often, or a larger stimulus is needed to produce transduction. Aspirin is effective for mild pain, but its use is limited by its common adverse effects, including gastric upset and bleeding. Other salicylates such as choline magnesium trisalicylate cause fewer GI disturbances and bleeding abnormalities. Similarly to Aspirin, acetaminophen (Tylenol) has analgesic and antipyretic effects, but it has no antiplatelet or anti-­inflammatory effects. Acetaminophen is well tolerated; however, dosages higher than

Freedom fr

om cancer pain

Opio moderate id for to severe pain ± Nonopio id ± Adjuvan t

Pain pers is

3

ting or in

creasing

Opioid fo

r mild to mo ± Nonop derate pain ioid ± Adjuva nt

Pain p e

rsisting

Nonop

ioid ±

2

or incr

Adjuva

easing

nt

1

FIG. 10.7  The analgesic ladder proposed by the World Health Organization. Source: Reprinted from Cancer, WHO analgesic ladder, WHO, Copyright 2018.

TABLE 10.12    MEDICATION THERAPY Comparison of Select Nonopioid Analgesics Medication

Analgesic Efficacy in Comparison to Standards Nursing Considerations

Acetaminophen (Tylenol)

Comparable to Aspirin

Rectal suppository available; sustained-­release preparations available; maximum daily dosage of 4 g

Standard for comparison

Rectal suppository available; sustained-­release preparations available Possibility of upper GI bleeding

Salicylates Acetylsalicylic acid (Aspirin)

Nonsteroidal Anti-­Inflammatory Drugs (NSAIDs) Ibuprofen (Motrin, Advil) Indomethacin Ketorolac (Toradol) Diclofenac (Voltaren) Cyclo-­oxygenase-­2 (COX-­2) inhibitors (Celecoxib) Meloxicam (Mobicox)

Superior at 200–650 mg of Aspirin 25 mg comparable with 650 mg of Aspirin 30–60 mg equivalent to 6–12 mg of morphine 25–50 mg BID to TID; has a longer duration than 650 mg of Aspirin Similar to NSAIDs Similar to other NSAIDs

BID, twice per day; GI, gastrointestinal; TID, three times per day.

Usually well tolerated despite the potential for upper GI bleeding Not routinely used because of high incidence of adverse effects; rectal, intravenous, and sustained-­release oral forms available Treatment should be limited to maximum of 7 days; may precipitate renal failure in dehydrated patients Available in oral, ophthalmic, and topical preparations Fewer GI complaints, including bleeding; more costly than other NSAIDs May cause fewer GI adverse effects, including bleeding, than do other NSAIDs, but risk is still present; is more costly than other NSAIDs

CHAPTER 10  Pain 4 000 mg per day, acute overdosage, or use by patients with alcoholism or liver disease can result in severe hepatotoxicity. The NSAIDs represent a broad class of medications with varying efficacy and adverse effects. Some NSAIDs possess analgesic efficacy equal to that of Aspirin, whereas others have somewhat higher efficacy. Patients vary greatly in their responses to a specific NSAID, so when one NSAID does not provide relief, another should be tried. NSAIDs inhibit the cyclo-­oxygenase-­1 (COX-­1) and -­2 (COX-­2) enzymes, which produce prostaglandins involved in inflammation. Because prostaglandins also play a key role in protecting the lining of the stomach from acids, adverse effects of NSAIDs can be serious and include bleeding tendencies secondary to decreased platelet aggregation, GI issues ranging from dyspepsia to ulceration and hemorrhage, renal insufficiency, and, on occasion, CNS dysfunction. For

Arachidonic acid

Lipoxygenase pathway COX-1 (constitutive)

Cyclooxygenase pathway COX-2 (inducible)

Promotes gastric and renal blood flow and platelet adhesion

Inflammation

Relative effects of NSAIDs Indomethacin (Indocin) Aspirin Ibuprofen (Advil) Celecoxib (Celebrex) FIG. 10.8  Arachidonic acid is oxidized by two different pathways: lipoxy-

genase and cyclooxygenase (COX). The cyclooxygenase pathway leads to two forms of the enzyme cyclooxygenase: COX-­1 and COX-­2. COX-­1 is known as constitutive (always present), and COX-­2 is known as inducible (its expression varies markedly depending on the stimulus). Nonsteroidal anti-­ inflammatory drugs (NSAIDs) differ in their actions, with some having more effects on COX-­1 and others more on COX-­2. Indomethacin acts primarily on COX-­1. Ibuprofen is equipotent on COX-­1 and COX-­2. Celecoxib primarily inhibits COX-­2.

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certain chronic conditions, such as rheumatoid arthritis and osteoarthritis, NSAIDs that more selectively inhibit COX-­2 only are used. The COX-­2 enzyme does not play a role in protecting the stomach or intestinal tract; therefore, its selective inhibition is not associated with the same risk for injury to these organs as is the inhibition of COX-­1. A common example of a COX-­2 inhibitor is meloxicam (Mobicox). Cautious use of anti-­ inflammatory medications long-­term has been recommended because of the increased risk for cardiovascular accidents.  Medication Therapy for Mild to Moderate Pain.  When pain is moderate in intensity (4 to 6 on a scale of 0 to 10) or mild but persistent despite nonopioid therapy, step 2 medications are indicated. Medications commonly used for mild to moderate pain are listed in Table 10.13. One class of step 2 medications is opioids. Opioids include many medications (Table 10.14; also see Table 10.13) that produce their effects by binding to receptors. Opioid receptors are found in the CNS, on the terminals of sensory nerves, and on the surface of immune cells. There are three major opioid receptors, traditionally referred to as mu, kappa, and delta. The receptors have been reclassified as OP1 (delta), OP2 (kappa), and OP3 (mu). Most clinically useful opioids bind to the mu receptors. Mu agonists include morphine, oxycodone, hydromorphone (Dilaudid), and methadone. Opioid agonists (e.g., morphine) bind to the receptors and cause analgesia. Antagonists (e.g., naloxone) bind to the receptors but do not produce analgesia; they also block other effects of opioid receptor activation, such as sedation and respiratory depression. Mixed agonists naloxone, such as pentazocine (Talwin) and butorphanol, should not be used because they bind as agonists on the kappa receptor and, as weak antagonists or partial agonists, on the mu receptor (Figure 10.9). When a mixed agonist–antagonist is given to someone taking an agonist (e.g., morphine), it will act like an agonist– antagonist, such as naloxone, and reverse any analgesic effect. These opioid agonist–antagonists also cause more dysphoria and agitation. In addition, they have an analgesic ceiling (a dosage at which no additional analgesia is produced regardless of further dosage increases) and can precipitate withdrawal in a patient who is physically dependent on agonist medications. At step 2, prescriptions for commonly used opioids are often for products combining an opioid with a nonopioid analgesic (e.g., oxycodone [Oxycontin] or codeine plus acetaminophen [Tylenol No. 3]), which may limit the opioid dose that can be given.

TABLE 10.13    MEDICATION THERAPY Opioid Analgesics Commonly Used for Mild to Moderate Pain Medication

Comments

Nursing Considerations

Weak opioid: Many preparations are combinations with nonopioid analgesics; codeine is a prodrug and metabolized to morphine; 1%–30% of people metabolize too efficiently and 10%–20% are unable to metabolize it Maximum dosage: 400 mg in 24 hours

For mild to moderate pain, preparations of codeine and other opioids are limited by the dosage of nonopioid analgesic (e.g., the maximum dosage of acetaminophen is 4 g in 24 hours) May cause seizures, although rarely

Not available orally; not scheduled under Controlled Drugs and Substances Act; butorphanol nasal spray is used to treat migraine headaches

May precipitate withdrawal in people taking opioids on a regular basis; may cause psychotomimetic effects; reacts with many other medications; not widely prescribed

Morphine-­Like Agonists Codeine

Tramadol (Ultram)

Mixed Agonist–Antagonists Butorphanol

Source: Adapted from Inturrisi, C., & Lipman, A. (2010). Opioid analgesics. In S. M. Fishman, J. C. Ballantyne, & J. P. Rathmell (Eds.), Bonica’s management of pain (4th ed., pp. 1174–1175). Wolters-­Kluwer/Lippincott Williams & Wilkins.

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TABLE 10.14    MEDICATION THERAPY Opioids Commonly Used for Severe Pain Medication

Comments

Nursing Considerations

Morphine

Standard comparison for opioid analgesics; sustained-­release preparation (MS Contin) available

For all opioids: Use with caution in people with impaired ventilation, bronchial asthma, increased intracranial pressure, liver failure; in some people, the metabolite M6G may cause excessive vomiting and hallucinations, necessitating a change of opioid.

Hydromorphone (Dilaudid)

—

Oxycodone (slow-­release formulation is OxyNeo)

May be given alone or combined with acetaminophen; immediate-­and slow-­release preparations are available; formulated to deter potential misuse Good oral potency; 24-­ to 36-­hour half-­life, which necessitates careful monitoring Available as sublingual tablet, as injection, or, for persistent pain, as transdermal preparation (Duragesic)

Well tolerated; also available in elixir form for patients unable to swallow tablets For moderate to severe pain; usually well tolerated; physical and psychological dependence can occur with long-­term use; withdrawal can occur if medication is abruptly stopped; should be used for short-­term pain relief. Licence required to prescribe; accumulates with repeated doses; on days 2–5, dosage size and frequency must be reduced Immediate onset after administration by intravenous route; within 7–8 minutes after intramuscular route; onset after transdermal route may take several hours; not recommended for acute pain management Not well absorbed through oral route and should not be used; normeperidine (toxic metabolite with half-­life of 14–21 hours) accumulates with repetitive dosing, causing CNS excitation and seizures; naloxone potentiates excitation and must not be used; avoid in patients taking monoamine oxidase inhibitors (e.g., selegiline)

Morphine-­Like Agonists

Methadone Fentanyl

Meperidine (Demerol)

Not recommended as first-­line treatment for acute pain and should not be used for persistent pain management

Mixed Agonist–Antagonists Butorphanol

Not available orally; not scheduled under Controlled Drugs and Substances Act

May precipitate withdrawal in opioid-­dependent patients

CNS, central nervous system. Source: Adapted from Inturrisi, C., & Lipman, A. (2010). Opioid analgesics. In S. M. Fishman, J. C. Ballantyne, & J. P. Rathmell (Eds.), Bonica’s management of pain (4th ed., pp. 1174–1175). Wolters-­Kluwer/Lippincott Williams & Wilkins.

A

B

Naloxone

Mo

M K D

D

rph

ine

K

M

Antagonist Not activated

D Pentazocine

K

C

D

K

M

Activated

Agonist

Naloxone

M

Morphine

D

Buprenorphine

K

M

D

M

D

K

Oxycodone is now administered for severe pain as well. Although propoxyphene (Darvon) is classified as a step 2 medication, it is not recommended in analgesia guidelines because its effectiveness is limited and its toxic metabolite can cause seizures. Propoxyphene is not approved for use in Canada. A third type of medication available for mild to moderate pain is tramadol (Ultram). Tramadol is a weak mu-­receptor agonist and is thought to inhibit the reuptake of norepinephrine and serotonin. It has approximately the same efficacy as acetaminophen plus codeine. The most common adverse effects, which are similar to those of other opioids, include nausea, constipation, dizziness, and sedation.  Medication Therapy for Moderate to Severe Pain.  Step 3 medications are recommended for moderate to severe pain (4 to 10 on a scale of 0 to 10) or when step 2 medications do not produce effective pain relief. Most commonly used step 3 analgesics are mu-­receptor agonists, although these medications also bind with the other receptors. These medications are effective for moderate to severe pain because they are potent, have no analgesic ceiling, and can be delivered via many routes of administration. Step 3 medications are listed in Table 10.14. Morphine is one of the opioids most commonly prescribed for moderate to severe pain, although fentanyl (Duragesic), hydromorphone (Dilaudid), methadone (Metadol), and oxycodone also are used extensively. A long-­acting morphine formulation (MS Contin) is available to treat moderate to severe persistent pain in patients who require continuous, round-­the-­clock therapy for an extended period. Meperidine (Demerol), a mu-­receptor agonist, is no longer recommended for acute or persistent pain because of the high incidence of neurotoxicity (e.g., seizures) associated with the accumulation of its neurotoxic metabolite, normeperidine.

Agonist–antagonist Activated Partial antagonist Activated FIG. 10.9  Opioid receptor subtypes. A, Agonist action. B, Antagonist action. C, Agonist–antagonist action. D, Partial antagonist action. D, delta receptor. K, kappa receptor; M, mu receptor;

Moreover, any adverse effect cannot be reversed by naloxone, which potentiates the effect of normeperidine. In addition, a hyperpyrexic syndrome with delirium, which can cause death, can occur if meperidine is given to patients taking monoamine oxidase inhibitors. Although step 3 opioids have no analgesic ceiling, people can experience dose-­limiting adverse effects. In

CHAPTER 10  Pain

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TABLE 10.15    MEDICATION THERAPY Adjuvant Medications Used for Pain Management Medication

Specific Indication

Nursing Considerations

Corticosteroids

Inflammation

Avoid high dosage for long-­term use.

Neuropathic pain

Monitor for anticholinergic adverse effects.

Neuropathic pain

Start with low dosages, increase slowly to appropriate level for effect. Clonazepam and carbamazepine: Check liver function, renal function, electrolytes, and blood cell counts at baseline, at 2 weeks and at 6 weeks. Gabapentin: Monitor for idiosyncratic adverse effects (e.g., ankle swelling, ataxia, sedation).

Neuropathic pain (e.g., trigeminal neuralgia, muscle spasms)

Monitor for weakness, urinary dysfunction; avoid abrupt discontinuation because of CNS irritability.

Antidepressants Amitriptyline (Elavil) Bupropion Duloxetine (Cymbalta) Desipramine Doxepin (Sinequan) Imipramine Maprotiline Nortriptyline (Aventyl) Venlafaxine

Antiseizure Medications Carbamazepine (Tegretol) Clonazepam (Rivotril) Gabapentin (Neurontin) Pregabalin (Lyrica) Oxcarbazepine (Trileptal) Topiramate (Topamax) Valproic acid (Epival, Depakene)

Muscle Relaxant Baclofen (Lioresal)

Anaesthetics: Systemic or Oral Mexiletine

Diabetic neuropathy; neuropathic pain

Monitor for adverse effects, including dizziness, perioral numbness, paresthesias, tremor; can cause seizures, dysrhythmias, and myocardial depression at high dosages; avoid in patients with pre-­existing cardiac disease.

Local skin analgesic before venipuncture, incision; possibly effective for postherpetic neuralgia Pain associated with arthritis, postherpetic neuralgia, diabetic neuropathy

Must be applied under an occlusive dressing (e.g., Tegaderm, DuoDerm) or on an anaesthetic disc; absorption from the genital mucosa is more rapid and onset time is shorter (5–10 min) than after application to intact skin; common adverse effects include mild erythema, edema, skin blanching. Apply sparingly, rub well into affected area; wash hands with soap and water after application; adverse effects include skin irritation (burning, stinging) at the application site and cough.

Managing opioid-­induced sedation

Adverse effect is insomnia; avoid administering late in the day; usually well tolerated at low dosages.

Neuropathic pain

Recommended as an adjuvant for neuropathic pain in cases where therapeutic effect is not achieved via gabapentin.

Anaesthetics: Local Topical EMLA: lidocaine 2.5% + prilocaine 2.5%

Capsaicin

Psychostimulants Dextroamphetamine (Dexedrine) Methylphenidate (Ritalin)

Cannabinoids Nabilone

EMLA, eutectic mixture of local anaesthetics.

opioid-­naive patients, adverse effects include constipation, nausea and vomiting, sedation, respiratory depression, and pruritus. With continued use, most adverse effects diminish; the exception is constipation. Less common adverse effects include urinary retention, myoclonus, dizziness, confusion, and hallucinations. MEDICATION ALERT—Opioids

• Opioids may cause respiratory depression. • If respirations are 12 or fewer breaths per minute, withhold medication and contact the health care provider. • Transdermal fentanyl should not be used for management of acute pain.

Methadone has a unique mechanism of action as an NMDA receptor antagonist and mu–opioid receptor agonist. It is used primarily in the treatment of chronic pain but can be used for acute pain. It produces analgesic effects independent of its action as an opioid (Kharasch, 2017).

Constipation is the most common opioid adverse effect. Because tolerance to opioid-­ induced constipation does not occur, a bowel regimen should be instituted at the beginning of opioid therapy and should continue for as long as the person takes opioids. Although dietary roughage, fluids, and exercise should be encouraged to the extent possible, these measures rarely are sufficient by themselves. Thus, most affected patients should immediately begin taking a gentle stimulant laxative (e.g., senna [Senokot]) plus a stool softener (e.g., docusate sodium [Colace]). Other agents (e.g., milk of magnesia, bisacodyl [Dulcolax], lactulose) can be added if necessary. Left untreated, constipation can lead to fecal impaction and paralytic ileus that can be difficult to differentiate from obstruction. Nausea often is a problem in opioid-­naive patients. The use of antiemetics such as ondansetron (Zofran), metoclopramide, hydroxyzine (Atarax), or a prochlorperazine can prevent or minimize opioid-­related nausea and vomiting until tolerance

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develops, which usually occurs within 1 week. Metoclopramide is particularly effective when a patient reports gastric fullness. Opioids delay gastric emptying, and this effect can be reversed by metoclopramide. If nausea and vomiting are severe and persistent, as with morphine because of the metabolite M6G, changing to a different opioid such as oxycodone or hydromorphone may be necessary. Two of the most common concerns associated with opioids are sedation and respiratory depression. Sedation may occur initially in opioid-­naive patients, although patients handling pain without relief may be sleep deprived. Respiratory depression is rare in opioid-­tolerant patients when opioids are titrated to analgesic effect. Individuals at risk for respiratory depression include opioid-­naive patients, older patients, and patients with underlying lung disease. If respiratory depression occurs and stimulating the patient (e.g., calling and shaking patient) does not reverse the somnolence or increase the respiratory rate and depth, naloxone (0.4 mg in 10 mL saline), an opioid antagonist, can be administered intravenously or subcutaneously in 0.5-­mL increments every 2 minutes. However, if the patient has been taking opioids regularly for more than a few days, naloxone should be used judiciously and titrated carefully because its use can precipitate severe, agonizing pain, profound withdrawal symptoms, and seizures. Because the half-­life (60 to 90 minutes) of naloxone is shorter than that of most opioids, nurses should monitor the patient’s respiratory rate because it can drop again 1 to 2 hours after naloxone administration. Itching may occur with opioids, most frequently when they are administered via intraspinal routes. An antihistamine such as diphenhydramine (Benadryl) often is effective. If measures are ineffective, a low-­dose opioid antagonist (e.g., naloxone) or a mixed agonist–antagonist can be used, but the patient must be carefully assessed for reversal of analgesia and withdrawal. SAFETY ALERT

• The most appropriate opioid depends on the patient’s clinical profile and the nature of the pain (e.g., mild to moderate, severe). • Patients should be advised that opioids can cause cognitive effects, impairing their ability to drive. • It is important to recognize that some women rapidly metabolize codeine to morphine. In the case of postoperative patients who are breastfeeding, the infant may be at risk for fatal opioid toxicity. If codeine is prescribed to breastfeeding mothers, consultation with the physician and other health care team members is crucial to ensure careful monitoring. The patient should be advised to monitor the infant for signs of CNS depression, including poor feeding and limpness, and to contact the health care provider immediately if any such signs are noted. 

Adjuvant Analgesic Therapy.  Adjuvant analgesic therapies are medications used in conjunction with opioid and nonopioid analgesics. Adjuvants are sometimes referred to as coanalgesics. They include medications that enhance pain therapy through one of three mechanisms: (a) enhancing the effects of opioids and nonopioids, (b) possessing analgesic properties of their own, or (c) counteracting the adverse effects of other analgesics. Commonly used analgesic adjuvants are listed in Table 10.15. Figure 10.10 shows the sites of actions of pharmacological and nonpharmacological therapies for pain. Adjuvant medications are used at every step in the WHO ladder. Antidepressants.  Tricyclic antidepressants have analgesic properties at dosages lower than those effective for depression. They enhance the descending inhibitory system by preventing

Cortex

Hypnosis, imagery, placebo

Midbrain Systemic opioids Medulla

Dermal stimulation massage NSAIDs

Tricyclics TENS

Intrathecal epidural opioids

Nerve block Relaxation Sympathetic block FIG. 10.10  The sites of commonly used pharmacological and nonpharmacological analgesic therapies. NSAIDs, nonsteroidal anti-­inflammatory drugs; TENS, transcutaneous electrical nerve stimulation.

synaptic reuptake of serotonin and norepinephrine. Higher levels of serotonin and norepinephrine in the synaptic cleft inhibit the transmission of nociceptive signals in the CNS. Tricyclic antidepressants have been shown to be effective for a variety of pain syndromes, especially those involving neuropathic pain. Anticholinergic effects such as dry mouth, urinary retention, sedation, and orthostatic hypotension may lessen patients’ acceptance of using the medication and adherence to the regimen. MEDICATION ALERT—Tricyclic Antidepressants

• Tricyclic antidepressants have been implicated in prolonged QT intervals. 

Antiseizure Medications.  Antiseizure medications such as gabapentin (Neurontin), carbamazepine (Tegretol), and clonazepam (Rivotril) stabilize the membrane of the neuron and prevent transmission. These medications are effective for some neuropathic pain and for prophylactic treatment of headaches.  Corticosteroids.  Corticosteroid medications, which include dexamethasone and methylprednisolone (Medrol), are used to treat several types of pain, including acute and persistent cancer pain, pain secondary to spinal cord or brain compression, and some neuropathic pain syndromes. Mechanisms of action are unknown but may involve the ability of corticosteroids to decrease edema and inflammation and, in some cases, to shrink tumours. Corticosteroids have many adverse effects, especially when used chronically in high dosages. Adverse effects include hyperglycemia, fluid retention, dyspepsia and GI bleeding, impairment in healing, muscle wasting, osteoporosis, and susceptibility to infection. 

CHAPTER 10  Pain Local Anaesthetics.  Oral, parenteral, and topical applications

of local anaesthetics are used to interrupt transmission of pain signals to the brain. Local anaesthetics are given for acute pain resulting from surgery or trauma. Persistent neuropathic pain also may be controlled with local anaesthetics. Adverse effects can include dizziness, paresthesias, and seizures (at high dosages). Incidence and severity of adverse effects depend on dosage and route of administration. These medications also affect cardiac conductivity and may cause dysrhythmias and myocardial depression.  Ketamine.  Ketamine has traditionally been used as an anaesthetic agent because of its dissociative and amnesic effects. However, ketamine at lower doses displays analgesic effects with opioid-­sparing capabilities (Davis et  al., 2019). Research has shown that the ketamine is beneficial in the management or both acute and chronic pain. Ketamine works by inhibiting pain signals to the brain and producing desired analgesic effects (Kremier, 2019). It is water and lipid soluble which allows for crossing of the blood–brain barrier. It can be administered via a variety of routes (Davis et al., 2019). Adverse effects of ketamine include nausea, vomiting, dizziness, and hallucinations. One benefit noted for the use of ketamine for management of pain is that because of its mechanism of action on receptors it preserves respiratory function, unlike traditional opioids (Davis et al., 2019).  Administration Routes.  Opioids and other analgesic medications can be delivered via many routes. This flexibility allows the health care provider to (a) target a particular anatomical source of the pain, (b) achieve therapeutic blood levels rapidly when necessary, (c) avoid certain adverse effects through localized administration, and (d) provide analgesia when patients are unable to swallow. The following discussion highlights the uses of and nursing considerations for analgesics delivered through a variety of routes. Oral.  In general, oral administration is the route of choice for the patient with a functioning GI system. Oral medications are usually less expensive than those delivered by other routes. Many opioids are available in oral preparations, such as liquid and tablet formulations. To obtain analgesia equivalent to that provided by doses administered intramuscularly or intravenously, oral doses must be higher. For example, 10 mg of parenteral morphine is equivalent to approximately 30 mg of orally administered morphine. Generally, oral administration is the route required for opioid-­naive patients because of the first-­ pass effect of hepatic metabolism. This means that oral opioids initially are absorbed from the GI tract into the portal circulation and shunted to the liver. Partial metabolism in the liver occurs before the medication enters systemic circulation and becomes available to peripheral receptors or before it can cross the blood–brain barrier and access CNS opioid receptors, a process necessary to produce analgesia. Many opioids are available in oral preparations, such as liquid and tablet form. Oral opioids are as effective as parenteral opioids if the dose administered is large enough to compensate for first-­pass metabolism. Oral preparations also are available in immediate-­release and sustained-­release preparations. For example, morphine is available in immediate-­release solutions or tablets. These products are effective in providing rapid, short-­term pain relief; concentration in the blood typically peaks within 30 to 60 minutes. Sustained-­release oral morphine tablets are administered every 8 to 12 hours; the most common preparation is morphine ER

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(MS Contin). As with other sustained-­release preparations, this product should not be crushed, broken, or chewed. Oxycodone also comes in a sustained-­release capsule (OxyNeo). Other opioids with sustained-­release formulations include hydromorphone and tramadol. The time to maximum blood plasma dose concentration typically ranges from 30 to 60 minutes and from 2 to 4 hours for immediate-­release and sustained-­release formulations, respectively. SAFETY ALERT Sustained-­Release or Extended-­Release Preparation

• These medications should not be crushed, broken, dissolved, or chewed. They are to be swallowed whole. • If all the medicine is released into a person at once, serious adverse effects can occur, including death from overdose. 

Sublingual and Buccal.  Opioids administered under the tongue

or held in the mouth and absorbed into systemic circulation are exempt from the first-­pass effect.  Intranasal.  Intranasal administration allows delivery of medication to highly vascular mucosa and avoids the first-­pass effect. Butorphanol is one of the few intranasal analgesics available. This medication is most commonly indicated for migraine headaches. Several intranasal opioids such as fentanyl drugs are being investigated.  Rectal.  The rectal route is often overlooked but is particularly useful when the patient cannot take an analgesic by mouth. Rectal suppositories that are effective for pain relief include hydromorphone (Dilaudid) and morphine.  Transdermal.  Fentanyl (Duragesic) is available as a transdermal patch system for application to nonhairy skin. This delivery system is useful for the patient who cannot tolerate oral analgesic medications. Absorption from the patch is slow. Therefore, transdermal fentanyl is not suitable for rapid-­dosage titration but can be effective if the patient’s pain is stable and the dosage required to control it is known. Patches may have to be changed every 48 hours rather than the recommended 72 hours, depending on individual patient responses. Currently, creams and lotions containing 10% trolamine salicylate (e.g., Aspercreme, Myoflex) are available. These medications have been recommended by the manufacturers for joint and muscle pain. This Aspirin-­like substance is absorbed locally. The topical route of administration precludes gastric irritation, but the other adverse effects of high-­dosage salicylate are not necessarily prevented. Ointments, lotions, gels, liniments, and balms (most of which are over-­the-­counter products) are sometimes applied topically to achieve pain relief. Common ingredients include methyl salicylate combined with camphor, menthol, or both. On application, these medications usually produce a strong hot or cold sensation and should not be used after massage or a heat treatment, when blood vessels are already dilated. Skin testing is advisable when the patient has not used the particular medication before because the strengths of the medications vary and different intensities of sensation are produced. These products are indicated for arthralgia, bursitis, myalgia, and tendinitis. Other topical analgesic medications, such as capsaicin (e.g., Flex-­ ol) and prilocaine plus lidocaine (eutectic mixture of local anaesthetics [EMLA]), and anti-­inflammatory medications such as Voltaren (1% diclofenac) also provide analgesia. Derived from red chili pepper, capsaicin depletes and prevents reaccumulation of substance P in the peripheral sensory neurons. It can control pain associated with postherpetic neuralgia,

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diabetic neuropathy, and arthritis. EMLA is useful for control of pain associated with venipunctures, ulcer debridement, and possibly postherpetic neuralgia. The area to which EMLA is applied should be covered with a plastic wrap for 30 to 60 minutes before a painful procedure begins.  Parenteral Routes.  The parenteral route includes subcutaneous and intravenous administration. The only opioid that must be injected intramuscularly is meperidine, and this medication is not recommended because its toxic metabolite, normeperidine, can accumulate with repeated administration, causing CNS excitation. Single-­dose administration (subcutaneous or intravenous) is possible via parenteral routes. The intramuscular route, although frequently used, is not recommended because these injections cause significant pain, result in unreliable absorption, and, with chronic use, can result in abscesses and fibrosis. Onset of analgesia after subcutaneous administration is slow, thus the subcutaneous route is rarely used for acute pain management. However, continuous subcutaneous infusions are effective for persistent cancer pain. This route is especially helpful for people with abnormal GI function and limited venous access. Intravenous administration is the best option when immediate analgesia and rapid titration are necessary. Continuous intravenous infusions provide excellent steady-­state analgesia through stable blood levels.  Intraspinal Delivery.  Intraspinal (epidural or intrathecal) opioid therapy involves inserting a catheter into the subarachnoid space (for intrathecal delivery) or the epidural space (for epidural delivery) and injecting an analgesic, by either intermittent bolus doses or continuous infusion. Percutaneously placed temporary catheters are used for short-­term therapy (2 to 4 days), and surgically implanted catheters are used for long-­term therapy. Although the lumbar region is the most common site of placement, epidural catheters may be placed at any point along the neuroaxis (cervical, thoracic, lumbar, or caudal). Intraspinally administered analgesics are highly potent because they are delivered close to the receptors in the dorsal horn of the spinal cord. Thus, much lower doses of analgesics are needed for intraspinal delivery in comparison with other routes, including intravenous. Medications delivered intraspinally include morphine, fentanyl, and hydromorphone. Nausea, itching, and urinary retention are common adverse effects of intraspinal opioids. Complications of intraspinal analgesia include catheter displacement and migration, neurotoxicity (especially of certain medications when infused intraspinally), and infection. Clinical manifestations of catheter displacement or migration depend on catheter location. Movement of a catheter out of the intrathecal or epidural space causes a decrease in pain relief with no improvement even when additional analgesic is administered. Correct placement of an intrathecal catheter can be checked by aspirating cerebrospinal fluid. Migration of a catheter into a blood vessel causes an increase in adverse effects because of systemic medication distribution. A number of medications and chemicals are highly neurotoxic when administered intraspinally, such as preservatives (e.g., alcohol and phenol), antibiotics, potassium, and total parenteral nutrition supplements. To avoid inadvertent injection of intravenous medications into an intraspinal catheter, the catheter should be clearly marked as an intraspinal access device, and only preservative-­free medications should be injected. Infection rarely occurs with intraspinal analgesia. However, it is a serious complication that can be difficult to detect. The skin around the exit site should be carefully assessed for

inflammation, drainage, or pain. Signs and symptoms of an intraspinal infection include diffuse back pain, pain or paresthesias during bolus injection, and unexplained sensory or motor deficits. Fever may or may not be present. Acute bacterial infection (meningitis) is manifested by fever, headache, and altered mental status. Infection is avoided with regular, meticulous wound care and with the use of sterile technique in caring for the catheter and injecting medications.  Patient-­Controlled Analgesia.  A specific type of subcutaneous, intravenous, or intraspinal delivery system is patient-­ controlled analgesia (PCA), or demand analgesia. PCA is an infusion system that allows the patient to self-­administer a dose of opioid through a pump when needed: The patient pushes a button to receive a bolus infusion of an analgesic within preprogrammed intervals. PCA is used widely for the management of acute pain, including postoperative pain and cancer pain. Often, the patient also receives an additional continuous basal infusion (known as PCA plus basal) at a preset dose and rate. The addition of a continuous basal infusion to a PCA regimen improves nighttime pain relief and promotes better sleep postoperatively. Common opioids used in PCA administration method include morphine, fentanyl, and hydromorphone (Dilaudid). Use of PCA begins with patient teaching. The patient needs to understand the benefits and principles of PCA therapy, the mechanics of obtaining a medication dose (i.e., the operation of the pump and button), and how to titrate the medication to achieve good pain relief. The patient should be encouraged to use the PCA pump prophylactically by self-­administering the analgesic before ambulation, physiotherapy, and dressing changes. The patient also needs to be reminded that apart from the involved health care providers, the patient is the only person who should press the button. The patient should also be assured—for safety reasons and to avoid excessive sedation or respiratory depression—that the pump is programmed to deliver a maximum number of doses per hour; pressing the button after the maximum dose is administered will not result in additional analgesic. If the maximum doses are inadequate to relieve pain, by order of a physician or nurse practitioner, the pump can be reprogrammed to increase the amount or frequency of administration. In addition, bolus doses can be given by the nurse if they are included in the physician’s orders. The patient should also be encouraged to report adverse effects such as nausea and vomiting or pruritus so that they can be managed effectively. To make a smooth transition from infusion PCA to oral therapy, the dosage of oral medication should be increased (as ordered) as the PCA analgesic is tapered. 

TRADITIONAL MEDICINAL THERAPIES OF INDIGENOUS POPULATIONS IN CANADA The Indigenous populations in Canada believe in a holistic approach to health and wellness. As the Indigenous populations account for 4% of Canada’s population, it is important to understand the traditional medicines used by Indigenous people (Uprety et al., 2016). Many of the traditional medicines come from the Boreal forest in Canada. Health care providers need to be knowledgeable of traditional medicinal practices and seek knowledge of such practices during pain assessments to ensure a comprehensive and holistic approach to planning care. Many medicinal plants are used in Indigenous populations.

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CHAPTER 10  Pain Preparation of the plants for medicinal purposes includes paste, poultice, infusion, and eating the plant raw. It is important to note that traditional medicinal practices are usually guided under the direction of an Elder, as some plants are poisonous or can have adverse reactions with other plants or Western medicines (Uprety et al., 2016).

Surgical Therapy for Pain Nerve Blocks.  Nerve blocks are used to reduce pain by temporarily or permanently interrupting transmission of nociceptive input. This is achieved with local anaesthetics or neurolytic drugs (e.g., alcohol, phenol). Neural blockade with local anaesthetics is sometimes used for perioperative pain. For intractable persistent pain, nerve blocks are used when more conservative therapies fail. Nerve blocks have been a successful pain management technique for more localized persistent pain states, such as peripheral vascular disease, trigeminal neuralgia, causalgia, and some cancer pain. A nerve block may be considered advantageous for managing localized pain caused by malignancy and in debilitated patients who could not otherwise withstand a surgical procedure for pain relief.  Interventional Therapy Therapeutic Nerve Blocks.  Nerve blocks generally involve one-­ time or continuous infusion of local anaesthetics into a particular area to produce pain relief. Such relief is also referred to as regional anaesthesia. Nerve blocks interrupt all afferent and efferent transmission to the area and thus are not specific to nociceptive pathways. They include local infiltration of anaesthetics into a surgical area (e.g., for excision of a breast lump, inguinal hernia surgery, intra-­articular infiltration after joint surgery, amputation, subcostal incisions) and injection of anaesthetics into a specific nerve (e.g., occipital or pudendal nerve) or nerve plexus (e.g., brachial or celiac plexus). Nerve blocks often are used during and after surgery to manage pain. For longer-­term relief of chronic pain, local anaesthetics can be administered via a continuous infusion. For intractable persistent pain, neuroablative nerve blocks (see next section) with phenol or alcohol may be used. For example, a neurolytic celiac plexus block may be induced for pain caused by pancreatic cancer, or an intercostal neurolytic block may be induced for post-­thoracotomy pain. Heat and microwaves, used in many neurolytic procedures, produce nerve tissue destruction.  Neuroablative Techniques.  Neuroablative interventions are performed for severe pain that is unresponsive to all other therapies. Neuroablative techniques destroy nerves, thereby interrupting pain transmission. Destruction is accomplished by surgical resection or thermocoagulation, including radiofrequency coagulation. Neuroablative interventions that destroy the sensory division of a peripheral or spinal nerve are classified as neurectomies, rhizotomies, and sympathectomies. Neurosurgical procedures that ablate the lateral spinothalamic tract are classified as cordotomies if the tract is interrupted in the spinal cord or as tractotomies if the interruption is in the medulla or the midbrain of the brain stem. Figure 10.11 depicts the sites of neurosurgical procedures for pain relief. Both cordotomy and tractotomy can be performed with the aid of local anaesthesia by a percutaneous technique.  Neuroaugmentation.  Neuroaugmentation involves electrical stimulation of the brain and the spinal cord. Spinal cord stimulation is performed much more often than deep brain stimulation. Technological advances have enabled the use of multiple

Fifth cranial nerve rhizotomy

Ninth cranial nerve rhizotomy

Cervical cordotomy lesion of spinothalamic tract only

Tractotomy

Thoracic cordotomy

Dorsal root

Sympathectomy

Sympathetic ganglion chain

Posterior rhizotomy

FIG. 10.11  Sites of neurosurgical procedures for pain relief.

TABLE 10.16    NONPHARMACOLOGICAL THERA-

PIES FOR PAIN

Physical Therapies

Cognitive Therapies

• Acupuncture • Application of heat and cold • Exercise • Massage • Percutaneous electrical nerve stimulation (PENS) • Transcutaneous electrical nerve stimulation (TENS)

• Distraction • Hypnosis • Imagery • Relaxation strategies • Self-­management

leads and multiple electrode terminals so as to stimulate large areas. In Canada and the United States, a common use of spinal cord stimulation is for chronic back pain secondary to nerve damage that is unresponsive to other therapies. Other uses include complex regional pain syndrome (CRPS), spinal cord injury pain, and interstitial cystitis. Potential complications include those related to the surgery (bleeding and infection), migration of the generator (which usually is implanted in the subcutaneous tissues of the upper gluteal or pectoralis area), and nerve damage. 

Nonpharmacological Therapy for Pain Use of nonpharmacological pain management strategies can reduce the dose of an analgesic required to control pain and thereby minimize adverse effects of pharmacological therapy. Some strategies are believed to alter ascending nociceptive input or stimulate descending pain modulation mechanisms. Nonpharmacological pain relief methods can be categorized as physical or cognitive strategies (Table 10.16).

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Physical Pain Relief Strategies Massage.  Massage is a common therapy for pain, and many massage techniques exist. Examples include moving the hands or fingers over the skin slowly or briskly with long strokes or in circles (superficial massage) or applying firm pressure to the skin to maintain contact while massaging the underlying tissues (deep massage). Specific massage techniques include acupressure and trigger-­point massage. A trigger point is a circumscribed hypersensitive area within a tight band of muscle that is the result of acute or persistent muscle strain. Several common trigger points have been identified on the neck, back, and arms. Trigger-­point massage is performed by either application of strong, sustained digital pressure, deep massage, or gentler massage with ice followed by muscle heating. (Massage is discussed further in Chapter 12.)  Exercise.  Exercise is a critical part of the treatment plan for patients with persistent pain, particularly those with musculoskeletal pain. Many patients become physically deconditioned as a result of their pain, which in turn can exacerbate pain. Exercise acts through many mechanisms to relieve pain: It enhances circulation and cardiovascular fitness, reduces edema, increases muscle strength and flexibility, and enhances physical and psychosocial functioning. This can include both passive and active range-­of-­ motion exercises. A safe exercise program should be tailored to the physical needs and lifestyle of the patient and should include mild to moderate aerobic exercise, stretching, and strengthening exercises. The program also should be supervised by trained personnel (e.g., physiologist, physiatrist, registered nurse with specialty training, exercise physiologist, physiotherapist). Turning and Positioning.  Patients experiencing immobility due to injury or illness can experience pain due to immobility. These patients are unable to turn and position themselves to decrease pressure on pressure points and increase their comfort and reduce the risk of impaired skin integrity (e.g., pressure injuries). Health care providers should turn and position patients frequently, every 2 hours, to promote circulation and comfort (RNAO, 2007).  Transcutaneous Electrical Nerve Stimulation.  In transcutaneous electrical nerve stimulation (TENS), an electric current is delivered through electrodes applied to the skin surface over the painful region, at trigger points, or over a peripheral nerve. A TENS system consists of two or more electrodes connected by lead wires to a small, battery-­operated stimulator (Figure 10.12). Usually, a physiotherapist is responsible for administering TENS therapy, although nurses also can be trained in the technique. TENS may be used for acute pain, including postoperative pain, visceral pain, and pain associated with physical trauma. Although the effect of TENS on persistent pain is less clear, it may be effective in such cases (Coutaux, 2017).  Heat Therapy.  Application of heat for pain management has been used for centuries. The premise is that applying heat to skin will increase blood flow and reduce pain-­related neurotransmitter activity. Heat therapy includes application of either moist or dry heat to the skin and can be superficial or deep. Superficial heat can be applied through an electric heating pad (dry or moist), a hot pack, hot moist compresses, or a hot water bottle. For exposure to large areas of the body, patients can immerse themselves in a hot bath, shower, or whirlpool. Physiotherapy departments provide deep-­heat therapy through such techniques as shortwave diathermy, microwave diathermy, and ultrasound therapy. Patient teaching regarding heat therapy is described in Table 10.17. 

FIG. 10.12  Transcutaneous electrical nerve stimulation (TENS). Source: iStock.com/Praisaeng.

TABLE 10.17    PATIENT & CAREGIVER TEACHING

GUIDE

Application of Heat and Cold When patients use superficial heating techniques, they should be taught the following: • Do not use heat on an area that is being treated with radiation therapy, is bleeding, has decreased sensation, or has been injured in the past 24 hours. • Do not use any menthol-­containing products (e.g., Vicks VapoRub) with heat applications because this combination may cause burns. • Cover the heat source with a towel or cloth to prevent burns. • Do not apply heat directly to transdermal analgesic preparations, such as fentanyl, as heat application may alter drug bioavailability. When patients use superficial cold techniques, they should be taught the following: • Cover the cold source with a cloth or towel. • Do not apply cold to areas that are being treated with radiation therapy, have open wounds, or have poor circulation. • If it is not possible to apply the cold directly to the painful site, try applying it directly above or below the painful site or on the opposite side of the body on the corresponding site (e.g., left elbow if the right elbow hurts).

Application of Cold.  Like heat therapy, application of cold therapy has long been used for pain relief. Cold therapy competes for nerve transmission and reduces sensation, effects that can be especially helpful for pain that resembles a burning sensation (RNAO, 2013). Cold therapy involves the application of either moist or dry cold to the skin. Dry cold can be applied by means of an ice bag, and moist cold by means of towels soaked in ice water, cold hydrocollator packs, or immersion in a cold bath or under running cold water. Icing with ice cubes or blocks of ice made to resemble popsicles is another technique used for pain relief. Cold therapy is believed to be more effective than heat for a variety of painful conditions, including acute pain from trauma or surgery, acute flares of arthritis, muscle spasms, and headache. Patient teaching regarding cold therapy is described in Table 10.17.  Cognitive Techniques.  A variety of cognitive strategies and behavioural approaches can alter the affective, cognitive, and behavioural components of pain. Some of these techniques require little training and often are adopted independently by the patient. For others, a trained therapist must administer therapy.

CHAPTER 10  Pain Distraction.  The redirection of attention on something other than the pain is a simple but powerful strategy to relieve pain. Distraction-­induced analgesia involves introducing competition for attention between a highly salient sensation (pain) and some other information-­processing activity. Distraction can be achieved by engaging the patient in any activity that can hold their attention (e.g., watching TV, conversing, listening to music, playing a game).  Relaxation Strategies.  Relaxation strategies are used to reduce stress, decrease acute anxiety, distract from pain, alleviate muscle tension, combat fatigue, facilitate sleep, and enhance the effectiveness of other pain relief measures (dos Santos Felix, 2019). Elicitation of the relaxation response requires a quiet environment, a comfortable position, and a mental device as a focus of concentration (e.g., a word, a sound, or the breath). Relaxation strategies include relaxation breathing, music, guided imagery, meditation, and progressive muscle relaxation. (See Chapter 8 for additional information.)  Self-­Management.  Self-­ management training is now in widespread use in Canada as an effective, adjunctive strategy for managing the effect of chronic pain on day-­to-­day functioning and quality of life (Boschen et al., 2016). Through structured rehearsal of various cognitive and behavioural self-­management techniques (e.g., energy conservation, pacing, sleep promotion, relaxation, communication skills, safe exercise), patients and family members learn to set realistic weekly goals that are directed at increasing overall functional capacity and emotional well-­being. Strong evidence supports the effectiveness of self-­ management training for (a) improving participants’ perceived self-­efficacy or ability to achieve selected goals, (b) reducing pain, and (c) improving perceived quality of life. 

NURSING AND INTERPROFESSIONAL MANAGEMENT PAIN The nurse is an important member of the interprofessional pain management team. The nurse acts as planner, educator, patient advocate, interpreter, and supporter of the patient in pain and of the patient’s family or caregivers. Because any patient in a wide variety of care settings (e.g., home, hospital, clinic) can be in pain, the nurse must be knowledgeable about current therapies and flexible in trying new approaches to pain management. The extent of the nurse’s involvement depends on the unique factors associated with the patient, the setting, and the cause of the pain. Many nursing roles were described earlier in this chapter: conducting pain assessments, administering therapies, monitoring for adverse effects, and teaching patients and caregivers. However, the success of these actions depends on the nurse’s ability to establish a trusting relationship with the patient and caregivers and to address the concerns they have regarding pain and its treatment.

Effective Communication Patients need to feel confident that their reporting of pain will be believed and will not be perceived as “complaining.” The patient and family also need to know that the nurse considers the pain significant and is committed to helping the patient obtain pain relief and cope with any unrelieved pain. Pharmacological and nonpharmacological interventions should be incorporated into the treatment plan, and the patient should be supported through the period of trial and error that may be necessary to implement an effective therapeutic plan. It also is important

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TABLE 10.18    NURSING ASSESSMENT Pain-­Related Nursing Diagnoses • Anxiety • Comfort • Constipation • Coping • Discomfort • Inadequate sleep

• Need for health teaching • Pain • Reduced functional ability • Reduced stamina • Self concept • Social isolation

TABLE 10.19    PATIENT & CAREGIVER TEACHING

GUIDE

Pain Management Teaching Needs The goals of teaching related to pain management include the expectation that the patient and the caregivers understand the following: • The need to maintain a record of pain intensity and effectiveness of treatment • No need to wait until pain becomes severe to take medications or use nonpharmacological therapies for pain relief • The possibility that the dosage of medication will have to be adjusted over time to maximize long-­term effectiveness • The potential adverse effects (e.g., nausea and vomiting, constipation, sedation and drowsiness, itching, urinary retention, sweating) and complications associated with opioid therapy or other pain relief therapies • The need to report when pain is not relieved to tolerable levels

to clarify responsibilities of pain relief. The nurse should help the patient understand the roles of the interprofessional health care team members, as well as the roles and expectations of the patient. In addition to addressing specific aspects of pain assessment and treatment, the nurse evaluates the total effect that the pain may have on the lives of the patient and family. Thus, other possible nursing diagnoses must also be considered. Table 10.18 lists possible nursing diagnoses that may be appropriate for assessing and managing pain. Table 10.19 addresses teaching needs of patients and caregivers in relation to pain management. 

Barriers to Effective Pain Management Pain is a complex, multidimensional, and subjective experience, and its management is influenced greatly by psychosocial, sociocultural, and legal and ethical factors. These factors include emotions, behaviours, misconceptions, and attitudes of patients and family members about pain and the use of pain therapies. Achieving effective pain management requires careful consideration of these factors. Concerns regarding tolerance, dependence, and addiction are common barriers to effective pain management, inasmuch as these phenomena are often misunderstood. Patients, family members, and health care providers often share these concerns. It is important for the nurse to understand and be able to explain the differences between these various concepts. Tolerance.  Tolerance occurs with chronic exposure to a variety of drugs. In the case of opioids, tolerance to analgesia is characterized by the need for an increased opioid dose to maintain the same degree of analgesia. Although the development of tolerance to adverse effects (except constipation) is more predictable, the incidence of clinically significant analgesic opioid

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TABLE 10.20    MANIFESTATIONS OF OPIOID

WITHDRAWAL SYNDROME

Psychosocial Secretions

Other

Early Response (6–12 hr)

Late Response (48–72 hr)

• Anxiety • Lacrimation • Rhinorrhea • Diaphoresis • Yawning • Piloerection • Shaking, chills • Dilated pupils • Anorexia • Tremor

• Excitation • Diarrhea

• Restlessness • Fever • Nausea and vomiting • Abdominal cramping pain • Hypertension • Tachycardia • Insomnia • Muscle aches

tolerance in patients with chronic pain is unknown, since dosage needs may increase as the disease (e.g., cancer) progresses. It is essential to assess for increased analgesic needs in patients on long-­term therapy. The interprofessional team must evaluate and rule out other causes of increased analgesic needs, such as disease progression or infection. The first sign of tolerance may be that the patient begins to experience regular end-­of-­dose failure. If manifestations of possible tolerance appear, appropriate evaluations should be made to rule out other causes of increased analgesic needs, such as disease progression or infection. Approaches to managing tolerance are (a) to increase the dosage of the analgesic, (b) to substitute another medication in the same class (e.g., changing from morphine to oxycodone), or (c) to add a medication from a different drug class that will augment pain relief without increasing adverse effects. It is important to note that there is no ceiling effect for opioid-­agonist medications and to recognize that drug tolerance is not synonymous with addiction.  Physical Dependence.  Like tolerance, physical dependence is an expected physiological response to ongoing exposure to pharmacological agents. It is manifested by a withdrawal syndrome when the drug is abruptly decreased. Manifestations of opioid withdrawal are listed in Table 10.20. When opioids are no longer needed to provide pain relief, a tapering schedule should be used in conjunction with careful monitoring. A typical tapering schedule involves reducing the dose by 20% to 50% per day. The goal is to reduce the amount of medication and at the same time minimize adverse and withdrawal effects. Despite this slow weaning schedule, the nurse should assess carefully for signs of opioid withdrawal. In addition, it is important to recognize that other commonly prescribed medications for pain also can induce physical dependence and therefore must be slowly tapered. These include benzodiazepines and muscle relaxants.  Substance Misuse.  Substance misuse or substance use disorders are complex neurobiological conditions characterized by the use of a substance in high doses or inappropriate situations that can impact one’s health or create social problems (McLellan, 2017) (see Chapter 11). Tolerance and physical dependence are not indicators of addiction or substance misuse. Rather, they are normal physiological responses to chronic exposure to certain drugs, including

opioids. For patients without a history of substance use disorder, the risk of addiction or substance misuse is thought to be significantly lower. People with a history of addiction can be managed successfully on opioids for their pain with careful monitoring; however, in this population, the risk for addiction may be higher. Expectations of the health care team and the patient must be discussed openly and documented. Signs and symptoms of possible addiction must be monitored and interventions promptly initiated. In addition to fears about substance misuse, physical dependence, and tolerance, other barriers hinder effective pain management. These include concern about adverse effects, difficulties with remembering to take medications, desire to handle pain stoically, and not wanting to distract the health care provider from treating the disease. Table 10.21 lists examples of patient-­related barriers to effective pain management and includes strategies to address the barriers. 

INSTITUTIONALIZING PAIN EDUCATION AND MANAGEMENT Besides patient and family barriers, other barriers to effective and safe pain management include inadequate health care provider education and lack of institutional support. Traditionally, medical and nursing school curricula have spent little time teaching future physicians and nurses about pain and effective pain management, although this is changing. This lack of emphasis was partially responsible for the insufficiency of health care providers’ knowledge of and skills for treating pain adequately. Over the past few decades, some improvements have been made in overcoming these barriers. Medical and nursing schools now devote more time to addressing pain. Numerous professional organizations have published evidence-­informed guidelines for assessing and managing pain in many patient populations and clinical settings. The IASP has published a core curriculum on pain that was developed for the learning needs of a range of health care provider groups. Provincial organizations such as the RNAO (2013) have also developed evidence-­ informed practice guidelines on pain that are readily accessible (see the Resources section at the end of this chapter for the Web links). Health care institutions are also directing more, much-­ needed attention to their support of pain management. Researchers and health care providers have documented the central role of institutional commitment and practices in changing clinical practice; without institutional support, pain outcomes are unlikely to change. The pain management standards from the Canadian Pain Task Force Report (2010) Chronic Pain in Canada: Laying a Foundation for Action (see the Resources section at the end of this chapter) emphasize that patients have a right to the best pain relief possible and that measures to prevent or reduce acute pain are a priority. Many large tertiary and quaternary university-­affiliated care settings now have specialized teams to manage pain. One such example is the establishment of dedicated acute pain services (APS) that include advanced-­practice nurses. These services provide expert management of postsurgical pain and complex pain conditions. Advanced-­practice nurses, often nurse practitioners, work collaboratively with anaesthesiologists and allied health care providers to assess and manage pain

CHAPTER 10  Pain

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TABLE 10.21    PATIENT & CAREGIVER TEACHING GUIDE Reducing Patient-­Related Barriers to Pain Management Barrier

Nursing Considerations

Fear of addiction

• Provide accurate definition of addiction. • Explain that addiction is uncommon in patients taking opioids for pain relief. • Provide accurate definition of tolerance. • Teach that tolerance is a normal physiological response to long-­term opioid therapy. If tolerance does develop, the medication may have to be changed (e.g., morphine in place of oxycodone). • Teach that there is no upper limit to pure opioid agonists (e.g., morphine). Dosages can be increased indefinitely, and the patient should not save medication for when the pain is worse. • Teach that tolerance to analgesic effects of opioids develops more slowly than do many adverse effects (e.g., sedation, respiratory depression). Tolerance does not ameliorate constipation; thus a regular bowel program should be started early. • Teach methods to prevent and to treat common adverse effects. • Emphasize that adverse effects such as sedation and nausea decrease with time. • Explain that different medications have unique adverse effects and that other pain medications can be tried to reduce the specific adverse effect. • Teach nonpharmacological therapies to minimize the dosage of medication needed to control pain. • Explain that oral medicines are preferred. • Emphasize that even if the oral route becomes unusable, transdermal or in-­dwelling parenteral routes can be used rather than injections. • Explain that patients are partners in their care and that the partnership requires open communication on the parts of both patient and nurse. • Emphasize to patients that they have a responsibility to keep the nurse informed about their pain. • Explain that although stoicism is a valued behaviour in many cultures, failure to report pain can result in undertreatment and severe, unrelieved pain. • Provide and teach use of pill containers. • Provide methods of record keeping for medication use. • Recruit family members, as appropriate, to assist with the analgesic regimen. • Explain that reporting pain is important for treating both the disease and its symptoms.

Fear of tolerance

Concern about adverse effects

Fear of injections

Desire to be a good patient

Desire to be stoic Forgetting to take analgesic

Fear of distracting the health care provider from treating the disease Concern that pain signifies disease progression

Sense of fatalism

Ineffectiveness of medication

• Explain that increased pain or analgesic needs may reflect tolerance. • Emphasize that new pain may come from a non–life-­threatening source (e.g., muscle spasm, urinary tract infection). • Institute pharmacological and nonpharmacological strategies to reduce anxiety. • Ensure that the patient and family members have current, accurate, comprehensive information about the disease and the prognosis. • Provide psychological support. • Explain that research has shown that pain can be managed in most patients. • Explain that with most therapies, a period of trial and error is necessary. • Emphasize that adverse effects can be managed. • Teach that there are multiple options within each category of medication (e.g., opioids, NSAIDs) and that another medication from the same category may provide better relief. • Emphasize that finding the best treatment regimen often requires trial and error. • Incorporate nonpharmacological approaches in the treatment plan.

NSAIDs, nonsteroidal anti-­inflammatory drugs. Source: Adapted from Ersek, M. (1999). Enhancing effective pain management by addressing patient barriers to analgesic use. Journal of Hospice & Palliative Nursing, 1, 87–96.

and also to serve in leadership roles to promote best practice guidelines. 

ETHICAL ISSUES IN PAIN MANAGEMENT Fear of Hastening Death by Administering Analgesics A common concern of health care providers and caregivers is that giving a sufficient amount of medication to relieve pain will hasten or precipitate death of a terminally ill person. However, there is no scientific evidence that opioids can hasten death, even among patients at the very end of life. Moreover, nurses and health care providers have a moral obligation to provide comfort and pain relief at the end of life. The ethical justification for administering analgesics despite the possibility of hastening death follows the bioethical principle of the rule of double effect: that if an unwanted consequence (e.g., hastened death)

occurs as a result of an action taken to achieve a moral good (e.g., pain relief), the action is justified according to ethical theory. Unrelieved pain is one of the reasons that patients make requests for assisted suicide. Aggressive and adequate pain management may decrease the number of such requests. Medical assistance in death, legal in Canada, is a complex issue that extends beyond pain and pain management. 

Use of Placebos in Pain Assessment and Treatment Placebos have been used inappropriately in the past to determine whether patients’ pain was “real.” Using medication placebos for pain, such as a saline injection instead of an opioid or an oral dosage of an inappropriate medication, is unethical. Many professional organizations condemn the use of placebos to assess or treat pain. 

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AGE-­RELATED CONSIDERATIONS PAIN Persistent pain is a common problem in older persons and is often associated with significant physical disability and psychosocial problems. The most common sources of pain among older people are musculoskeletal conditions, such as osteoarthritis and low back pain, and previous fracture sites. Persistent pain often results in depression, sleep disturbance, decreased mobility, increased use of health care services, and physical and social role dysfunction. Despite its high prevalence, pain in older persons often is inadequately assessed and treated. However, there are several barriers to pain assessment in the older patient. In general, the barriers discussed earlier in the chapter are more prevalent among this population. For example, many older patients believe that pain is a normal, inevitable part of aging. They may also believe that nothing can be done to relieve the pain. Older persons may not report pain for fear of being a “burden” or a “bad patient.” They may have greater fears of taking opioids than patients in other age groups. Nurses must be vigilant in asking older patients about their pain and its effects. Additional barriers to pain assessment in older persons include cognitive changes, inconsistency with experience of pain, and acceptance of pain as a normal process in aging (Resnick et  al., 2019). Also, hearing and vision deficits may complicate assessment. Therefore, pain assessment tools may have to be adapted for older patients. For example, it may be necessary to use a large-­print pain intensity scale. Although there is some concern that older persons have difficulty using pain scales, it has been documented that many older people, even those with mild to moderate cognitive impairment, can use quantitative scales accurately and reliably (see Figure 10.6). As for other patients with persistent pain, a thorough physical examination should be performed and the history thoroughly documented to identify causes of pain, possible therapies, and potential problems. Because depression and functional impairments are common among older persons with pain, the possibility of these also must be assessed. Treatment of pain in older people is complicated by several factors. First, older people metabolize medications more slowly than do younger patients and thus are at greater risk for higher blood levels and adverse effects. For this reason, the adage “start low and go slow” is applied to analgesic therapy in this age group. Second, the use of NSAIDs in older persons is associated with a high frequency of serious GI bleeding. For this reason, acetaminophen should be used whenever possible. Third, many older people take multiple medications for one or more chronic conditions. The addition of analgesics can result in dangerous drug interactions and more adverse effects. Fourth, cognitive impairment and ataxia can be exacerbated when analgesics such as opioids, antidepressants, and anticonvulsant medications are used, a possibility that again necessitates health care providers to titrate medications slowly and monitor carefully for adverse effects. Treatment regimens for older people must incorporate nonpharmacological modalities. Exercise and patient teaching are particularly important nonpharmacological interventions for older persons with persistent pain. The roles of family and paid caregivers should be included in the treatment plan. 

SPECIAL POPULATIONS Cognitively Impaired Individuals Although patient self-­report is a gold standard of pain assessment in most circumstances, severe cognitive impairment often prevents patients from communicating clearly about their pain. For these individuals, behavioural and physiological changes may be the only indicators that they are in pain. Therefore, the nurse must be astute at recognizing behavioural symptoms of pain. Several scales have been developed to assess pain in cognitively impaired older patients. Typically, these scales help assess pain according to common behavioural indicators, such as the following: • Vocalization: moaning, grunting, crying, sighing • Facial expressions: grimacing, wincing, frowning, clenching teeth • Breathing: noisy, laboured • Body movements: restlessness, rocking, pacing • Body tension: clenching fist, resisting movement • Consolability: inability to be consoled or distracted Because it is not possible to validate the meaning of the behaviours, nurses should rely on their own knowledge of the patient’s usual behaviour. If the nurse does not know the patient’s baseline behaviours, the nurse should obtain this information from other caregivers, including family members. When pain behaviours are present, pain therapy should be instituted on an empirical basis, and patients should be carefully reassessed to evaluate treatment effectiveness. 

PATIENTS WITH SUBSTANCE USE PROBLEMS Individuals with a past or current substance use disorder have the right to receive effective pain management. A comprehensive pain assessment is imperative, including a detailed history, physical examination, psychosocial assessment, and diagnostic workup to determine the cause of the pain. The use of screening tools to determine the possible risk for addiction has been described above. The goal of the pain assessment is to facilitate the establishment of a treatment plan that will relieve the individual’s pain effectively, as well as prevent or minimize withdrawal symptoms. Opioids may be used effectively and safely in patients with substance dependence when indicated for pain control. Opioid agonist and antagonist medications (e.g., pentazocine [Talwin], butorphanol) should not be used in this population because they may precipitate withdrawal. The use of “potentiators” and psychoactive medications that do not have analgesic properties should also be avoided. In individuals who are tolerant to CNS depressants, larger doses of opioids or increased frequency of medication administration is necessary to achieve pain relief. Effective pain management for people with addiction is challenging and requires expert leadership and consultation for assessment and facilitation of a planned, interprofessional team approach. Team members must be aware of their own attitudes and misbeliefs about people with substance use problems, which may contribute to undertreatment of pain.

CHAPTER 10  Pain

161

CASE STUDY Pain Patient Profile

Discussion Questions

S. C., 33 years old (pronouns she/her), is admitted for an incision and drainage of a right renal abscess. S. C.’s renal function is not impaired. She has a history of low back pain and takes oxycodone, 5 to 10 mg, every 6 hours as needed. Her weight is 112 kg and height is 162 cm. 

. Initially, what dosage of intravenous morphine should be given to S. C.? 1 2. Describe the assessment data that support the dosage selected in Question 1. 3. How long should the nurse wait after the intravenous morphine dose to begin S. C.’s dressing change? 4. If an initial dose of 6 mg intravenous morphine reduces the pain to a 6 during the dressing change, what nursing action is indicated for the next dressing change? 5. What nursing action is indicated if S. C. has pain 5 hours after her dressing change? 6. When S. C. is discharged, needing dressing changes for 3 days at home, how would the home care nurse organize S. C.’s care? (The nurse knows that S. C. has obtained adequate pain relief with 8 mg of intravenous morphine.)

Subjective Data • L  ives alone • Desires 0 pain during therapy but will accept 1 to 2 on a scale of 0 to 10 • Reports incision-­area pain as a 2 or 3 between dressing changes and as a 10 during dressing changes • States sharp, throbbing pain persists 1 to 2 hours after dressing change • Reports that pain between dressing changes is controlled by two oxycodone tablets 

Objective Data • R  equires twice-­a-­day dressing changes for 1 week • Morphine, 2 to 15 mg intravenously, for every dressing change • Oxycodone, 5 to 10 mg, for breakthrough pain between dressing changes 

Answers are available at http://evolve.elsevier.com/Canada/Lewis/medsurg.

 REVIEW QUESTIONS 7. Which of the following are appropriate nonopioid analgesics for mild pain? (Select all that apply.) a. Oxycodone b. Ibuprofen c. Lorazepam d. Acetaminophen e. Acetaminophen with codeine 8. Which of the following is an important nursing responsibility related to pain? a. Encourage the client to stay in bed. b. Help the client appear not to be in pain. c. Believe what the client says about the pain. d. Assume responsibility for eliminating the client’s pain. 9. A nurse is administering a prescribed dose of an intravenous opioid titrated for a person with severe pain related to a terminal illness. Which of the following actions is reflective of this practice? a. Euthanasia b. Assisted suicide c. Enabling the client’s addiction d. Palliative pain management 10. A nurse believes that clients with the same type of tissue injury should have the same amount of pain. Which of the following statements best describes this belief? a. It will contribute to appropriate pain management. b. It is an accurate statement about pain mechanisms and an expected goal of pain therapy. c. The nurse’s belief will have no effect on the type of care provided to people in pain. d. It is a common misconception about pain and a major contributor to ineffective pain management. 1. b; 2. d; 3. d, f; 4. c; 5. c; 6. b; 7. b, d; 8. c; 9. d; 10. d.

The number of the question corresponds to the same-­numbered objective at the beginning of the chapter. 1. Pain is best described as a. A creation of a person’s imagination b. An unpleasant, subjective experience c. A maladaptive response to a stimulus d. A neurological event resulting from activation of nociceptors 2. Which of the following inhibiting neurotransmitters is known for its involvement in pain modulation? a. Dopamine b. Acetylcholine c. Prostaglandin d. Norepinephrine 3. Which of the following words is most likely to be used to describe neuropathic pain? (Select all that apply.) a. Dull b. Mild c. Aching d. Burning e. Sickening f. Electric 4. Which of the following is true of unrelieved pain? a. It is to be expected after major surgery. b. It is to be expected in a person with cancer. c. It is dangerous and can lead to many physical and psychological complications. d. It is an annoying sensation, but it is not as important as other physical care needs. 5. Which of the following is a critical step in the pain assessment process? a. Assessment of critical sensory components b. Teaching the client about pain therapies c. Conducting a comprehensive pain assessment d. Provision of appropriate treatment and evaluation of its effect 6. Which of the following is an example of distraction to provide pain relief? a. TENS b. Music c. Exercise d. Biofeedback

For even more review questions, visit http://evolve.elsevier.com/Canada/ Lewis/medsurg.

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REFERENCES Asthana, R., Goodall, S., Lau, J., et al. (2019). Framing of the opioid problem in cancer pain management in Canada. Current Oncology, 26(3), e410. https://doi.org/10.3747/co.26.4517. Ballantyne, J. C. (2014). Adaptation to continuous opioid use: The role of tolerance, dependence, and memory. In S. N. Raja, & C. L. Sommer (Eds.), Pain 2014 refresher course: 15th World Congress on Pain (pp. 375–380). IASP Press. Blyth, F. M. (2018). Global burden of neuropathic pain. Pain, 159(3), 614–617. https://doi.org/10.1016/j.pain.2011.09.014. Booker, S. Q., Herr, K. A., & Garvan, C. W. (2020). Racial differences in pain management for patients receiving hospice care. Oncology Nursing Forum, 47(2), 228–240. https://doi.org/10.1188/20. onf.228-­240. Boschen, K. A., Robinson, E., Campbell, K. A., et al. (2016). Results from 10 years of a CBT pain self-­management outpatient program for complex chronic conditions. Pain Research and Management, 2016, 1–10. https://doi.org/10.1155/2016/4678083. Browne, A. J., Varcoe, C., Lavoie, J., et al. (2016). Enhancing health care equity with Indigenous populations: evidence-­based strategies from an ethnographic study. BMC Health Services Research, 16(544), 1–17. https://doi.org/10.1186/s12913-­016-­1707-­9. Busse, J. W., Craigle, S., Juurlink, D. N., et al. (2017). Guideline for opioid therapy for chronic noncancer pain. CMAJ, 189(18), E652– E658. https://www.cmaj.ca/content/cmaj/189/18/E659.full.pdf. Canadian Pain Task Force. (2019). Chronic pain in Canada: Laying a foundation for action. www.canada.ca/content/dam/hc-­sc/docume nts/corporate/about-­health-­canada/public-­engagement/external-­ advisory-­bodies/canadian-­pain-­task-­force/report-­2019/canadian-­ pain-­task-­force-­June-­2019-­report-­en.pdf. Cassell, E. J. (1982). The nature of suffering and the goals of medicine. New England Journal of Medicine, 306(11), 639–645. https://doi. org/10.1056/NEJM198203183061104. (Seminal). Choinière, M., Watt-­Watson, J., Victor, J. C., et al. (2014). Prevalence of and risk factors for persistent postoperative nonanginal pain after cardiac surgery: A 2-­year prospective multicentre study. Canadian Medical Association Journal, 186(7), E213–E223. https:// doi.org/10.1503/cmaj.131012. (Seminal). Clouter, E., Grondin, C., & Lévesque, A. (2018). Canadian survey on disability (2017): Concepts and methods guide. Statistics Canada. ht tps://www150.statcan.gc.ca/n1/pub/89-­654-­x/89-­654-­x2018001-­ eng.htm. Coutaux, A. (2017). Non-­pharmacological treatments for pain relief: TENS and acupuncture. Joint Bone Spine, 84(6), 657–661. https:// doi.org/10.1016/j.jbspin.2017.02.005. Davis, W. D., Davis, K. A., & Hooper, K. (2019). The use of ketamine for the management of acute pain in the emergency department. Advanced Emergency Nursing Journal, 41(2), 111–121. https://doi. org/10.1097/TME.0000000000000238. dos Santos Felix, M. M., Ferreira, M. B. G., da Cruz, L. F., et al. (2019). Relaxation therapy with guided imagery for postoperative pain management: an integrative review. Pain Management Nursing, 20(1), 3–9. https://doi.org/10.1016/j.pmn.2017.10.014. Drew, D. J., Gordon, D. B., Morgan, B., et al. (2018). “As-­needed” range orders for opioid analgesics in the management of pain: A consensus statement of the American Society for Pain Management Nursing and the American Pain Society. Pain Management Nursing, 19(3), 207–210. https://doi.org/10.1016/j.pmn.2018.03.003. Fields, H. (1987). Pain. Toronto: McGraw-­Hill (Seminal). Gaskin, D. J., & Richard, P. (2012). The economic costs of pain in the United States. The Journal of Pain, 13(8), 715–724. https://doi. org/10.1016/j.pain.2012.03.009

Horch, J., VanDerKerkhof, E. G., Sawhney, M., et al. (2019). Knowledge and attitudes about pain management among Canadian nursing students. Pain Management Nursing, 20(4), 382–389. https:// doi.org/10.1016/j.pmn.2018.12.005. Huang, A., Azam, A., Segal, S., et al. (2016). Chronic postsurgical pain and persistent opioid use following surgery: the need for a transitional pain service. Pain management, 6(5), 435–443. https:// doi.org/10.2217/pmt-­2016-­0004. Institutes of Medicine of the National Academies. (2011). Relieving pain in America: A blueprint for transforming prevention, care, education, and research. National Academies Press, 260. https://bo oks.nap.edu/openbook.php?record_id=13172&page=260. Jarvis, C. (2019). Physical Examination and Health Assessment (3rd ed). Elsevier. Jensen, M. P., Tomé-­Pires, C., de la Vega, R., et al. (2017). What determines whether a pain is rated as mild, moderate, or severe? The importance of pain beliefs and pain interference. The Clinical Journal of Pain, 33(5), 414. https://doi.org/10.1097/ AJP.0000000000000429. Kharasch, E. D. (2017). Current concepts in methadone metabolism and transport. Clinical Pharmacology in Drug Development, 6(2), 125–134. https://doi.org/10.1002/cpdd.326. Kremier, N. (2019). Low dose ketamine for chronic pain. AANLCP Journal of Nurse Life Care Planning, XIX(3), 10–18. Latimer, M., Rudderham, S., Lethbridge, L., et al. (2018). Occurrence of and referral to specialists for pain-­related diagnoses in First Nations and non-­First Nations children and youth. CMAJ, 190(49), 1434–1440. https://doi.org/10.1503/cmaj.180198. Main, C. J. (2016). Pain assessment in context: a state of the science review of the McGill pain questionnaire 40 years on. Pain, 157(7), 1387–1399. https://doi.org/10.1097/j.pain.0000000000000457. McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual for nursing practice (2nd ed.). Mosby (Seminal). McGillion, M. H., & Watt-Watson, J. (2015). Pain Assessment and Management in Canada: We've Come a Long Way but there are Challenges on the Road Ahead. The Canadian Journal of Nursing Research = Revue Canadienne De Recherche En Sciences Infirmieres, 47, 9–16. https://doi.org/10.1177/084456211504700102 McLellan, A. T. (2017). Substance misuse and substance use disorders: Why do they matter in healthcare? Transactions of the American Clinical and Climatological Association, 128, 112–130. Melzack, R., & Wall, P. D. (1987). The challenge of pain. Penguin Books (Seminal). Mifflin, K. A., & Kerr, B. J. (2014). The transition from acute to chronic pain: Understanding how different biological systems interact. Canadian Journal of Anaesthesia, 61(2), 112–122. https:// doi.org/10.1007/s12630-013-0087-4 O’Keefe-­McCarthy, S., McGillion, M., Clarke, S., et al. (2015). Pain and anxiety in rural acute coronary syndrome patients awaiting diagnostic cardiac catheterization. Journal of Cardiovascular Nursing, 30(6), 546–557. https://doi.org/10.1097/JCN0000000000000203. Pelletier, R., Higgins, J., & Bourbonnais, D. (2015). Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? BMC Musculoskeletal Disorders, 16(1), 1. https://doi.org/10.1186/s12891-­015-­0480-­y. Pergolizzi, J. V., Raffa, R. B., & Taylor, R. (2014). Treating acute pain in light of chronification of pain. Pain Management Nursing, 15(1), 380–390. https://doi.org/10.1016/j.pmn.2012.07.004. Raja, S. N., Carr, D. B., Cohen, M., et al. (2020). The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain, 161(9), 1976–1982. https://doi.org/10.1097/j.pain.0000000000001939

CHAPTER 10  Pain Registered Nurses’ Association of Ontario (RNAO). (2007). Positioning techniques in long term care: Self-­directed learning package for healthcare providers. https://rnao.ca/sites/rnao-­ca/files/Positionin g_Techniques_in_Long-­Term_Care_-­_Self-­directed_learning_package_for_health_care_providers.pdf. Registered Nurses’ Association of Ontario (RNAO). (2013). Assessment and management of pain (3rd ed.). http://rnao.ca/bpg/guideli nes/assessment-­and-­management-­pain. Resnick, B., Boltz, M., Galik, E., et al. (2019). Pain assessment, management, and impact among older adults in assisted living. Pain Management Nursing, 20(3), 192–197. https://doi.org/10.1016/j. pmn.2019.02.008. Salter, M. W. (2014). Neurobiology of acute and persistent pain: Spinal cord mechanisms. In S. N. Raja, & C. L. Sommer (Eds.), Pain 2014 refresher course: 15th World Congress on Pain (pp. 3–12). IASP Press. https://ebooks.iasp-­pain.org/pain_2014_refresher_courses. (Seminal). Sánchez, J. S., Tenias, J. B., Arias, A. A., et al. (2015). Cardiovascular risk associated with the use of non-steroidal anti-­inflammatory drugs: cohort study. Revista espanola de salud publica, 89(6), 607–613. https://doi.org/10.4321/s1135-­57272015000600008. Uprety, Y., Lacasse, A., & Asselin, H. (2016). Traditional uses of medicinal plants from the Canadian Boreal Forest for the management of chronic pain syndromes. Pain Practice, 16(4), 459–466. https://doi.org/10.1111/papr.12284. Von Gunten, C. F. (2011). Pathophysiology of pain in cancer. Journal of Pediatric Hematology/Oncology, 33, S12–S18. Wang, L., Guyatt, G. H., Kennedy, S. A., et al. (2016). Predictors of persistent pain after breast cancer surgery: A systematic review and meta-­analysis of observational studies. CMAJ, 188(14), E352– E361. https://doi.org/10.1503/cmaj.151276. Watt-Watson, J. H., Clark, A. J., Finely, G. A., & Watson, C. P. N. (1999). Canadian pain society position statement on pain relief. Pain Research and Management, 4(2), 75–78. https://doi. org/10.1155/1999/643017. (Seminal) Yoshikawa, K., Brady, B., Perry, M. A., et al. (2020). Sociocultural factors influencing physiotherapy management in culturally

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and linguistically diverse people with persistent pain: A scoping review. Physiotherapy, 107, 292–305. https://doi.org/10.1016/j. physio.2019.08.002.

RESOURCES Canadian Guideline for Opioids for Chronic Non-­Cancer Pain (NOUGG) https://healthsci.mcmaster.ca/npc/guidelines Canadian Pain Task Force Report: June 2019 https://www.canada.ca/en/health-­canada/corporate/about-­health-­ canada/public-­engagement/external-­advisory-­bodies/canadian-­ pain-­task-­force/report-­2019.html Promoting Awareness of RSD and CRPS in Canada: Charter of Pain Patient’s Rights and Responsibilities https://www.rsdcanada.org/parc/english/resources/coalition.htm Winnipeg Regional Health Authority: Pain Assessment and Management: Clinical Practice Guidelines http://www.wrha.mb.ca/extranet/eipt/files/EIPT-­017-­001.pdf Agency for Healthcare Research and Quality https://www.ahcpr.gov City of Hope Pain & Palliative Care Resource Center https://prc.coh.org/ Core Curriculum for Professional Education in Pain https://issuu.com/iasp/docs/core-­corecurriculum?mode=embed&l ayout=http%3A%2F%2Fskin.issuu.com%2Fv%2Fdarkicons%2Flay out.xml&showFlipBtn=true International Association for the Study of Pain https://www.iasp-­pain.org McGill Pain Questionnaire http://www.chcr.brown.edu/pcoc/MCGILLPAINQUEST.PDF

For additional Internet resources, see the website for this book at http://evolve.elsevier.com/Canada/Lewis/medsurg.

CHAPTER

11

Substance Use Emma Garrod Originating US chapter by Mariann M. Harding

WEBSITE http://evolve.elsevier.com/Canada/Lewis/medsurg • R  eview Questions (Online Only) • Key Points • Answer Guidelines for Case Study

• C  onceptual Care Map Creator • Customizable Nursing Care Plan • Alcohol Withdrawal

• A  udio Glossary • Content Updates

LEARNING OBJECTIVES 1. Describe social and biological perspectives on substance use. 2. Describe factors that contribute to substance use. 3. Discuss the nursing role in education, advocacy, offering evidence-­ informed interventions, and establishing collaborative relationships with people experiencing substance use–related conditions. 4. Describe the harm reduction model. 5. Describe how motivational interviewing can be used to support patients who use substances. 6. Discuss screening, assessment, and treatment planning for people experiencing substance use–related conditions.

7. Identify common substances, their effects, and associated health consequences. 8. Discuss nursing interventions for common substance use disorders and care for patients experiencing substance-­induced intoxication or withdrawal. 9. Discuss the nursing management of pain in the patient who has a substance use disorder. 10. Describe nursing management of the surgical patient with a substance use disorder. 11. Discuss substance use considerations specific to the older person.

KEY TERMS brain reward system cross-­tolerance Korsakoff syndrome lapses motivational interviewing naloxone opiates

  

opioids opioid agonists potentiation relapse relief craving reward craving substance use disorder

  SUBSTANCE USE IN CANADA There is a long history of humans consuming psychoactive substances, including alcohol, cannabis, and opioids, for medical use and pleasure. While not all substance use is problematic, there can be harm related to substance use. Thus nurses should routinely assess for substance use with every individual in all practice settings and offer evidence-­informed interventions when appropriate. It is important to situate substance use along a continuum of use, capturing a spectrum ranging from non-­use or abstinence to substance use disorder. A continuum allows for a broader understanding of the range and severity of substance use behaviours across populations (Figure 11.1). A

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tolerance transtheoretical model of change Wernicke’s encephalopathy withdrawal withdrawal management

substance use disorder is diagnosed by a health care provider and is defined as “a cluster of cognitive, behavioural, and psychological symptoms indicating that the individual continues using despite significant substance-­related problems” (American Psychiatric Association [APA], 2013). Substance use disorder is the preferred terminology in health care over the word addiction. Knowing the severity of substance use allows the health care team to work with the patient, tailoring treatment according to individual needs and preferences. Problematic substance use affects a broad spectrum of Canadians, regardless of age, gender, socioeconomic status, educational level, cultural background, or geographic region.

CHAPTER 11  Substance Use Abstinence

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Non-problematic

Problematic Beneficial

Potentially Harmful

Substance Use Disorder

FIG. 11.1  Continuum of substance use. Source: Adapted from First Nations Health Authority, British Columbia Ministry of Health & Health Canada. (2013). A path forward: A provincial approach to facilitate regional and local planning and action. http://www.fnha.ca/documents/fnha_mwsu.pdf

In 2017, substance use trends were measured by the Canadian Tobacco, Alcohol and Drugs Survey (Health Canada, 2019). The survey found that 15% of Canadians aged 15 years and older reported current smoking (11% daily smokers); 78% reported past-­year consumption of alcohol; 15% reported cannabis use; and 3% reported use of other substances, including cocaine or crack, speed, methamphetamines, ecstasy, heroin, or hallucinogens. Of individuals reporting psychoactive pharmaceutical use (opioids, stimulants, and sedatives), 5% reported nonprescribed use or problematic use. Substance use trends and related harms shift frequently; most recently, opioid-­related deaths have caused significant public health concern. Between 2016 and 2019, 13 900 opioid-­related deaths occurred, including overdose; 80% of these involved illicit fentanyl, a very potent opioid (Special Advisory Committee on the Epidemic of Opioid Overdoses, 2019). The opioid overdose crisis has worsened during the coronavirus (COVID­19) pandemic that spread globally in 2020. The United Nations Office on Drugs and Crime (2020) projected that the illicit drug supply would be altered due to COVID-­19 restrictions, and this worsening in conjunction with increased isolation has already led to a record spike in overdose deaths in British Columbia (British Columbia Coroner’s Report, 2021). Hospital settings are a point-­of-­care intersection for individuals who are diagnosed with both a substance use disorder and COVID-­19. There are significant personal and social costs of problematic substance use for Canadians and their families, including poor physical and mental health, exacerbated health conditions, and decreased functioning and quality of life. Overall, 4% of Canadians aged 15 years and older report experiencing at least one harm in the past year due to their illegal substance use (Health Canada, 2019). Many of these concerns put individuals in contact with the health care setting, including acute care. This chapter focuses on the role of the medical-­surgical nurse in identifying and working with patients in acute care settings who have a history of substance use or are currently using substances. In this setting, nurses must recognize substance use, understand its effects on the patient’s health, provide nonjudgemental care, treat pain, help the patient manage withdrawal, and provide evidence-­informed care. The health care setting provides an opportunity for substance use screening and education, as well as the provision of and connection to evidence-­informed interventions and services. 

FACTORS THAT INFLUENCE SUBSTANCE USE There are many social and biological factors that contribute to, overlap with, or intersect with substance use. These include but are not limited to genetics, family environment, social environment, trauma (past, current, intergenerational), concurrent mental illness, chronic pain, the social determinants of health, access to health care, and experiences with stigma and discrimination.

For example, about 50% of alcohol use disorder cases are attributable to genetics (Deak et  al., 2019). Early adverse childhood experiences such as abuse or neglect also account for a significant portion of risk; one-half to two-thirds of serious substance use issues were found to be correlated with these experiences (Dube et  al., 2003). Finally, approximately 50% of individuals with severe mental illness have a concurrent substance use disorder, leading to treatment challenges and poorer outcomes (Khan, 2017). Although any Canadian may be affected, physical and social harms of substance use and substance use disorders are experienced inequitably across social contexts. Indigenous people in Canada are disproportionately affected by harms related to substance use (Firestone et al., 2015), including alcohol-­related mortality and opioid overdose death. In one cohort study of Indigenous people aged 14 to 30 years who used substances, the death rate was 12.9 times higher than that of non-­Indigenous Canadians of the same age (Jongbloed et  al., 2017). Much of this inequity stems from social determinants of health and colonization, which resulted in loss of land, culture, language, and identity. Many Indigenous people were forced to attend residential schools, the devastating impact of which has been linked to higher rates of substance use and mental illness as well as many other health conditions (Wilk et al., 2017). These harms were not only experienced by those who attended residential schools but have affected subsequent generations through intergenerational trauma: psychological, physiological, and social processes which are at the root of substance-­related issues facing Indigenous communities (Aguir & Halseth, 2015). Unfortunately, Indigenous people are often portrayed as victims (Nelson et al., 2016), which ignores the resilience and strength of community and culture. In fact, evidence supports the promise of culturally based and community-­owned services that reduce health disparities and promote individual and community health (Urbanowski, 2017). Addressing the harms of substance use is both a health and social issue and requires attention to these many complex factors. Each individual’s risk factors for and experience with substance use will be different, as will be their treatment. Understanding these complexities is an important part of nursing care.

Neurophysiology of Substances Psychoactive substances affect key areas of the brain involved in survival, pleasure, and reinforcement. Many psychoactive substances increase the availability of dopamine in the “pleasure area” of the mesolimbic system of the brain. This mechanism, the brain reward system, creates the sensation of pleasure or meaning in reaction to certain behaviours that are required for survival of the human species, such as eating and sex (Burchum & Rosenthal, 2016). Psychoactive substances also increase the activity of the reward pathway by increasing the neurochemical dopamine in the synaptic cleft. Dopamine affects brain processes that control motivation, emotional responses, and the ability to experience pleasure and pain. Substances that act in this area can disrupt

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SECTION 1  Concepts in Nursing Practice

normal processes and cause the brain to perceive substances as more important than other activities, such as eating. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-­5) is a widely used manual that contains descriptions, symptoms, and other criteria for diagnosing mental disorders. The DSM-­5 has recently replaced the terms substance abuse and substance dependence with substance use disorder (APA, 2013), and specific diagnostic criteria determine the level of severity of the disorder as mild, moderate, or severe. Substance use disorders often result from the prolonged effects of psychoactive substances on the brain. Repeated long-­term use of substances changes the neural circuitry involving the dopamine neurotransmitter system and reduces the responsiveness of dopamine receptors. This decreased responsiveness leads to tolerance, the need for a larger dose of a substance to obtain the original effects, and also reduces the sense of pleasure from experiences that previously resulted in positive feelings. This also leads to withdrawal; without the substance, the individual may experience physical withdrawal symptoms, or depression, anxiety, and irritability. To feel normal, the individual must take the substance. A key aspect of substance use is the formation of the memory of the pleasurable experience of the substance that is long-­lasting even in periods of nonuse. Relief craving, the intense desire for a substance, usually experienced after decreased use, is the result of the memory aspect related to the brain reward pathway. An important type of craving experienced by people who have experienced problematic substance use or substance use disorder is reward craving, which occurs when in the presence of people, places, or things that they have previously associated with taking the substance. Cue-­induced reward craving may occur after long periods of abstinence and is a common cause of relapse, or returning to substance use after a period of abstinence (Koob et al., 2015), as is exposure to stressful circumstances. The goal of medications used to treat substance use disorders is to treat withdrawal symptoms at the level of the synapse, reduce cravings, and prevent relapse, and in time, the brain can recover. Recovery.  Recovery is a process of change through which individuals improve their health and wellness. Recovery is built on access to evidence-­informed clinical treatment and recovery support services, available to all populations (Substance Abuse and Mental Health Services Administration [SAMHSA], 2020b). It is important that a variety of treatment options and approaches are explored, as recovery is an individualized process. Individuals face many barriers when starting the process of recovery, including not believing they have a problem with substances or not believing their use is serious enough to address. They may also not know where to access help. Nurses play an integral role in providing patients hope, support, and access to evidence-­informed treatment and services. 

Attitudes Toward People Experiencing Substance-­Related Problems People with substance use–related conditions face significant stigma and prejudice, largely perpetuated by characterizations of substance use as a moral issue in the media and society at large. Misunderstanding regarding the biopsychosocial aspects of substance use and associated health complications contributes to the generally accepted perspective that substance use disorders are purely matters of personal choice, which may affect the way health services are delivered. Indeed, studies have indicated that some health care providers have negative attitudes toward people with substance use disorders, in part

because of the perception that the disorder is a matter of personal choice as well as lack of support or adequate education for health care providers (Chu & Galang, 2013). As stated earlier, however, substance use disorder is intimately linked to the effects of substances on the neurophysiology of the brain reward system as well as to environmental and genetic factors; it is a complex biopsychosocial condition that involves the whole person. Substance use disorders are considered chronic, relapsing conditions with relapse rates similar to those of other chronic diseases. For example, relapse rates are similar in people treated for asthma and hypertension when compared to those with substance use disorders—signaling a need for further assessment, support, and potentially a revised treatment plan (McLellan et al., 2000). However, due to associated stigma, relapse to substance use is often viewed more negatively, by both the patient and health care providers. Other chronic conditions add complexity; the co-­occurrence of mental illness and substance use disorder (concurrent disorder) requires supportive interventions due to the increases in the severity of symptoms and poor outcomes for both disorders (Rush, 2015). Unfortunately, people with substance use disorders frequently report stigmatizing encounters in health care settings (Carusone et  al., 2019; van Boekel et al., 2013); this experience may be a contributing factor to patients leaving hospital before completing treatment. Hospitalizations can be a key point of intervention; by offering approaches discussed in this chapter, including harm reduction and evidence-­informed medications, health care providers communicate nonjudgement toward substance use and a commitment to meeting patients’ needs. Nurses must explore their own attitudes about people who use substances. It is critical to work with patients in a nonstigmatizing and collaborative way, as upheld by the CNA Code of Ethics (Canadian Nurses’ Association [CNA], 2017a). Education is an essential place to start; visit the Resources section at the end of this chapter for further resources. An open nurse– patient dialogue about substance use can significantly improve health outcomes and increase the likelihood that the person will attempt to reduce harms associated with substance use. It is important to reduce the stigma related to substance use so that patients access and stay engaged in health care.

  KEY CONCEPTS AND APPROACHES All of the approaches discussed in this section can apply to patients with substance use issues, depending on their current status and goals. 

THE HARM REDUCTION PERSPECTIVE Harm reduction focuses on reducing the harms associated with substance use across the continuum of use, from abstinence to high-­risk use (Table 11.1). Harm reduction encompasses policies, programs, and practices that aim to reduce the harms associated with substances in people unable or unwilling to stop; the focus is on prevention of harm as opposed to abstinence (CNA, 2017b). Laws against drinking and driving and nonsmoking bylaws are examples of community harm-­reduction strategies to protect people from the harms related to alcohol and smoking. Other examples include evidence-­informed interventions such as programs that provide sterile supplies (i.e., syringes) and naloxone (Narcan) kit distribution (Figure 11.2); these measures reduce the harms associated with high-­ risk substance use without requiring that the person stop such

CHAPTER 11  Substance Use

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TABLE 11.1    KEY ELEMENTS OF HARM

TABLE 11.2    KEY ASPECTS OF SUCCESSFUL

Harm Reduction

• Express empathy. • Provide positive reinforcement and encouragement for gains made by the patient. • Listen rather than tell. • Understand that change is up to the patient. • Identify discrepancy between patient’s goals or values and current behaviour. • Help the patient recognize the discrepancies between where they are and where they hope to be. • Avoid argument and direct confrontation, which can cause defensiveness and a power struggle. • Adjust to, rather than oppose, patient resistance. • Focus on the patient’s strengths to support the hope and optimism needed to make changes.

REDUCTION

• Represents a value-­neutral view of drug use and of drug user, with no moral, legal, or medical-­reductionist limitations • Targeted at risks and harms • Evidence-­informed and cost-­effective • Incremental success is celebrated • Accepts that at any given time some people are not ready to choose abstinence • Promotes multiple services at one site as an alternative to traditional complex multisite service approaches • Accepts that substance use occurs and works to minimize its harmful effects • Promotes user participation in planning and creating programs and policies designed to serve them • Recognizes that users are capable of making choices and taking responsibility in prevention of harm, treatment, and recovery • Calls for nonjudgemental, noncoercive provision of services and resources for people who use drugs • Does not attempt to minimize or ignore the many real and tragic harms and dangers associated with drug use • Does not exclude abstinence as an option Source: Adapted from Harm Reduction Coalition. (n.d.). Principles of harm reduction. http://harmreduction.org/about-­us/principles-­of-­harm-­reduction/; Marlatt, G. A. (1996). Harm reduction: Come as you are. Addictive Behaviours, 21(6), 779–788. https://doi. org/10.1016/0306-­4603(9600042-­1;) and UBC Continuing Professional Development. (2020). Addiction care and treatment online course. https://elearning.ubccpd.ca/course/ view.php?id=164#section-­2

FIG. 11.2  Naloxone kit. Source: The University of British Columbia. (2017,

January 23). Naloxone: The antidote to a public health emergency. https://st udents.ubc.ca/ubclife/naloxone-­antidote-­public-­health-­emergency

use. For example, infections related to injecting substances can be reduced by use of alcohol swabs and sterile syringes. Given the increasing number of opioid-­related deaths, naloxone kits are now widely distributed across Canada, including in hospitals. Another approach to reduce overdose risk is supervised consumption, where people use nonprescribed substances they have purchased in the presence of trained staff who can respond if an overdose occurs. Many new supervised consumption facilities are opening across Canada and are often staffed by nurses. Foundational to harm reduction are respect for patient autonomy and a nonjudgemental approach. Harm reduction is collaborative and honours the patient’s inherent dignity and their ability to make informed decisions. There is a broad evidence base to support harm reduction, and it is within nursing scope to engage in these health-­promoting activities (CNA, 2017b).

MOTIVATIONAL INTERVIEWING

Trauma-­Informed and Culturally Competent Approaches to Care As noted above, a history of adverse childhood experiences or intergenerational and historical trauma can lead to greater risk for problematic substance use; such history has also been established as a link to other adverse health outcomes (Felitti et al., 1998). This understanding has led to the creation of trauma-­ informed approaches to care, which emphasize physical and emotional safety in service delivery, as well as promoting individuals’ choice and control in their treatment. This can be as simple as asking permission to perform a blood pressure. It is not necessary to know someone’s history in order to provide trauma-­informed care and create welcoming services (Nathoo et al., 2018). In Canada, there is also an emphasis on providing culturally competent services that build trust between health care providers and Indigenous people accessing health services, in order to address disparities. See the Resources section for more information on how to engage in trauma-­informed and culturally competent practice.  Motivational Interviewing: Engaging in a Supportive Dialogue Around Problematic Substance Use The nurse is in a unique position to motivate and facilitate behaviour change while caring for patients in primary and acute care settings, as the patient’s awareness may be increased. Intervention by nurses at this time can be a crucial factor in promoting behaviour change. Motivational interviewing is “a directive, patient-­centred counselling style for eliciting behaviour change by helping patients to explore and resolve ambivalence” (Rollnick & Miller, 1995, p. 326), using nonconfrontational techniques to motivate patients to change behaviour by eliciting talk about substance use. The role of the nurse is to listen and reflect back to the person and to recognize that ambivalence is normal and expected when anyone is confronted with having to make a change. The key aspects of successful motivational interviewing are presented in Table 11.2. The stages of change identified in the transtheoretical model of change include precontemplation, contemplation, preparation, action, maintenance, and termination (Prochaska & Velicer, 1997), as described in Chapter 4. The stages are not viewed as linear, and during the process of change, relapse and small lapses (very short periods of substance use, followed by quick return to maintaining nonuse) are part of the journey and a normal aspect of behaviour change (Figure 11.3). Patients who do not change behaviours or who return to substance use

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SECTION 1  Concepts in Nursing Practice

Precontemplation No intention to change behaviour Relapse

Contemplation

Fall back into old patterns of behaviour

Aware a problem exists but with no commitment to action

Maintenance

Upward spiral Learn from each relapse

Sustained change; new behaviour replaces old

Preparation Intent on taking action to address the problem

Action Active modification of behaviour

FIG. 11.3  Stages of change model. Source: Adapted from Prochaska, J., & DiClemente, C. (1983). Stages and processes of self-­change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390–395.

after a period of cessation are often labelled “noncompliant” and “unmotivated.” However, this development may reflect a normal relapse or may indicate that the interventions used do not align with the patient’s stage of change. It is important for the nurse to identify the patient’s readiness for change and the stage to which the patient is moving. In the precontemplation stage, the nurse can help the patient increase awareness of risks and problems related to current substance use. A patient in the contemplation stage of change often experiences ambivalence and the nurse can help the patient thoughtfully consider the positive and negative aspects of their substance use. As the patient moves from contemplation to preparation, the nurse should support self-­efficacy and even the smallest effort to change. The resolution of acute health conditions, or discharge from the hospital may occur before the patient moves to the preparation and action stages of change. In this case, the nurse must support the continuation of the change process by making appropriate referrals to community resources. 

NURSING MANAGEMENT SUBSTANCE USE NURSING ASSESSMENT The nurse needs to engage with patients to understand if they use substances in ways that place them at risk or may necessitate nursing or medical interventions. Screening, brief intervention, and referral to treatment are recommended in all settings, including acute care (SAMHSA, 2020a). As a baseline, the nurse should ask every patient about the use of all substances, including alcohol, prescribed medications, over-­the-­counter (OTC) drugs, caffeine,

TABLE 11.3    BRIEF SCREENING TOOL FOR

SUBSTANCE USE

1. Single-­Question Tests Use one of the following questions to screen for the presence of alcohol, drug, or tobacco use. • How often in the past year have you had five (men) or four (women) or more drinks in a day? • How many times in the past year have you used illegal drugs or prescription medications for nonmedical reasons? • In the past year, how often have you used tobacco products?

2. Two-­Question Tests Use the following two questions to screen for alcohol or drug use. • In the past year, have you ever had more alcohol or other drugs than you meant to? • Have you felt you wanted or needed to cut down on your drinking or drug use in the past year? Source: Reprinted from Primary Care: Clinics in Office Practice, 41(2), Strobbe, S., Prevention and screening, brief intervention, and referral to treatment for substance use in primary care, pages 185–213. Copyright 2014, with permission from Elsevier.

tobacco, and other substances. The nurse may use a simple one-­ or two-­question screening test for substance use (Table 11.3) or a more in-­depth tool. Another instrument frequently used is the CAGE-­AID questionnaire (Table 11.4). If there are indications of substance use, the nurse determines when the patient last used the substance so that drug interactions or the onset of withdrawal can be anticipated. Screening all patients for substance use with a nonjudgemental manner decreases stigma and results in more patients being offered evidence-­informed treatments; a therapeutic relationship with the patient also allows for more accurate

CHAPTER 11  Substance Use TABLE 11.4    CAGE QUESTIONNAIRE ADAPTED

TO INCLUDE DRUGS (CAGE AID)

Have you felt you ought to cut down on your drinking (or drug use)? _________Yes __________No Have people annoyed you by criticizing your drinking (or drug use)? _________Yes __________No Have you felt bad or guilty about your drinking (or drug use)? _________Yes __________No Have you ever had a drink (or used drugs) first thing in the morning to steady your nerves or get rid of a hangover (or to get the day started)? _________Yes __________No Note: In the general population, two or more positive answers indicates a need for a more in-­depth assessment. Source: Hinkin, C. H., Castellon, S. A., Dickson-­Fuhrman, E., Daum, G., Jaffe, J., & Jarvik, L. (2001). Screening for drug and alcohol abuse among older adults using a modified version of the CAGE. American Journal of Addiction, 10, 319–326.

assessments. Biological assessments, including serum and urine drug tests, may indicate substance use. A complete blood count, serum electrolytes, blood urea nitrogen, creatinine, and liver function tests are used to evaluate for electrolyte imbalances and cardiac, kidney, or liver dysfunction, which may be related to acute or chronic effects of substances. HEALTH COMPLICATIONS OF SUBSTANCE USE.  Health complications and harms related to substance use are related to three general factors: the substance, the route, and related high-­risk behaviours. First, the inherent properties of the substance itself may have specific physiological harms associated with its use, such as liver damage related to alcohol use and lung damage related to smoking. Second, the route by which the substance is taken will pose specific harms. For example, intravenous (IV) use may expose the individual to bacteria if sterile supplies are not used and cause infections (e.g., endocarditis). Third, high-­ risk sexual behaviours, exposure to violence and trauma, and placing one’s personal safety at risk may occur during substance use. Harm reduction interventions and education can mitigate many of these harms.  PLANNING.  Nurses need to effectively assess for, manage, and evaluate patients experiencing intoxication, overdose, and withdrawal symptoms because these clinical situations will arise in all settings, from the emergency department to a surgical environment. A positive, nonjudgemental, supportive, and therapeutic dialogue is fundamental. The nurse and patient should collaborate to establish goals related to achieving the best possible outcome related to their admission diagnosis and nursing diagnoses (Table 11.5) and participation in evidence-­informed treatment or harm reduction strategies. Nurses can also coordinate treatment plans that involve the interprofessional team and other important resources, such as family or community support groups.  NURSING IMPLEMENTATION URGENT CARE SITUATIONS.  Urgent care situations precipitated by substance use are acute intoxication, overdose, or withdrawal. The patient may also present with trauma or injuries. Intoxication responses usually last less than 24 hours and are directly related to the ingestion of psychoactive substances. Overdose occurs with the ingestion of an excessive dose of one drug or with a combination of similarly acting drugs. Table 11.6 lists commonly used substances, routes, and effects. Overdose.  An overdose is an emergency situation, and management is based on the type of substance involved. Overdose may include respiratory and circulatory arrest and other

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TABLE 11.5    POSSIBLE NURSING DIAGNOSES

FOR PATIENTS WITH SUBSTANCE-­ RELATED CONDITIONS

Acute confusion resulting from substance intoxication (e.g., as evidenced by alteration in level of consciousness, agitation, disorientation) Potential for injury as evidenced by alteration in cognitive function (impaired judgement) Potential for infection as evidenced by injection drug use Imbalanced nutrition as evidenced by insufficient dietary intake and electrolyte imbalances Potential for seizure as evidenced by signs of alcohol withdrawal: increased heart rate, tremor, confusion Potential for opioid overdose as evidenced by altered level of consciousness, decreased respiratory rate Potential for leaving hospital before completing medical treatment as evidenced by low mood and disengaging from care

life-­threatening complications. If multiple substances have been ingested, a complex and clinical picture can result. The first priority of care in the case of overdose is always the patient’s ABC (airway, breathing, and circulation). Emergency management of overdose and toxicity of central nervous system (CNS) stimulants and CNS depressants is presented later in the chapter, in Tables 11.16 and 11.17. As soon as the patient is stable, a thorough history and physical examination must be attempted, which may involve collateral history. A patient who intentionally overdosed should not return home until seen by a psychiatric professional.  Withdrawal.  The nurse must be alert to the possibility of withdrawal in any patient who has a history of substance use. Withdrawal is defined as a constellation of physiological and psychological responses that occur upon abrupt cessation or reduced intake of a substance on which an individual is physiologically dependent. Withdrawal from some substances, including alcohol and benzodiazepines, can be life-­threatening. Opioid withdrawal is not life-­threatening but causes significant discomfort and may cause a patient to leave the hospital before receiving the medical care they need. Specific approaches to withdrawal are discussed in sections on each substance. 

HEALTH PROMOTION Prevention of substance use issues includes primary, secondary, and tertiary prevention. Primary prevention targets primarily adolescents and young adults by offering education and harmreduction strategies. Secondary prevention focuses on early detection of substance use and offering evidence-­ informed interventions to try to prevent severe substance use disorders from developing. Tertiary prevention addresses substance use disorders and includes working with patients to match evidence-­informed interventions to their goals, including pharmacotherapy and counselling. 

 OMMON SUBSTANCES, TREATMENT, AND C NURSING INTERVENTIONS NICOTINE Characteristics Nurses are very likely to encounter patients with tobacco use disorder, which is diagnosed using DSM-­5 criteria. A

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TABLE 11.6    EFFECTS OF SUBSTANCES Substance and Route of Consumption

Physiological and Psychological Effects

Effects of Overdose

Withdrawal Symptoms

Nausea, abdominal pain, diarrhea, vomiting, dizziness, weakness, confusion, decreased respirations, seizures, death from respiratory failure or cardiac arrest Agitation; increased temperature, heart rate, respiratory rate, blood pressure; cardiac dysrhythmias; myocardial infarction; hallucinations; seizures; possible death

Craving, attention difficulties, depression, hyperirritability, headache, insomnia, increased appetite. Onset: 2–4 hours

Initial relaxation, decreased inhibitions, drowsiness, lack of coordination, impaired judgement, slurred speech, hypotension, bradycardia, bradypnea

Shallow respirations; cold, clammy skin; weak, rapid pulse; hyporeflexia; coma; possible death

Anxiety, agitation, insomnia, diaphoresis, tremors, delirium, seizures, possible death. Onset: 6–12 hours after last drink for alcohol, 12–16 hours for oral sedatives

Analgesia, euphoria, drowsiness, detachment from environment, relaxation, constricted pupils, nausea, decreased respiratory rate, slurred speech, impaired judgement

Slow, shallow respirations; clammy skin; unresponsive, constricted pupils; coma; possible death

Watery eyes, dilated pupils, runny nose, yawning, tremors, pain, chills, diaphoresis, nausea, vomiting, diarrhea, abdominal cramps, anxiety, restlessness. Onset: 4–6 hours after last use for short-acting, 8–12 hours for longer-acting

Relaxation, euphoria, lack of motivation, abrupt mood changes, impaired memory and attention, impaired judgement, reddened eyes, dry mouth, lack of coordination, decreased reflexes, tachycardia, increased appetite

Fatigue, paranoia, panic reactions, psychosis

Insomnia, anxiety, nausea

Perceptual distortions, hallucinations, depersonalization, heightened sensory perception, euphoria, mood swings, suspiciousness, panic, impaired judgement, increased body temperature, hypertension, flushed face, tremor, dilated pupils; PCP: constricted pupils, nystagmus, delusions, violence

Anxiety, panic, confusion, blurred vision, increases in blood pressure and temperature, paranoia, psychosis PCP only: seizures, coma, death

These substance are not typically used regularly enough to cause dependence, no withdrawal symptoms known

Euphoria, decreased inhibitions, giddiness, slurred speech, illusions, drowsiness, clouded sensorium, tinnitus, nystagmus, cough, nausea, vomiting, diarrhea; irritation to eyes, nose, mouth

Anxiety, respiratory depression, asphyxiation, cardiac dysrhythmias, loss of consciousness, sudden death, suicide

Nausea, tremors, irritability, difficulties sleeping, mood changes

Stimulants Nicotine (cigarettes, chewing tobacco, snus, snuff, e-­cigarettes, cigars) Smoked, snorted, chewed, vaporized Cocaine (coke, crack), amphetamine (speed), dextroamphetamine (Dexedrine), methamphetamine (crystal meth, ice, Tina), methylenedioxy-­ methamphetamine (MDMA, Ecstasy), methylphenidate (Ritalin) Oral, snorted, smoked, injected

Increased alertness; increased heart rate and blood pressure; cutaneous vasoconstriction; decreased appetite; increased gastric motility Euphoria, grandiosity, mood swings, hyperactivity, hyper-­alertness, restlessness, anorexia, insomnia, hypertension, tachycardia, marked vasoconstriction, tremor, dysrhythmias, seizures, dilated pupils (cocaine, MDMA), diaphoresis

Craving, severely depressed mood, exhaustion, prolonged sleep, apathy, irritability, disorientation. Onset: ∼2 hours for intravenous use

Depressants Alcohol Oral, snorted Sedative–hypnotics Oral, snorted, injected • Barbiturates • Benzodiazepines: diazepam (Valium), alprazolam (Xanax) • Gamma-­hydroxybutyrate (GHB)

Opioids Heroin (down), morphine, opium, codeine, fentanyl, meperidine (Demerol), hydromorphone (Dilaudid), oxycodone hydrochloride (Percocet) Methadone Oral, snorted, smoked, injected

Cannabis Marijuana: hash, weed, bud, shatter, butter; synthetic: K2, spice Oral, smoked

Hallucinogens Lysergic acid diethylamide (LSD) Psilocybin (mushrooms) Dimethyltryptamine (DMT) Mescaline (peyote) Phencyclidine (PCP) Oral, smoked (DMT, PCP), injected (PCP)

Inhalants Solvents, aerosols, and gases found in household products like glue, cleaning products, paint thinner, hairspray, whipping cream (called poppers, whippets) Inhaled through nose or mouth

Sources: Adapted from National Institute on Drug Abuse. (2017). Commonly abused drugs. https://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts#alcohol; American Lung Association. (2019). What it means to be “nic-­sick.” https://www.lung.org/about-­us/blog/2019/10/nic-­sick.html

number of products contain nicotine, including smoked tobacco leaf (cigarettes, cigars, pipes), smokeless tobacco leaf (chew, snuff, dip), and some electronic cigarettes. It is important to differentiate these tobacco products from ceremonial tobacco, which is used by some Canadian Indigenous people

in ceremonies and is rarely inhaled or consumed in a manner that can cause harm (Jetty, 2017). Smoking tobacco is the most popular form of tobacco use in Canada; in 2017, 11% (3.3 million) of Canadians reported smoking daily, and 4% (1.3 million) reported smoking occasionally (Health Canada,

CHAPTER 11  Substance Use 2019). Tobacco smoking is the leading cause of premature death in Canada, with estimated national health care costs due to tobacco exceeding $20 billion per year (Krueger et al., 2014). Most tobacco smokers state that they want to quit, yet relapse occurs frequently. It is estimated that approximately half of current users will die of a tobacco-­related disease. Considering the magnitude and severity of the risks associated with tobacco use, it is crucial that nurses screen for tobacco use and offer interventions in all settings, including acute care. 

Physiological Effects of Use Nicotine has a rapid onset of action, especially in smoked form. When nicotine is absorbed, it produces a wide range of effects in the peripheral nervous system and CNS. Responses include increased blood pressure, heart rate, cardiac output, coronary blood flow, and cutaneous vasoconstriction. During inhalation, nicotine is absorbed quickly into the bloodstream and travels to the brain in a matter of seconds. In the brain, the action of nicotine on nicotinic receptors causes general CNS stimulation with increased alertness and arousal. The effects last about 1 to 2 hours before withdrawal symptoms occur, which can leave the person feeling tired, irritable, and anxious. The activity of nicotine on the dopamine reward system can result in ongoing use and cravings and eventual physiological dependence. During withdrawal from nicotine, cue-­induced relief craving may cause smoking relapse. Nicotine itself is highly psychoactive and can lead to physiological dependence, but it is the many chemicals contained in tobacco products, especially the smoked form, that cause most of the harm and health complications. These include carbon monoxide, tar, arsenic, and lead, which are poisonous and toxic to the human body.  Electronic Cigarettes Electronic cigarettes (e-­cigarettes) are battery-­operated devices that turn nicotine and other chemicals, including propylene glycol, glycerin, and flavourings, into an aerosol or vapour. These devices do not contain tobacco leaf, although some resemble traditional cigarettes. Emerging information indicates that e-­cigarettes are not harmless. E-­cigarettes containing nicotine have the potential to increase the risk for cardiovascular and respiratory issues (Hajek et al., 2014), and the liquid solutions used in refillable e-­cigarettes may cause poisoning or skin irritation and are not subject to quality control. Studies indicate that e-­cigarettes are increasing in use, particularly among current smokers, pose less harm to smokers than traditional cigarettes, are being used to reduce or quit smoking, and are widely available (Glasser et al., 2017). However, the long-­term health effects of vaping have not been examined and are unknown at this time. Acute effects have included lung injury and a number of associated deaths (Centers for Disease Control and Prevention [CDC], 2020).  Health Complications The complications of tobacco use are related to dose and method of ingestion. Cigarette smoking is the single most preventable cause of death and also causes significant morbidity, including chronic lung disease, cardiovascular disease, stroke, and cataracts. Smoking during pregnancy can cause stillbirth, low birth weight, sudden infant death syndrome (SIDS), and other serious pregnancy complications (Center for Chronic Disease Prevention and Health Promotion, 2020). Together with the increased

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myocardial oxygen consumption that nicotine causes, carbon monoxide significantly decreases the oxygen available to the myocardium. The result is an even greater increase in heart rate and myocardial oxygen consumption that may lead to myocardial ischemia. Users of smokeless tobacco also experience the systemic effects of nicotine on the cardiovascular system. The chronic respiratory irritation caused by cigarette smoke is the most important risk factor in the development of lung cancer and chronic obstructive pulmonary disease (COPD). Chronic irritation from smoking also is a factor in the increased incidence of cancer of the mouth, larynx, and esophagus in persons who smoke tobacco in any form. Women are at particular risk for smoking-­related diseases. Women who smoke have a 25% higher risk of coronary heart disease than men and have greater risks of reproductive health issues, many forms of gynecological cancer and other types of cancer, chronic obstructive lung disease, and osteoporosis (American College of Obstetricians and Gynecologists, 2011). Lastly, attention should be paid to the inequities in tobacco use patterns, especially among young women, women with a history of trauma, women with mental health issues, and Indigenous women (Greaves et al., 2016), which may affect their ability to have successful quit attempts. 

Interprofessional Care: Nursing Interventions for Tobacco Use Disorder A combination of medications, behavioural approaches, and support has been shown to be most effective in addressing nicotine dependence and long-­term tobacco cessation, with immediate benefit to the patient (Figure 11.4). Tobacco Use Cessation.  With each patient encounter, the nurse should ask about tobacco use, assess the person’s level of motivation to change, and advise the person about the importance of quitting. The “5 A’s” brief intervention (ask, advise, assess, assist, arrange) is an effective approach for working collaboratively with people with nicotine dependence (Tobacco Use and Dependence Guideline Panel, 2008). This approach identifies clinical interventions that can be used at each patient encounter, depending on the time available (Table 11.7). These interventions are designed to identify tobacco users, encourage them to quit, determine their willingness to quit, assist them in quitting, and arrange for follow-­up to prevent relapse. Simply screening for and assessing for smoking has a significant impact as an intervention to help people quit smoking. Smoking cessation is the single most effective intervention to increase quality of life and decrease the morbidity and mortality directly caused by smoking. See the Resources section at the end of this chapter for more information on nursing interventions.  Nicotine Replacement Therapy and Pharmacotherapeutic Interventions for Nicotine Dependence.  A variety of smoking cessation products are available to help support users in quitting or cutting down, including prescription medicines as well as OTC products such as nicotine patches, inhalers, and gum (Table 11.8). Nicotine replacement therapy (NRT) products reduce the craving and withdrawal symptoms associated with cessation by supplying the body with a safer delivery of nicotine. Because most health care facilities are tobacco-­free environments, admitted patients who are dependent on nicotine may experience withdrawal symptoms since they are unable to smoke. Offering NRT to those who desire it will assist in controlling withdrawal symptoms during hospitalization, support patients to stay and get their medical treatment and promote

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SECTION 1  Concepts in Nursing Practice

continued cessation after discharge. Many patients with concurrent disorders have tobacco use disorders and often can’t smoke due to admission on a secured unit; NRT can be a successful approach to calming patients who wish to leave to smoke. People continuing to smoke while on NRT should not discontinue treatment; in these cases the potential need for increased doses or the addition of a second type of NRT agent should be considered (UBC Continuing Professional Development [CPD], 2020). Non-­nicotine products also support smoking cessation, such as Varenicline (Champix). Varenicline is unique in that it has both agonist and antagonist actions. Its agonist activity at one subtype of nicotinic receptor provides some nicotine effects to ease withdrawal symptoms. If the person does resume smoking, its antagonist action blocks the effects of nicotine at another subtype of nicotinic receptor, which mutes the effects. Bupropion

(Zyban), an antidepressant, reduces the urge to smoke, some symptoms of withdrawal, and helps prevent weight gain associated with smoking cessation. These products can also be used in conjunction with NRT. Varenicline has the strongest evidence for smoking abstinence, but NRT and bupropion are also very effective (Anthenelli et al., 2016). Along with using a smoking cessation product, individuals who wish to quit are more likely to succeed if they participate in a tobacco cessation program. Nurses should be aware of community resources that assist patients in navigating these services. Many programs teach people skills to decrease triggers and relapse risk and help them develop coping skills, such as cigarette refusal skills, assertiveness, alternative activities, and peer support systems. The advice and motivation provided by health care providers can be a powerful force in smoking cessation. Best Practice Guideline on smoking cessation, available on

The Benefits of Quitting 20 minutes after quitting Your blood pressure and pulse rate return to normal.

After 24 hours

After 1 year

Your lungs start to clear out the mucus. Coughing is actually a good sign.

Your risk of having a heart attack is cut in half.

10 to 15 years after quitting Your risk of coronary heart disease is the same as someone who never smoked.

10

After 8 hours

After 48 hours

After 10 years

You can breathe easier. Your oxygen levels are back to normal and your chance of having a heart attack goes down.

You are nicotine-free. Your sense of taste and smell begins to return.

Your risk of dying from lung cancer is cut in half.

Former smokers say that after they quit they feel more in control, more relaxed, have more energy and have more money to spend on things that matter to them.

FIG. 11.4  Benefits of quitting smoking. Source: Canadian Cancer Society. [n.d.]. The benefits of quitting. https://smokershelpline.ca/quit-­plan-­public/volume4/static/thinking-­about-­quitting

TABLE 11.7    CARING FOR THE PATIENT WITH

TABLE 11.8    COMMONLY USED MEDICATIONS

TO TREAT NICOTINE USE DISORDER

TOBACCO USE DISORDER

The Five A’s for Patients Who Desire to Quit 1. Ask: Identify all tobacco users at every contact. a. “Have you used any form of tobacco in the past 6 months?” b. “Do you smoke (even a puff now and again) or use tobacco products of any kind?” c. “Have you ever considered stopping?” 2. Advise: Strongly urge all tobacco users to quit. a. “As your nurse, the most important advice I can give you is to quit smoking.” 3. Assess: Determine willingness to make a quit attempt. 4. Assist: Develop a plan with the patient to help the patient quit (e.g., counselling, medication). 5. Arrange: Schedule follow-­up or refer patient to smoking cessation program. Source: Agency for Healthcare Research and Quality. (2008). AHCPR supported clinical practice guideline: Treating tobacco use and dependence: 2008 update. U.S. Public Health Service; and Registered Nurses Association of Ontario. (2007). Best practice guideline: Integrating smoking cessation into nursing practice. Author. http://rnao.ca/bp g/guidelines/integrating-­smoking-­cessation-­daily-­nursing-­practice

Medication

Key Features

Nicotine patch

Provides long-­acting source of nicotine to help mitigate cravings and other symptoms of nicotine withdrawal For prn use; provides short-­acting source of nicotine to help mitigate cravings and other symptoms of nicotine withdrawal Prescription medication that blocks effects of nicotine; most effective approach to helping smokers quit; can be used in conjunction with nicotine patch or prn delivery; monitor for adverse effects including gastrointestinal symptoms and mood changes. Prescription medication that makes smoking less pleasurable and reduces cravings; can be used in conjunction with nicotine patch or prn delivery; monitor for adverse effects including mood changes.

Nicotine gum, inhaler, spray, or lozenge Varenicline (Champix®)

Bupropion (Zyban®)

Source: Data from QuitNow. Methods and medications. https://www.quitnow.ca/quitti ng/methods-­and-­medications

CHAPTER 11  Substance Use RNAO’s website, is an excellent resource for the nurse helping patients to quit smoking. A link to this document appears in the Resources section at the end of this chapter. Table 11.8 lists tobacco cessation interventions. 

ALCOHOL Characteristics Alcohol is the most widely consumed substance in Canada, where 78% of the population aged 15 years and older drinks alcohol (Health Canada, 2019). Canada has low-­risk drinking guidelines (Table 11.9), which recommend that women limit consumption to 10 standard drinks per week, with no more than two drinks per day most days and that men limit consumption to no more than 15 standard drinks per week, with no more than three drinks per day most days. In 2017, 21% of Canadians who consume alcohol reported exceeding the guidelines for chronic use and 15% exceeded guidelines for acute use. It is estimated that up to 18% if Canadians aged 18 years and older have met criteria for alcohol use disorder in their lifetime (British Columbia Centre on Substance Use [BCCSU], 2019). Alcohol use contributes to substantial health burden: Nearly 200 disease or injury conditions are wholly or in part attributable to alcohol use, with resulting economic, health care, and social costs. Numerous factors appear to be interrelated in the development of alcohol use disorder and include genetic, psychosocial, and cultural–environmental factors. Alcohol use disorder is viewed as a chronic, relapsing, and potentially fatal condition if left untreated. Unfortunately, many individuals are not offered evidence-­ informed treatment. Hospital admissions provide an opportunity for pharmacological and nonpharmacological interventions. In a systematic review, patients who received a brief intervention in hospital had a greater reduction in alcohol consumption compared to usual-­care groups at 6 months (McQueen et  al., 2011). Nurses play a role in offering these supports. Health teaching about the risks associated with consuming more than the low-­risk drinking guidelines (see Table 11.9) is recommended. It is also important to assess patient goals and readiness to change alcohol-­related behaviours. Parts of the Canadian population have been disproportionately affected by alcohol use. Given historical, social, political, and economic factors, Indigenous people have experienced elevated harm related to alcohol use. In one survey 25.1% of Indigenous people reported heavy drinking in the past month, compared to 19.6% of non-­Indigenous Canadians, and alcohol-­ related mortality was estimated to be 5.43 times higher in Indigenous men and 10.11 times higher in Indigenous women than in their non-­Indigenous counterparts (Statistics Canada, 2019). As noted in previous sections, there are several contributing factors to these statistics: colonization, the trauma of residential schools, the reserve system, loss, grief, and intergenerational trauma. It is important to understand that many individuals may be using alcohol to cope with trauma and distressing experiences (Brave Heart, 2003; Parappilly et al., 2020). Adding to these harms, Indigenous people have reported negative experiences and stigma when accessing health care, especially in the context of substance use disorders (Goodman et. al, 2017). Harmful stereotypes around Indigenous people and alcohol use persist and greatly affect their health care experiences. Despite these misconceptions, it is important to note

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that a higher proportion of Indigenous people over 12 years old reported past-­year abstinence from alcohol when compared to the rest of the Canadian population (27.4% vs. 24.6%). In order to address these disparities and not perpetuate stigma or institutionalized racism, health care providers working with individuals with alcohol use disorder should be familiar with and incorporate harm-­reduction, trauma-­informed, and culturally competent approaches and principles.  TABLE 11.9    CANADA’S LOW-­RISK DRINKING

GUIDELINES

Drinking is a personal choice. If you choose to drink, these guidelines can help you decide when, where, why, and how much.

Your Limits Reduce your long-­term health risks by drinking no more than: • 10 drinks per week for women, with no more than two drinks per day most days • 15 drinks per week for men, with no more than three drinks per day most days. Plan nondrinking days every week to avoid developing a habit.

Special Occasions Reduce your risk for injury and harm by drinking no more than three drinks (for women) and four drinks (for men) on any single occasion. Plan to drink in a safe environment. Stay within the weekly limits.

When Zero Is the Limit Do not drink when you are: • Driving a vehicle or using machinery and tools • Taking medicine or other drugs that interact with alcohol • Doing any kind of dangerous physical activity • Living with mental or physical health conditions • Living with alcohol dependence • Pregnant or planning to be pregnant • Responsible for the safety of others • Making important decisions

Pregnant? Zero Is the Safest If you are pregnant or planning to become pregnant, or if you are about to breastfeed, the safest choice is to drink no alcohol at all.

Delaying Your Drinking Alcohol can harm the way the body and brain develop. Teens should speak with their parents about drinking. If they choose to drink, they should do so under parental guidance; never more than one to two drinks at a time, and never more than one to two times per week. They should plan ahead, follow local alcohol laws, and consider the safer drinking tips.

Defining “a Drink” For these guidelines, “a drink” means: • 341 mL (12 oz.) bottle of 5% alcohol beer, cider, or cooler • 142 mL (5 oz.) glass of 12% alcohol wine • 43 mL (1.5 oz.) serving of 40% distilled alcohol (e.g., rye, rum, gin) Low-­risk drinking helps to promote a culture of moderation. Low-­risk drinking supports healthy lifestyles.

Tips Set limits for yourself and abide by them. Drink slowly. Have no more than two drinks in any 3 hours. For every drink of alcohol, have one nonalcoholic drink. Eat before and while you are drinking. Always consider your age, body weight, and health issues that might suggest lower limits. Although drinking may provide health benefits for certain groups of ­people, do not start to drink, or increase your drinking, for health benefits. Source: Butt, P., Beirness, D., Gliksman, L., et al. (2011, updated 2018). Alcohol and health in Canada: A summary of evidence and guidelines for low-­risk drinking. Canadian Centre on Substance Abuse.

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Effects of Use Alcohol is a small, water-­ soluble molecule that is rapidly absorbed into the bloodstream through the digestive tract; faster absorption occurs when alcohol is mixed with carbonated liquids. Absorption is slower in the presence of water or food, especially proteins and fats. Alcohol has complex CNS effects; it generally acts as a depressant or sedative, but when the blood alcohol level is rising, a period of disinhibition and arousal can occur. With chronic use, the brain becomes tolerant to alcohol and changes activity of excitatory (glutamate) and inhibitory (GABA) neurotransmitters. When alcohol is abruptly stopped, there is an increase in the excitatory activity and the person experiences withdrawal symptoms. The effects of alcohol are related to the blood alcohol concentration (BAC) in the body and individual susceptibility. BAC is affected by the amount consumed, the drinking rate, body size and composition, drink concentration, and hormones. Children and youth or individuals who have lower body mass are more susceptible to the effects of alcohol. Alcohol Intoxication.  Intoxication, as evidenced by increasing BAC, results in behavioural and physical changes. People are at higher risk for self-­injurious behaviours while intoxicated, as a result of impaired judgement and impulsivity. People are also at risk for significant mood dysregulation and depression, and risk for suicide is an important consideration. Fatalities caused by drinking and driving, head injuries, physical trauma, and violence are closely linked to alcohol intoxication. Acute Alcohol Intoxication.  It is important to obtain as accurate a history as possible, using collateral information as necessary, and assess for injuries, trauma, diseases, and hypoglycemia. Vital signs and level of consciousness should be monitored. The nurse should remain with the intoxicated patient as much as possible, orienting to reality as necessary. Agitation and anxiety are common, and the patient should be assessed for increasing disorientation and potential for violence. The patient is also at high risk for injury because of lack of coordination and impaired judgement, and protective environmental measures should be used (i.e., supervision). It is critical to continue assessment and interventions until the BAC has decreased to at least 21.7 mmol/L and until any associated disorders or injuries have been ruled out. After acute intoxication, individuals may experience hangovers manifested by malaise, nausea, headache, thirst, and a general feeling of fatigue.  Alcohol Withdrawal.  Alcohol withdrawal occurs when an individual with tolerance to alcohol abruptly ceases consumption. Approximately 50% of individuals with long-­term, heavy alcohol use will experience some withdrawal symptoms upon cessation of alcohol use (Goodson et al., 2014); for the majority of individuals, symptoms are mild to moderate and resolve quickly. A patient with alcohol dependence who is hospitalized for other health conditions is at risk for alcohol withdrawal. If there is any indication of alcohol or other CNS-­depressant use when a patient is hospitalized, the nurse should always assess when the patient last used the substance. This information will help the nurse anticipate drug interactions or the time of possible onset of withdrawal symptoms. The signs and symptoms of alcohol withdrawal generally begin 6 to 12 hours after the patient’s last drink and last up to 5 days. Characteristic symptoms include tremors, anxiety, increased heart rate, increased blood pressure, sweating, nausea, vomiting, hyperreflexia, agitation, insomnia, and in some cases hallucinations. Withdrawal hallucinations are not

TABLE 11.10    STAGES OF ALCOHOL

WITHDRAWAL

Time of Onset After Last Use 6–12 hours

12–14 hours 24–48 hours 48–72 hours

Symptoms Minor withdrawal symptoms: insomnia, tremors, anxiety, gastrointestinal upset, headache, diaphoresis, palpitations, anorexia, nausea, tachycardia, hypertension Visual, auditory, or tactile hallucinations Withdrawal seizures: generalized tonic–clonic seizures Alcohol withdrawal delirium (delirium tremens): hallucinations (predominantly visual), disorientation, agitation, diaphoresis

Source: Sachdeva, A., Choudhary, M., & Chandra, M. (2015). Alcohol withdrawal syndrome: Benzodiazepines and beyond. Journal of Clinical and Diagnostic Research, 9(9), VE01–VE07. https://doi.org/10.7980/JCDR/2015/13407.6538

the same as delirium tremens, developing within 12 to 24 hours and clearing within 24 to 48 hours; during this time the patient is aware they are hallucinating. Severe and life-­ threatening alcohol withdrawal syndrome include seizures (10%) or delirium tremens (3–5%) (Mirijello et  al., 2015). Delirium tremens typically begins 48 to 96 hours after the last drink and presents as severe confusion and autonomic hyperactivity (i.e., hyperthermia) and global clouding of sensorium. Death may be caused by hyperthermia, peripheral vascular collapse, or cardiac failure. Seizures are most likely to occur 24 to 48 hours after the last drink in untreated alcohol withdrawal (Table 11.10). The Predictor of Alcohol Withdrawal Severity Scale is a tool that helps health care providers determine the risk of severe withdrawal and can guide treatment decisions (Maldonado et al., 2015). Key nursing interventions for and management of alcohol withdrawal are based on early and accurate assessment. Nurses should assess for tachycardia, dehydration, fever, diaphoresis, dysrhythmias, and liver impairment, in addition to cognition and level of consciousness. The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (Table 11.11) is a standardized assessment tool that can be used to assess and monitor for withdrawal symptoms caused by alcohol withdrawal. Treatment of intermediate withdrawal usually involves the administration of a benzodiazepine (chlordiazepoxide, diazepam, lorazepam, and oxazepam are most commonly used) to prevent withdrawal-­ related seizure (Sachdeva et  al., 2015). If the person has compromised liver function or is an older person, a short-­acting benzodiazepine may be preferred (Hammond et al., 2015). Table 11.12 presents the clinical manifestations of alcohol withdrawal and suggested treatment. A quiet, calm environment is important to preventing exacerbation of symptoms, and frequent reorientation should be provided. The use of restraints and IV lines should be avoided whenever possible. Supportive care is needed to ensure adequate rest and nutrition. Nursing care for the patient in alcohol withdrawal is presented in Nursing Care Plan 11.1. 

Complications The long-­term physical effects of alcohol use disorder, outlined in Table 11.13, may be the reason that individuals seek health care. Complications may also arise from the interaction of alcohol with commonly prescribed or OTC drugs. Drugs that interact with alcohol in an additive manner include antihypertensives, antihistamines, antianginals, and salicylates (Aspirin).

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TABLE 11.11    CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT FOR ALCOHOL–REVISED (CIWA-­AR) Patient Name:________________________________ (Last Name, First Name) Time:_____ Total Score (max score = 67)______ Temp: ______BP:_____/_____ Apex rate:_________ Resps:______ Initials:_________________________ (print name and credentials) (signature)(dd/mm/yyyy):_______________________ F0136-­20100721 Chart Tab: Assessments/Plans Patient ID Label

Nausea & Vomiting

Tactile Disturbances

Ask: “Do you feel sick to your stomach? Have you vomited?” Observation: 0 No nausea/vomiting 1 2 3 4 Intermittent nausea with dry heaves 5 6 7 Constant nausea, frequent dry heaves and vomiting

Ask: “Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?” Observation: 0 None 1 Very mild itching, pins and needles, burning or numbness 2 Mild itching, pins and needles, burning or numbness 3 Moderate itching, pins and needles, burning or numbness 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations

Tremor

Auditory Disturbances

Arms extended and fingers spread apart Observation: 0 No tremor 1 Not visible, but can be felt fingertip to fingertip 2 3 4 Moderate, with patient’s arms extended 5 6 7 Severe, even with arms not extended

Ask: “Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?” Observation: 0 Not present 1 Very mild harshness or ability to frighten 2 Mild harshness or ability to frighten 3 Moderate harshness or ability to frighten 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations

Paroxysmal Sweats Observation: 0 No sweat visible 1 Barely perceptible sweating, palms moist 2 3 4 Beads of sweat obvious on forehead 5 6 7 Drenching sweats

Anxiety Ask: “Do you feel nervous?” Observation: 0 No anxiety, at ease 1 Mildly anxious 2 3 4 Moderately anxious, or guarded, so anxiety is inferred 5 6 7 Acute panic as seen in severe delirium or acute schizophrenic reactions

Agitation Observation: 0 Normal activity 1 Somewhat more than normal activity 2 3 4 Moderately fidgety and restless 5 6 7 Paces back and forth during most of interview or constantly thrashes about

Visual Disturbances Ask: “Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?” Observation: 0 Not present 1 Very mild sensitivity 2 Mild sensitivity 3 Moderate sensitivity 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations

Headache, Fullness in Head Ask: “Does your head feel different? Does it feel like there is a band around your head?” Do not rate for dizziness or lightheadedness. Otherwise, rate severity. 0 Not present 1 Very mild 2 Mild 3 Moderate 4 Moderately severe 5 Severe 6 Very severe 7 Extremely severe

Orientation & Clouding of Sensorium Ask: “What day is this? Where are you? Who am I?” Observation: 0 Oriented and can do serial additions 1 Cannot do serial additions or is uncertain about date 2 Disoriented for date by no more than 2 calendar days 3 Disoriented for date by more than 2 calendar days 4 Disoriented for place and/or person

Source: Brands, B., Kahan, M., Selby, P., et al. (Eds.). (2000). Management of alcohol, tobacco and other drug problems: A physician’s manual (p. 77). Centre for Addiction and Mental Health.

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TABLE 11.12    ALCOHOL WITHDRAWAL TREATMENT Clinical Manifestations

Pharmacological Treatment

• Minor withdrawal syndrome • Tremulousness, anxiety • Increased heart rate • Increased blood pressure • Sweating • Nausea • Hyperreflexia • Insomnia • Hallucinations • Major withdrawal • DTs • Seizures • Preventative: Wernicke’s encephalopathy

• Benzodiazepines • Gabapentin • Haloperidol (Haldol) for hallucinations • Naltrexone • Supports individuals to cut down on drinking • Person does not need to be abstinent from alcohol while on this medication • Is an opioid antagonist so can not be concurrently administered with opioids • Acamprosate • Preferred if goal is abstinence • Person does not need to be abstinent from alcohol while on this medication • Continue to administer benzodiazepines as ordered • Additional antiseizure medications for seizures or past history of seizures • Thiamine • Some individuals may also be administered magnesium sulphate or multivitamins (folic acid, B vitamins)

DTs, delirium tremens. NOTE: For DTs, provide intravenous fluids (do not overhydrate), cooling blanket, well-­lit quiet room, consistent staff, and frequent checks of vital signs; check for hypoglycemia; assess any other health issues. Source: Data from British Columbia Centre on Substance Use. (2020). Provincial guideline for the clinical management of high risk drinking and alcohol use disorder. https://www.bccsu. ca/wp-­content/uploads/2020/03/AUD-­Guideline.pdf.

NURSING CARE PLAN 11.1 Alcohol Withdrawal NURSING DIAGNOSIS

Potential for injury as evidenced by alteration in psychomotor functioning (sensorimotor deficits)

Expected Patient Outcomes Nursing Interventions and Rationales • Reports no falls or injuries • Experiences decrease in tremors and psychomotor activity • Reports no seizures

• Assess for risk factors such as impaired mobility (e.g., unsteady gait), sensory deficits, tremors, impaired judgement, confusion, seizure activity to plan appropriate preventive measures. • Assess for signs of injury such as lacerations, bruises, or burns to treat appropriately. • Monitor vital signs frequently, especially heart rate, because prompt recognition of extreme autonomic nervous system response is necessary for early intervention to prevent progression of symptoms. • Administer benzodiazepines as ordered to control hyperactivity, thiamine to reduce neurological complications (e.g., Wernicke’s encephalopathy), and antiseizure medications as ordered to prevent seizures. • Use seizure precautions to prevent injury.

NURSING DIAGNOSIS

Acute confusion resulting from alcohol withdrawal as evidenced by alteration in cognitive functioning, misperception, agitation, hallucinations resulting from sensory overload as evidenced by impaired interpretation of environmental stimuli, disorientation, and hallucinations

Expected Patient Outcomes Nursing Interventions and Rationales • Reports no hallucinations • Reports reduced agitation • Remains oriented to person, place, and time

• Assess patient’s orientation and cognition to determine appropriate interventions. • Provide quiet and nonstimulating environment to reduce external stimuli and calm overactive CNS. • Orient to nurse and environment with each contact; use calm, approach; provide consistent staff; explain procedures and what is expected to assist in orientation and decrease anxiety. • Administer benzodiazepines as ordered to reduce CNS stimulation. • Administer antipsychotic medication (e.g., haloperidol [Haldol]) if ordered to decrease severity of hallucinations. (Be aware that Haldol lowers the seizure threshold.)

NURSING DIAGNOSIS

Ineffective breathing pattern resulting from hyperventilation and respiratory muscle fatigue

Expected Patient Outcomes Nursing Interventions and Rationales • Maintains effective breathing • Reports no indications of hypoxia

• Monitor respiratory rate, depth, and pattern so appropriate interventions may be taken. • Position patient on their side and in semi-­Fowler’s position to reduce possibility of aspiration and to enhance lung expansion by lowering diaphragm. • Monitor effects of medications given for withdrawal to detect respiratory depression. • Encourage coughing and deep breathing to prevent complications of hypoventilation. • Administer supplemental oxygen to treat hypoxia.

CNS, central nervous system.

Alcohol taken with Aspirin may cause or exacerbate gastrointestinal (GI) bleeding. Alcohol taken with acetaminophen (Tylenol) may increase the risk for liver damage. Potentiation, a drug interaction causing a response greater than the sum of the individual responses to each drug, occurs when an additional CNS depressant is taken with alcohol, increasing the effect.

People with high alcohol tolerance may also be tolerant (require an increased dose for effect) to other CNS depressants such as benzodiazepines or opioids, even if they have never used these drugs. This is called cross-­tolerance. Complications Associated With Chronic Alcohol Use Disorder.  One severe complication of long-­term heavy alcohol use

CHAPTER 11  Substance Use TABLE 11.13    EFFECTS OF LONG-­TERM, HEAVY

ALCOHOL USE

Body System

System Effects

Central nervous system

Dementia; Wernicke’s encephalopathy (confusion, nystagmus, paralysis of ocular muscles, ataxia); Korsakoff syndrome (confabulation, amnesic disorder); impairment of cognitive function, psychomotor skills, abstract thinking, and memory; depression, attention deficit, labile moods, seizures, sleep disturbances Peripheral neuropathy including pain, paresthesias, weakness Increased risk for tuberculosis and viral infections, especially pneumonia; increased risk for cancer of oral cavity, pharynx, esophagus, liver, colon, rectum, and possibly breast Bone marrow depression, anemia, leukopenia, thrombocytopenia, blood clotting abnormalities Painful or tender swelling of large muscle groups; painless progressive muscle weakness and wasting; osteoporosis Elevated pulse and blood pressure; decreased exercise tolerance; cardiomyopathy (irreversible); increased risk for hemorrhagic stroke, coronary artery disease, hypertension, sudden cardiac death Steatosis (reversible)—nausea, vomiting, hepatomegaly; hepatitis (reversible)— anorexia, nausea, vomiting, fever, chills, abdominal pain, cirrhosis; cancer Gastritis, peptic ulcer, esophagitis, esophageal varices, enteritis, colitis, Mallory– Weiss tear, pancreatitis Decreased appetite, indigestion, malabsorption, vitamin deficiencies Diuretic effect from inhibition of antidiuretic hormone Altered gonadal function, testicular atrophy, decreased beard growth, decreased libido, diminished sperm count, gynecomastia, glucose intolerance, early menopause, fetal alcohol spectrum disorder Palmar erythema, spider angiomas, rosacea, rhinophyma

Peripheral nervous system Immune system

Hematological system

Musculoskeletal system

Cardiovascular system

Hepatic system

Gastrointestinal system

Digestive system Urinary system Endocrine and reproductive system

Integumentary system

is Wernicke’s encephalopathy, an inflammatory, hemorrhagic, degenerative condition of the brain caused by a thiamine deficiency. Because Wernicke’s encephalopathy is potentially reversible, IV thiamine is often administered to patients with alcohol use disorder, especially those in withdrawal. Untreated or progressive Wernicke’s encephalopathy may lead to Korsakoff syndrome, an irreversible form of amnesia characterized by loss of short-­term memory and an inability to learn (Xiong, 2018). 

Interprofessional Care There are many interventions available to individuals with alcohol use disorder, including withdrawal management, pharmacotherapies, and psychosocial interventions. Cessation of drinking is the short-­term goal of withdrawal management and consists of interventions and processes aimed at addressing the physiological and psychological symptoms that occur in response to stopping alcohol use. Management

177

of alcohol withdrawal frequently includes the use of medications to decrease symptoms, increase the level of comfort, and decrease the risk of seizures and delirium tremens. Patients should also be offered additional medications that may support goals of alcohol reduction (e.g., naltrexone) and abstinence (e.g., acamprosate) and that treat protracted withdrawal symptoms such as anxiety and insomnia (e.g., gabapentin) (BCCSU, 2019). Lastly, managed alcohol programs are a harm-reduction approach to manage withdrawal symptoms in populations who consume high-­risk, non-­beverage alcohol such as rubbing alcohol. These are evidence-­ informed, typically community-­based programs that supply regular dosing of safer alcohol sources, such as wine or beer. These treatments are starting to be used in some hospitals (Brookes et al., 2018). Nurses may administer these medications and can provide education on the rationale for these treatments. Patients should be referred to inpatient or intensive outpatient programs for continued support and treatment if this aligns with their goals. Outpatient options include counselling, Self-­Management and Recovery Training (SMART) groups, and Alcoholics Anonymous (AA) meetings. 

CANNABIS Characteristics According to the Health Canada (2019), about 11% of all Canadians aged 15 years and older had used cannabis at least once in the past year, and about 32% of those who had used cannabis in the past 3 months reported that they used it every day or almost every day. In Canada, 37% of cannabis users report doing so for medical reasons, and there is evidence for the treatment of chronic pain, use as an antiemetic in cancer treatment, and treatment of multiple sclerosis spasticity. However, there are also substantial risks, including prompting the onset of schizophrenia or other psychoses, impairment leading to motor vehicle accidents, newborn low birth weight, respiratory issues, and cannabis use disorder. Adolescents who use cannabis regularly are at higher risk for psychotic symptoms, particularly when there is coexisting or family history of psychosis (George & Vaccarino, 2015). In 2018, the Canadian government legalized the use of cannabis for recreational use for legal-­age adults, while previously it was only legal for specific medical reasons. People may purchase cannabis in several different forms at dispensaries. For medical reasons, pharmaceutical cannabinoids, nabilone (an oral tablet containing a synthetic tetrahydrocannabinol [THC]), or cannabis may still be prescribed. There are illegal synthetic THC derivatives (e.g., K2, Spice), which contain varying amounts of different ingredients, have unpredictable effects, and are more toxic. (See Chapter 12 for further information.) 

Effects of Use Humans have an endocannabinoid system, the receptors of which bind with cannabinoids consumed by taking a natural or synthetic cannabis product orally or by inhalation. Cannabinoids are chemicals found in the cannabis plant, and the chemical most responsible for the psychoactive effects is THC. THC can cause euphoria, relaxation, anxiety, and memory impairment. Cannabidiol (CBD), another chemical in cannabis, mitigates some of these negative effects and has antipsychotic

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and anti-­inflammatory effects. People use cannabis for a variety of desired effects, including euphoria, elation, pain relief, and appetite stimulation, but they may also experience negative effects, such as panic, fear, trouble concentrating, decreased coordination, and lower interest in completing tasks. Signs of intoxication are presented in Table 11.6. In acute intoxication, the nurse should perform a physical examination, a urine or serum drug test, and a thorough history. Cannabis can induce tachycardia and hypertension and, in some users, hypotension, and it can increase cardiovascular risks such as arrythmias (Goyal et al., 2017). Although rare and difficult to diagnose, one presentation that nurses may see in hospital settings is cannabis hyperemesis syndrome, which is characterized by cyclic vomiting and is associated with long-­term, heavy cannabis use (Venkatesan et al., 2019). Withdrawal can occur in a hospitalized patient who is a heavy cannabis user. The patient may experience irritability, anxiety, decreased appetite, disturbed sleep, depressed mood, and one of the following physical symptoms: chills, headache, abdominal pain, fever, or tremors (Livne et al., 2019). No specific pharmacological therapy is effective in treating withdrawal. Supportive care includes measures such as administration of antiemetics, analgesics, and hydration to ensure patient comfort. Benzodiazepines may provide symptom relief. 

Interprofessional Care Nurses should screen for cannabis use as with other substances and determine patient risks, goals, and opportunities for health promotion. Canada has low-­risk cannabis use guidelines (see Resources section) which can be shared with patients. The nurse can also support patients with harm reduction strategies, including delaying age of trying cannabis until after 18, limiting use, using edibles instead of smoking, not using high-­potency synthetic products, not driving after consumption, and avoiding use for high-­risk groups: pregnant women, people with heart disease, and people with a history of psychosis or a family history of psychosis (CNA, 2017c). In the case of cannabis use disorder, there are no currently approved pharmacological treatments, but patients can be supported with inpatient treatment, withdrawal management, counselling, and group therapy. In some hospital settings, cannabis may actually be used therapeutically (e.g., the patient’s medical supply may be brought in); the nurse should consult local policies. 

OPIOIDS Characteristics Opiates are substances that are directly derived from the opium poppy, such as morphine and codeine. Opioids is an umbrella term that includes both opiates and the many semisynthetic and synthetic agents used as analgesics. Commonly used opioids are identified in Table 11.6. Opioids are very effective analgesics, and the majority of people who are prescribed opioid medications for the treatment of acute and chronic pain do not develop problematic use patterns. The risk of nonmedical use is increased by factors discussed earlier in this chapter, including early childhood experiences and mental illness. People may use prescription opioids nonmedically, or purchase illicit opioids such as heroin, oxycodone, or fentanyl. The presence of fentanyl and analogues in the illicit opioid supply has been increasing since 2014, placing users at risk of overdose and death due to its potency. Other risks of opioid use include human immunodeficiency virus (HIV)

infection if injecting equipment is shared, and contact with the criminal justice system if illicit opioids are used. 

Effects of Use Opioids contain opioid agonists, which are chemicals that activate opioid receptors in the brain and exert effects; they include both prescribed medications like morphine or methadone and nonprescribed substances like heroin. Binding to opiate receptors and neurotransmitter systems in the CNS, opioid agonists cause a number of effects, including CNS depression and stimulation of the brain reward system. Opioid antagonists include naloxone (Narcan), which binds to the same receptor but has no activity. Opioids can be consumed orally or intravenously or they can be sniffed or smoked. Initial effects can include euphoria, analgesia, drowsiness, slurred speech, decreased respiratory rate, GI peristalsis, and decreased pupil size. Tolerance to opioids develops quickly; therefore, people who use opioids nonmedically will require increasingly high amounts to achieve the same effect and eventually develop physical dependence as the brain adjusts. Over time, people with opioid use disorder go into withdrawal if they do not use opioids, and they need to use in order to feel normal and alleviate the discomfort of withdrawal. Physiological tolerance to opioids is lost very quickly. After a few days of abstinence, lower tolerance may lead to fatal overdoses should people resume taking the same amount they had been previously accustomed to taking. Opioid Overdose.  Unintentional overdose can occur with illicit opioid use because of the unpredictability in potency. Overdose can also occur with prescribed or nonprescribed opioids if used by someone with lower tolerance. Signs of overdose of opioids include pinpoint pupils, clammy skin, depressed respirations, and decreased level of consciousness that can lead to coma and death if the overdose is not treated (Figure 11.5). Opioid overdose is a medical emergency; treatment can include administering naloxone and maintaining airway. Giving naloxone can put the person into withdrawal temporarily, and when they regain consciousness, they can be reassured that these uncomfortable symptoms will subside soon. Naloxone has a shorter half-­life than that of other opioids, meaning it will wear off and repeat doses may be required. Naloxone is a very safe medication, and kits are now available widely across Canada so that individuals can respond to an overdose in the community while waiting for emergency services. In some areas, nurses may train and dispense kits to patients (see Resources section).  Opioid Withdrawal.  Withdrawal from opioids occurs with decreased amounts or cessation after a period of moderate to heavy use. Symptoms may include craving, abdominal cramps, diarrhea, tremor, chills, overall body aches, sleep disturbances, anxiety, nausea, and vomiting. Severe withdrawal is extremely uncomfortable (Table 11.14). Opioid withdrawal can begin 4 to 6 hours after last use, depending on the opioid, usually peaks 2 to 3 days after last use, and resolves by days 5 to 7. Interventions to support withdrawal include comfort measures and medications for relief of symptoms (i.e., acetaminophen). Ongoing opioid use despite consequences often results as individuals try to relieve these uncomfortable withdrawal symptoms. In acute care, nurses need to assess for and anticipate opioid withdrawal in patients with regular nonmedical use. This withdrawal should be treated with opioid agonists, discussed below, and in some cases with short-­acting opioids. Untreated withdrawal can lead to patients leaving the hospital before completing medical

CHAPTER 11  Substance Use

179

SIGNS OF AN

OPIOID OVERDOSE Learn how to spot an overdose and what to do.

Cannot be woken up or not moving Breathing slow or absent

Choking or coughing, gurgling, or snoring sounds Cold or clammy skin

Dizziness and disorientation

Pupils extremely small Discoloration of lips and nails

CALL 911 IMMEDIATELY! Your address

THEN: Give breaths 1 breath every 5 seconds

fraserhealth

fraserhealth.ca/overdose

Use naloxone if you have it

Catalogue#265247 (August 2016) English To order:Patienteduc.fraserhealth.ca

FIG. 11.5  Opioid overdose signs and symptoms. Source: Reproduced with permission from fraserhealth, Canada (2016). Recognizing an overdose: Depressants/Opioids. Signs of an Opioid Overdose. fraser health.ca.

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TABLE 11.14    SYMPTOMS OF OPIOID

TABLE 11.15    COMMONLY USED MEDICATIONS

Early Symptoms

Advanced Symptoms

Medication

Key features

• Abdominal cramps • Myalgia (muscle pain) • Lacrimation (teary eyes) • Rhinorrhea (runny nose) • Anxiety • Sweating • Yawning

• Enlarged pupils • Piloerection • Diarrhea • Insomnia • Agitation • Tachycardia • Nausea or vomiting • Tremor • Chills

Methadone

Long-­acting, oral opioid full agonist that reduces withdrawal and cravings with once-­daily dosing; usually administered in liquid form; protects against overdose; monitor patients for sedation, especially during titration phase Long-­acting, opioid partial agonist that reduces withdrawal and cravings with once-­daily dosing; most commonly used in sublingual form but injectable forms are also available; protects against overdose; less drug interactions and sedation risk than with methadone Slow-­release oral opioid full agonist that reduces withdrawal and cravings with once-­daily dosing; potential safety advantage for patients with cardiac complications (e.g., QTc prolongation) when compared to methadone

WITHDRAWAL

TO TREAT OPIOID USE DISORDER

Buprenorphine-­naloxone

Note: Each patient’s withdrawal looks different. Withdrawal symptoms are measured using the Clinical Opioid Withdrawal Scale (COWS); see Resources section.

treatment (Ti et al., 2015). Treating withdrawal improves care outcomes and nurse–patient interactions.  Other Complications.  A key consideration in people with regular, chronic use of opioids is opioid-­induced constipation, which can lead to complications such as bowel obstruction. Nurses can support patients to improve bowel health; traditional laxatives such as stool softeners and osmotic, stimulant, and lubricant agents are recommended as initial treatment (Rao et al., 2019). Other health complications are related to route of use, such as contracting hepatitis C or other blood-­borne illnesses from sharing injection equipment if there is no access to sterile equipment. Harm reduction interventions are essential to prevent such complications. 

Interprofessional Care Opioid use disorder is considered a chronic and relapsing condition; thus, a long-­term treatment approach is taken. Opioid agonist therapy (OAT), such as methadone, has the most evidence for reducing morbidity, mortality, and criminal justice system involvement (Canadian Research Institute in Substance Misuse [CRISM], 2018). Withdrawal management alone (going off all opioids, including OAT) is not recommended because of the risk of relapse and overdose. There are several types of OAT, varying in intensity (Table 11.15). It is recommended that harm reduction be offered across the treatment spectrum, including naloxone kits and access to supervised consumption and sterile supplies if use is ongoing. In the acute care setting, it is important to review the routine and medication history of patients. A person on OAT should have their daily dose continued while they are in hospital to ensure optimal treatment; on admission it is also essential to confirm when the person last took a dose to avoid double-­ dosing. If someone starts on methadone for the first time in hospital, doses will be lower and increase during the course of admission. Upon discharge, the health care team must coordinate care to ensure that the patient can continue treatment in the community. A patient can have their care transferred back to their community provider but may need support finding a prescriber if OAT was started in hospital. Not all prescribers provide OAT to patients, so a patient may need a referral to an OAT or methadone clinic to bridge care. Methadone.  Methadone is the most commonly used OAT in Canada. It is a potent long-­acting opioid agonist that alleviates withdrawal and cravings for 24 hours at the right dose. Methadone is typically an oral, liquid form that is taken daily. Until a period of stability is achieved, the person undergoes witnessed daily ingestion at a pharmacy. With stability, the patient may be provided take-­home doses of methadone, as long as they can be

Slow-­release oral morphine (Kadian®)

Source: Data from Canadian Research Initiative in Substance Misuse (CRISM). (n.d.). CRISM national guideline for the clinical management of opioid use disorder. https://crism.ca/wp-­content/uploads/2018/03/CRISM_NationalGuideline_OUD-­ENG.pdf

responsible for ensuring safe storage and handling. Usually a dose of 60 mg or above would be considered therapeutic, but doses can be above 200 mg (CRISM, 2018). Since methadone can be sedating, people on methadone should be advised to avoid using other sedating substances such as alcohol and benzodiazepines.  Buprenorphine.  Buprenorphine is a partial opioid agonist that is less sedating than methadone and has less drug interactions. It is available as a sublingual oral tablet and is taken once daily. It is important that the sublingual tablet dissolves completely and is not swallowed. Buprenorphine has a lower risk of overdose than methadone because it is a partial agonist and does not create as much CNS depression (CRISM, 2018). It also binds closely to the receptor and blocks other opioids from binding, so effects are not felt if the individual uses another form of opioids. In Canada, buprenorphine is usually combined with naloxone in the tablet—this does not decrease overdose risk but is included to prevent diversion. If the sublingual tablet is crushed and snorted or injected, the naloxone becomes active and may cause withdrawal. Taken sublingually, the naloxone is inactive.  Specialist Treatments.  There are many evolving treatment approaches for opioid use disorder in Canada, including slow-­ release oral morphine and injectable formulations such as hydromorphone. Slow-­release oral morphine, or Kadian®, is an oral alternative that may be prescribed to patients who have not benefitted from methadone or buprenorphine/naloxone; these doses are higher than when used for analgesia (e.g., 1 800 mg) (CRISM, 2018). Injectable treatment for opioid use disorder using diacetylmorphine (the active ingredient in heroin) or hydromorphone has been studied in Canada since 2005 and clinically applied since 2013 for patients who did not benefit from oral medications. Improvements in health outcomes and decrease in illicit opioid use have been observed (Oviedo-­Joekes et al., 2016). In community settings, patients self-­inject a prescribed dose of the medication; when admitted to an acute care hospital, most often these doses are administered by a nurse. These treatment approaches are becoming more widely available, providing a larger range of treatment options for this chronic disease. 

CHAPTER 11  Substance Use

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TABLE 11.16    EMERGENCY MANAGEMENT CNS Stimulant—Cocaine and Amphetamine Toxicity

TABLE 11.17    EMERGENCY MANAGEMENT CNS Depressant Overdose

Assessment Findings

Interventions

Assessment Findings

Interventions

Cardiovascular

Initial

• Palpitations • Tachycardia • Hypertension • Dysrhythmias • Myocardial ischemia or infarction

• Ensure patent airway • Anticipate need for intubation if respiratory distress evident • Establish IV access and initiate fluid replacement as appropriate • Obtain a 12-­lead ECG • Treat ventricular dysrhythmias as appropriate • Administer IV medications for psychosis • Administer IV diazepam (Valium) or lorazepam (Ativan) for seizures • Naloxone IV should be given if CNS depression is present and concurrent opiate use is possible • Anticipate the need for propranolol (Inderal) or labetalol for hypertension and tachycardia

• Agitation • Confusion • Lethargy • Hallucinations • Slurred speech • Pinpoint pupils (opioids) • Nystagmus • Seizures • Cold, clammy skin • Rapid, weak pulse • Slow or rapid shallow respirations • Decreased O2 saturation • Hypotension • Dysrhythmia • ECG changes • Cardiac or respiratory arrest

Initial

Central Nervous System • Euphoria • Agitation • Combativeness • Seizures • Hallucinations • Confusion • Paranoia • Fever

Ongoing

• Monitor vital signs, level of consciousness, cardiac rhythm • Use restraints only if needed to protect the patient and staff CNS, central nervous system; ECG, electrocardiogram; IV, intravenous.

  STIMULANTS COCAINE, AMPHETAMINES, AND PRESCRIPTION STIMULANTS Characteristics Stimulants may be illicit (i.e. cocaine, crack, amphetamines) or prescribed, such as methylphenidate (treatment of narcolepsy or attention-­ deficit/hyperactivity disorders). In 2017, 2% of Canadians reported using cocaine within the past year (Health Canada, 2019) and 2% of Canadians aged 15 years and older reported using a prescription stimulant in the past year, with 19% indicating problematic use. In the United States, stimulant-­ related hospitalizations are increasing (Winkelman et al., 2018).  Acute Effects of Use All stimulants work in part by increasing the amount of dopamine in the brain, causing euphoria and increasing energy, alertness, and improved performance. This action on the brain reward system enhances pleasure and, over time, can lead to ongoing use despite consequences, by hijacking the reward system. Stimulants also affect the cardiovascular system, causing increased heart rate and blood pressure and increasing cardiovascular risk (Diercks, 2008). There are also acute psychiatric and behavioural effects, including psychosis, agitation and aggression, and skin-­picking due to delusions of insects. Stimulants may be used by many routes, including intravenously, snorted, orally, and smoking; smoking and IV methods result in the fastest absorption. Effects of cocaine use are short, which leads to more frequent use, increasing spending and other risks. Amphetamines have a longer half-­life than that of cocaine.

• Ensure patent airway • Anticipate intubation if respiratory distress evident • Establish IV access • Obtain temperature • Obtain 12-­lead ECG • Obtain information about substance (name, route, when taken, amount) • Obtain specific drug levels or comprehensive toxicology screen • Obtain a health history including substance use and allergies • Administer antidotes as appropriate: • Opioids: naloxone • Benzodiazepines: flumazenil • Perform gastric lavage if no antidote available • Administer activated charcoal if within 4–6 hours of consumption

Ongoing • Monitor vital signs, temperature, level of consciousness, O2 saturation, cardiac rhythm CNS, central nervous system; ECG, electrocardiogram; IV, intravenous, O2, oxygen.

During sustained periods of stimulant use, the person may not be sleeping, eating, or performing self-­care. Stimulant Toxicity or Overdose.  Currently, there are no recommended pharmacological treatments for stimulant overdose or intoxication. Generally, treatment is supportive and focuses on the system at risk (e.g., cardiovascular). Symptoms of stimulant toxicity and emergency management are presented in Table 11.16.  Withdrawal.  Withdrawal from cocaine and amphetamines does not usually cause obvious physical symptoms, but physical and behavioural manifestations do occur. Cravings can be intense during the first hours to days of cessation and may continue for weeks. The nurse may identify withdrawal symptoms in a patient with stimulant use disorder who is hospitalized for management of other health conditions. Abrupt cessation of stimulants can also lead to a “crash,” where the patient may be depressed and experience fatigue, prolonged sleep, vivid dreams, irritability, increased appetite, and disorientation. Supportive care includes maintaining a quiet environment and allowing the patient to sleep and eat as desired, clustering care to reduce interruptions, and possibly providing sedating medications to support sleep. If a patient has severe depression, the nurse should initiate suicide precautions and refer the patient for further treatment. With prolonged stimulant cessation, most patients’ moods will stabilize. 

Complications Stimulants can lead to a variety of health complications, most significantly those involving the cardiovascular system; psychiatric issues; and subsequent health issues due to route of use or high-­risk activity. IV administration may result in collapse and scarring of the veins at the injection site, cellulitis, wound

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abscess, endocarditis, hepatitis B virus (HBV) and hepatitis C virus (HCV) infection, and HIV infection. With intranasal use, the nasal septum and mucosa may become damaged and pulmonary damage from smoking crack may occur. Over time, stimulant use may lead to paranoia and other forms of persistent psychosis. Persistent psychiatric conditions may be treated with antipsychotics. Elevated mortality also results from overdose, toxicity, and other accidents (Darke et al., 2017). 

Interprofessional Care Treatment will depend on the goals and health status of the patient. Nurses should offer harm reduction to patients with active use, including supervised consumption, sterile supplies, and safer sex supplies. There is an absence of evidence-­informed pharmacotherapies at this time (UBC CPD, 2020), so psychosocial interventions are recommended, such as SMART recovery groups, Narcotics Anonymous (NA), or a rewards-­based intervention called contingency management. 

SEDATIVE–HYPNOTICS Characteristics Sedative–hypnotic agents include barbiturates, benzodiazepines, and barbiturate-­ like drugs. Benzodiazepine-­ class medications are effective in the short-­term treatment of panic attacks and severe anxiety and alcohol withdrawal. However, long-­term prescription can contribute to the development of tolerance and risk for problematic use. A person who becomes tolerant to the effects may increase the dose and frequency of use without medical advice or indication. People may also purchase illicit sedative–hypnotics. These substances elevate risk for respiratory depression when combined with other CNS depressants. 

Effects of Use Sedative–hypnotic drugs act primarily on the CNS, causing relaxation or sedation at low doses and sleep at high doses. Excessive amounts produce an initial euphoria and an intoxication that includes impaired judgement, slurred speech, and loss of inhibitions and motor coordination. Although benzodiazepines are believed to have a wide margin of safety, they are not without adverse reactions, including rebound anxiety and insomnia with short-­acting drugs and confusion and memory loss with long-­acting drugs. These drugs are usually taken orally, but barbiturates may be injected intravenously. The effects of sedative–hypnotics are presented in Table 11.6.  Complications An overdose of a sedative–hypnotic may cause death as a result of respiratory depression. Symptoms of overdose are listed in Table 11.17. Overdoses of benzodiazepines may be treated with flumazenil, a specific benzodiazepine antagonist. There are no known antagonists to counteract the effects of other sedative– hypnotic medications. Emergency life support measures must be taken in cases of overdose. Withdrawal From Sedative–Hypnotics.  Withdrawal from sedative–hypnotics can be highly variable, and the severity and onset of symptoms depend on many factors, including the drug, the pattern of use, the dose and duration of use, and the presence of concurrent alcohol use. Withdrawal from sedative–hypnotics may include anxiety, tremors, weakness, nausea with or without

vomiting, muscle cramps, and increased reflexes. Withdrawal from benzodiazepines is potentially life-­threatening and necessitates close monitoring in an inpatient setting as it can lead to delirium, seizures, and respiratory and cardiac arrest. Management is symptomatic and includes a gradual reduction in drug dosage; abrupt cessation of the drug is not recommended. Long-­acting agents such as diazepam (Valium), chlordiazepoxide (Librax), clonazepam, or phenobarbital may be substituted and tapered after stabilization. 

Interprofessional Care Nurses can work with patients to set goals and monitor symptoms. Medically supervised tapering over an extended period of time is recommended for withdrawal management in people with benzodiazepine use disorder. Inpatient treatment centres or outpatient support groups may support a patient’s goals. Underlying mental health diagnoses should be treated. 

  OTHER SUBSTANCES INHALANTS Inhalation (i.e., sniffing, huffing, bagging) is the major route of ingestion for a number of common household and industrial substances. There are four main classes of inhalants: volatile solvents, aerosols, anaesthetic agents, and nitrites. Inhalants are rapidly absorbed and reach the CNS quickly. Most are depressants, and their effects are similar to those of alcohol, including slurred speech, lack of coordination, euphoria, and dizziness. The effects are relatively brief, lasting only 60 to 90 minutes. Long-­term use can result in neurological issues, including damage to parts of the brain that control cognition, movement, vision, and hearing. Common agents and their effects are presented in Table 11.6. The patient with inhalant toxicity may experience dizziness, euphoria, disinhibition, nystagmus, slurred speech, and lethargy. The effects usually resolve within minutes to a few hours. Managing inhalant toxicity usually consists of providing supportive care. However, in some cases, users need emergency treatment for dysrhythmias, heart failure, or CNS hyperactivity (e.g., seizures). 

HALLUCINOGENS Hallucinogens are a variety of psychoactive substances that produce a change in level of consciousness, alter mood, and may induce hallucinations; they include psilocybin (magic mushrooms) and lysergic acid diethylamide (LSD). Table 11.6 identifies common hallucinogens and their effects. Hallucinogens do not typically cause physiological dependence, so withdrawal states are not noted. Some hallucinogens (e.g., psilocybin) are being studied for their therapeutic effect in medical settings for the treatment of mental health disorders and substance use disorders. 

GAMMA HYDROXYBUTYRATE (GHB) GHB is a CNS depressant, causing sedation and slowing heart rate and respirations. It is typically in oral solution and difficult to dose, leading to great overdose risk. Chronic use can lead to physical dependence and life-­threatening withdrawal, which should be medically managed. 

CHAPTER 11  Substance Use SPECIAL CONSIDERATIONS Acute Pain Management Considerations Health care providers may demonstrate reluctance to treat acute pain with opioid medications in people who use substances. However, the effective treatment of acute pain is a key priority for all people, including those who use substances. It is appropriate, therefore, to use opioids to help all people manage acute pain. Untreated pain is more likely to lead to relapse than to exacerbating a substance use disorder (Ries et al., 2015). If the patient acknowledges opioid use, it is important to determine the type and amount of opioids used. Severe pain may be treated with opioids. The use of one opioid is preferred, and nonopioid and adjuvant analgesics and nonpharmacological pain relief measures may also be used, as appropriate. Withdrawal symptoms can exacerbate pain and need to be addressed in order to provide adequate pain management. Patients need their baseline opioid needs met to treat withdrawal, and acute pain will require additional opioids or other pain management methods. For example, a patient’s regular methadone dose will not provide analgesia for acute pain, and they will also have increased tolerance to other opioid medications. To maintain opioid blood levels and prevent withdrawal symptoms, health care providers should give regular doses around the clock or use longer-­ acting opioids. Supplemental doses should be used to treat breakthrough pain. For adequate pain control in patients with opioid use disorder, the nurse should advocate for much higher doses than those used in opioid-­naive patients because of tolerance (Ries et  al., 2015). Depending on whether these patients are on OAT to treat their opioid use disorder, these doses can vary widely. Patients on buprenorphine may need specialized care when needing acute pain control, as buprenorphine blocks the effects of other opioids. 

Perioperative Care All patients undergoing emergency surgery must be carefully assessed for signs and symptoms of substance use or overdose that could lead to adverse drug interactions with analgesics or anaesthetics. The prevalence of alcohol use disorders in emergency departments is as high as 40%, and the incidence of symptomatic alcohol withdrawal is two to five times higher in trauma and surgical patients (Ries et al., 2015). Special precautions must be taken for the patient who is intoxicated or alcohol dependent and requires surgery, owing to the risk of withdrawal and postsurgical complications. Vital signs, including body temperature, must be closely monitored to identify signs of withdrawal, possible infections, and respiratory or cardiac problems. Preoperative assessment for elective surgical procedures must include a thorough health history and assessment of substance use, including questions related to alcohol, nicotine, and other substance use. Any type of withdrawal that may be caused by abrupt cessation should be monitored for and treated proactively, including nicotine withdrawal. Other complications may occur as well; respiratory changes in smokers make introduction of endotracheal and suction tubes more difficult and increase the risk for postoperative respiratory problems. Patients on opioid agonist therapy should be continued on their treatment and may need additional doses of opioids to manage acute pain, as discussed above. 

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ETHICAL DILEMMAS Situation A patient who has been treated for severe alcohol-­withdrawal complications discloses to the nurse that he is a long-­distance truck driver and has been working for the past 10 years. As part of the substance use assessment, the nurse learns that he seems to have developed high tolerance to alcohol, with daily consumption and only short periods of abstinence since his divorce last year. He has no previous substance use history and had no problematic substance use before last year.

Important Points for Consideration • N  urses identify ethical issues; consult with the appropriate person or body; and take action to resolve and evaluate the effectiveness of actions. • Nurses have an ethical responsibility to promote health and well-­ being, as well as a responsibility to base their practice on current evidence. • Nurses have an ethical obligation to prevent harm to patients and the public. • Nurses are responsible for communicating concerns regarding harms to the patient as well as communicating them to the patient’s team of health care providers. • Nurses must know the legal reporting obligations regarding driver licensing for their province or territory. 

Clinical Decision-­Making Considerations More information is needed about this case and a team approach should be taken to determine if this patient’s alcohol use needs to be reported and to whom. Involving the patient in care planning is essential, and voluntary acceptance of treatment is ideal. Nurses can contact the Canadian Nurses Protective Society about ethical concerns in the workplace. See Resources section for link.

AGE-­RELATED CONSIDERATIONS Problematic substance use in older persons is under-­recognized, for several reasons: patterns of substance use in older persons may be different from that of younger persons; substance use among older persons can be mistaken for other medical or psychiatric conditions, such as insomnia, depression, poor nutrition, heart failure, and frequent falls; and there is a lack of clinician training and comfort in this area (Han, 2018). For example, opioid use disorder in older persons has been under-­ recognized and undertreated (Canadian Centre on Substance Use and Addiction [CCSA], 2018; Payne et al., 2018), yet there is an increase in older persons seeking treatment for opioid use disorder (both for prescription and illicit opiates) (Huhn et al., 2018). Many specific circumstances place the older person at particular risk for a substance use disorder, including difficulty coping with losses that occur with increasing age, such as retirement, death of family and friends, relocation, social isolation, and poor health. Senior advocacy groups are calling for greater attention to the issue of problematic substance use among older persons. Aging is associated with cognitive and functional changes that can make the brain more vulnerable to the effects of substances. The effects of alcohol and other psychoactive substances increase with aging. Age-­related changes in function, especially in the liver and kidneys, alter circulation, metabolism, and the body’s ability to eliminate substances. Older persons tend to have more physical illnesses and be prescribed more medications with exposure to

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drug combinations; older persons are at increased risk for potentially harmful drug–drug interactions. When taken in combination, alcohol, sedative–hypnotic drugs, and CNS depressants have additive and synergistic effects. Problematic substance use and high rates of prescription medication use in older persons may contribute to confusion, disorientation, delirium, memory loss, and neuromuscular impairment. Older persons have high rates of hospitalization for opiate toxicity in Canada (CCSA, 2018). As with all patients, it is important for the nurse to discuss all substance use with older patients, including use of OTC medications, and assess the patient’s knowledge of the medications they take. Patient education for the older person includes teaching about the desired effects, possible adverse effects, and appropriate use of prescribed and OTC medications. The nurse

should recommend that the patient use only one pharmacy, because many pharmacies maintain a medication profile on each individual that may prevent problems with drug interactions. Patients should be advised about risks of combining CNS depressants. The nurse should monitor people who are experiencing losses and identify those who may need additional supports. Home visits by a nurse provide a good opportunity for assessment of challenges and also provision of valuable support. A nurse who assesses for an alcohol or substance use disorder in an older patient should refer the patient for treatment. Older persons benefit from the treatments discussed in this chapter. Quality of life can be improved significantly by addressing problematic substance use, regardless of a person’s age. Older persons can live long, healthy, and productive lives while in recovery.

CASE STUDY Substance Use Patient Profile C. M., 78 years old (pronouns she/her), is admitted to the emergency department after falling and injuring her right shoulder and arm. Her partner died 4 years ago and she lives alone. Recently, her best friend died. Her only family is a daughter who lives out of town. When the nurse contacts C. M.’s daughter by phone, her daughter tells the nurse that C. M. appears to have been more disoriented and confused over the past year when they have talked on the phone. 

Subjective Data • R  eports severe pain in her right shoulder and upper arm • Reports she had some wine in the late afternoon to stimulate her appetite • Has experienced several falls with minor bruising in the past 2 months • Reports that she fell after taking her sleeping pill, prescribed by her physician because she does not sleep well • Speaks with hesitation and slurs • Says she smokes about half a pack of cigarettes a day 

Objective Data Physical Examination • O  riented to person and place, but not time • Blood pressure 162/94, pulse 92, respirations 24

• B  ruising and edema of right upper arm • Tremors of hands 

Diagnostic Tests • R  adiographic examination reveals comminuted fracture of the proximal humerus necessitating surgical repair • Blood alcohol concentration (BAC) 24 mmol/L • Complete blood count: hemoglobin 106 g/L; hematocrit 0.38 (38%)

Discussion Questions . What other information is needed to assess C. M.’s condition? 1 2. How should questions regarding these areas be addressed? 3. What factors may contribute to C. M.’s use of psychoactive substances? 4. Priority decision: What priority nursing interventions are appropriate during C. M.’s preoperative period? 5. What possible complications and other health concerns may become apparent during C. M.’s postoperative recovery? 6. What nursing interventions are appropriate following C. M.’s surgery? 7. Priority decision: Based on the assessment data presented, what are the priority nursing diagnoses for C. M.? Are there any interprofessional issues?

Answers are available at http://evolve.elsevier.com/Canada/Lewis/medsurg.

 REVIEW QUESTIONS The number of the question corresponds to the same-­numbered objective at the beginning of the chapter. 1. What term best describes a pattern of continued substance use despite significant harms and withdrawal symptoms? a. Abuse b. Substance use disorder c. Tolerance d. Addictive behaviour 2. Which of these statements is true? a. Only a small percentage of Canadians are affected by substance use issues. b. About 50% of risk for problematic alcohol use is attributable to genetics. c. All people are equally susceptible to risk of problematic substance use. d. Substance use is more prevalent in urban areas.

3. When engaging a client experiencing substance use or problematic substance use, which of the following is part of the role of the nurse in acute care? (Select all that apply.) a. Screen all patients for substance use. b. Advocate for adequate pain and withdrawal management for patients with opioid use disorder. c. Promote a nonjudgemental, collaborative therapeutic relationship that honours client autonomy and choice. d. Assess safety concerns and stabilization of acute illness. 4. When using a harm reduction approach with clients experiencing substance use problems, what is the key aim of the nurse? a. To provide harm reduction supplies and health teaching b. Not to coerce or force the individual to quit their substance use c. To ensure that clients have access to health care services d. To reduce the harms associated with substance use

CHAPTER 11  Substance Use

11. T  o which factors are substance use issues in older persons most commonly related? a. Use of drugs and alcohol as a social activity b. Misuse of prescribed and OTC drugs and alcohol c. Continued use of illegal drugs initiated during middle age d. A pattern of binge drinking for weeks or months with periods of sobriety 1. b; 2. b; 3. a, b, c, d; 4. d; 5. b, d; 6. a; 7. d; 8. a, c, d, e; 9. a; 10. b; 11. b.

5. In which of the following behaviours should the nurse engage during motivational interviewing with a client? (Select all that apply.) a. Insist that the client maintain abstinence while undergoing therapy. b. Relate motivational techniques to the client’s stage of behaviour change. c. Use any method of communication that will make the client change behaviour. d. Identify discrepancies between the client’s goals or values and current behaviour. e. Ask a prescribed set of questions to increase the client’s awareness of negative behaviours. 6. When screening and assessing for substance use, which of the following is the most urgent to cover in acute care in order to determine imminent risks? a. Use of substances, pattern of use, route, frequency of use, and date and time of last use b. Medical history and psychiatric history c. Social supports d. Legal history 7. Which of the following is the most appropriate nursing intervention for a client who is seen at the clinic for increasing shortness of breath but who is not interested in quitting smoking? a. Accept the client’s decision and do not intervene until the client expresses a desire to quit. b. Realize that some smokers will never quit and that trying to assist them only increases the client’s and the nurse’s frustration. c. Increase the client’s motivation to quit by explaining that continued smoking will only increase the breathing problems. d. Ask the client about smoking at every clinic visit, advise of the benefits of quitting smoking, assess reasons for wanting to continue smoking, assist with goal-­setting, and arrange a follow-­up plan. 8. While caring for a client who is experiencing alcohol withdrawal, what actions should the nurse take? (Select all that apply.) a. Monitor neurological status on a routine basis. b. Administer medications by IV route only. c. Pad the side rails and place suction equipment at the bedside. d. Orient the client to environment and person with each contact. e. Administer antiseizure drugs and sedatives to relieve symptoms during withdrawal. 9. Which of the following is important in pain management of clients with opioid use disorder or other substance use disorders? a. The goal is to treat acute pain. b. Never administer IV opioids. c. Understand that opioid analgesia may worsen a substance use disorder. d. These clients should not be prescribed prn opioids. 10. A client who has an opioid use disorder is scheduled for surgery following an automobile accident. What is important for the nurse to recognize in this case? a. The client may need less pain medication during the postoperative period. b. The client should be continued on any opioid agonist therapy (e.g., methadone) throughout the perioperative period. c. The client may have an immediate onset of withdrawal symptoms when given anaesthetic and analgesic agents. d. The client has a low risk for physical withdrawal symptoms but is likely to experience craving during the postoperative period.

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For even more review questions, visit http://evolve.elsevier.com/Canada/ Lewis/medsurg.

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Canadian Nurses Association (CNA). (2017c). Harm reduction for non-­medical cannabis use. https://www.cna-­ aiic.ca/∼/media/cna/page-­content/pdf-­en/harm-­reduction-­for-­ non-­medical-­cannabis-­use.pdf?la=en Canadian Research Institute for Substance Misuse (CRISM). (2018). CRISM National Guideline for the Clinical Management of Opioid Use Disorder. https://crism.ca/wp-­content/uploads/2018/03/CRIS M_NationalGuideline_OUD-­ENG.pdf Carusone, S. C., Guta, A., Robinson, S., et al. (2019). “Maybe if I stop the drugs, then maybe they’d care?”—Hospital care experiences of people who use drugs. Harm Reduction Journal, 16(1), 16. https:// doi.org/10.1186/s12954-­019-­0285-­7 Center for Chronic Disease Prevention and Health Promotion. (2020). Substance Use During Pregnancy. https://www.cdc.gov/repr oductivehealth/maternalinfanthealth/substance-­abuse/substance-­ abuse-­during-­pregnancy.htm#tobacco Centers for Disease Control and Prevention (CDC). (2020). Outbreak of Lung Injury Associated with the Use of E-­Cigarette, or Vaping, Products. https://www.cdc.gov/tobacco/basic_information/e-­ cigarettes/severe-­lung-­disease.html Chu, C., & Galang, A. (2013). Hospital nurses’ attitudes toward patients with a history of illicit drug use. The Canadian Nurse, 109(6), 29–33. Collins, S., Clifasefi, S., Logan, D., et al. (2012). Current status, historical highlights and basic principles. In G. Marlatt, M. Larimer, & K. Witkiewitz (Eds.), Harm reduction: Pragmatic strategies for management of high-­risk behaviours (2nd ed.). Guilford Press (Seminal). Darke, S., Kaye, S., & Duflou, J. (2017). Rates, characteristics and circumstances of methamphetamine‐related death in Australia: A national 7‐year study. Addiction, 112(12), 2191–2201. https://doi. org/10.1111/add.13897 Deak, J. D., Miller, A. P., & Gizer, I. R. (2019). Genetics of alcohol use disorder: A review. Current Opinion in Psychology, 27, 56–61. https://doi.org/10.1016/j.copsyc.2018.07.012 Diercks, D. B., Fonarow, G. C., Kirk, J. D., et al. (2008). Illicit stimulant use in a United States heart failure population presenting to the emergency department (from the Acute Decompensated Heart Failure National Registry Emergency Module). American Journal of Cardiology, 102(9), 1216–1219. https://doi.org/10.1016/j.amjcard.2008.06.045. (Seminal). Dube, S. R., Felitti, V. J., Dong, M., et al. (2003). Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: The adverse childhood experiences study. Pediatrics, 111(3), 564–572. https://doi.org/10.1542/peds.111.3.564. (Seminal). Felitti, V. J., Anda, R. F., Nordenberg, D., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/S0749-­3797(98)00017-­8. (Seminal). Firestone, M., Tyndall, M., & Fischer, B. (2015). Substance use and related harms among Aboriginal people in Canada: A comprehensive review. Journal of Health Care for the Poor and Underserved, 26(4), 1110–1131. https://doi.org/10.1353/hpu.2015.0108 Fischer, B., Russell, C., Sabioni, P., et al. (2017). Lower-­Risk Cannabis Use Guidelines (LRCUG): An evidence-­based update. American Journal of Public Health, 107(8). https://doi.org/10.2105/ AJPH.2017.303818 George, T., & Vaccarino, F. (2015). Substance abuse in Canada: The effects of cannabis use during adolescence. Canadian Centre on Substance Abuse. http://www.ccsa.ca/Resource%20Library/CCSA-­ Effects-­of-­Cannabis-­Use-­during-­Adolescence-­Report-­2015-­en.pdf

Glasser, A. M., Collins, L., & Pearson, J. L. (2017). Overview of electronic nicotine delivery systems: A systematic review. American Journal of Preventive Medicine, 52(2), e33–e66. https://doi. org/10.1016/j.amepre.2016.10.036 Goodman, A., Fleming, K., Markwick, N., et al. (2017). “They treated me like crap and I know it was because I was Native”: The healthcare experiences of Aboriginal peoples living in Vancouver’s inner city. Social Science & Medicine, 178, 87–94. https://doi. org/10.1016/j.scocscimed.2017.01 Goodson, C. M., Clark, B. J., & Douglas, I. S. (2014). Predictors of severe alcohol withdrawal syndrome: a systematic review and meta-­ analysis. Alcoholism: Clinical and Experimental Research, 38(10), 2664–2677. https://doi.org/10.1111/acer.12529. (Seminal). Goyal, H., Awad, H. H., & Ghali, J. K. (2017). Role of cannabis in cardiovascular disorders. Journal of Thoracic Disease, 9(7), 2079. https://doi.org/10.21037/jtd.2017.06.104 Greaves, L., Hemsing, N., Poole, N., et al. (2016). From fetal health to women’s health: expanding the gaze on intervening on smoking during pregnancy. Critical Public Health, 26(2), 230–238. https:// doi.org/10.1080/09581596.2014.968527 Hajek, P., Etter, J. F., Benowitz, N., et al. (2014). Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction, 109(11), 1801–1810. https://doi. org/10.1111/add.12659 .(Seminal). Hammond, C., Niciu, M., Drew, S., et al. (2015). Anticonvulsants for the treatment of alcohol withdrawal syndrome and alcohol use disorders. CNS Drugs, 29(4), 293–311. https://doi.org/10.1007/ s40263-­015-­0240-­4 Han, B. H. (2018). Aging, multimorbidity, and substance use disorders: The growing case for integrating the principles of geriatric care and harm reduction. The International Journal on Drug Policy, 58, 135. https://doi.org/10.1016/j.drugpo.2018.06.005 Health Canada. (2019). Canadian Tobacco, Alcohol and Drugs Survey: Summary of results for 2017. https://www.canada.ca/en/health-­ canada/services/canadian-­tobacco-­alcohol-­drugs-­survey/2017-­ summary.html Hesse, M., & Thylstrup, B. (2013). Time-­course of the DSM-­5 cannabis withdrawal symptoms in poly-­substance abusers. BMC Psychiatry, 13(1), 258. https://doi.org/10.1186/1471-­244X-­13-­258. (Seminal). Huhn, A. S., Strain, E. C., Tompkins, D. A., et al. (2018). A hidden aspect of the U.S. opioid crisis: rise in first-­time treatment admissions for older adults with opioid use disorder. Drug and Alcohol Dependence, 193, 142–147. https://doi.org/10.1016/j.drugalcdep.2018.10.002 Jetty, R. (2017). Position statement: Tobacco use and misuse among Indigenous children and youth in Canada. Paediatrics and Child Health, 22(7), 395–399. https://doi.org/10.1093/pch/pxx124 Jongbloed, K., Pearce, M. E., Pooyak, S., et al. (2017). The Cedar Project: mortality among young Indigenous people who use drugs in British Columbia. CMAJ, 189(44), E1352–E1359. https://doi. org/10.1503/cmaj.160778 Khan, S. (2017). Concurrent mental and substance use disorders in Canada. https://www150.statcan.gc.ca/n1/pub/82-­003-­ x/2017008/article/54853-­eng.htm Koob, G., Kandel, D., Baler, R., et al. (2015). Pathophysiology of addiction. In A. Tasman, J. Kay, J. Lieberman, et al. (Eds.), Psychiatry (4th ed.). John Wiley & Sons. https://doi. org/10.1002/9781118753378 Krueger, H., Turner, D., Krueger, J., et al. (2014). The economic benefits of risk factor reduction in Canada: tobacco smoking, excess weight and physical inactivity. Canadian Journal of Public Health, 105(1), e69–e78 (Seminal).

CHAPTER 11  Substance Use Livne, O., Shmulewitz, D., Lev-­Ran, S., et al. (2019). DSM-­5 cannabis withdrawal syndrome: demographic and clinical correlates in US adults. Drug and alcohol dependence, 195, 170–177. https://doi. org/10.1016/j.drugalcdep.2018.09.005 Maldonado, J. R., Sher, Y., Das, S., et al. (2015). Prospective validation study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in medically ill inpatients: a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol and Alcoholism, 50(5), 509–518. https://doi-­org.proxy.queensu.ca/10.1093/alc alc/agv043 McLellan, A. T., Lewis, D. C., O’Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA, 284(13), 1689–1695. https://doi.org/10.1001/jama.284.13.1689 McQueen, J., Howe, T. E., Allan, L., et al. (2011). Brief interventions for heavy alcohol users admitted to general hospital wards. Cochrane Database of Systematic Reviews, 10(8), CD005191 https:// doi.org/ 10.1002/14651858.CD005191.pub3. (Seminal). Mirijello, A., D’Angelo, C., Ferrulli, A., et al. (2015). Identification and management of alcohol withdrawal syndrome. Drugs, 75(4), 353–365. https://doi.org/10.1007/s40265-­015-­0358-­1 Mukherjee, S. (2013). Alcoholism and its effects on the central nervous system. Current Neurovascular Research, 10(3), 256–262 https://doi.org/10.2174/15672026113109990004. (Seminal). Nathoo, T., Poole, N., & Schmidt, R. (2018). Trauma Informed Practice and the Opioid Crisis: A Discussion Guide for Health Care and Social Service Providers. https://bccewh.bc.ca/2018/05/trauma-­ informed-­practice-­and-­the-­opioid-­crisis-­a-­discussion-­guide-­for-­h ealth-­care-­and-­social-­service-­providers/ Nelson, S. E., Browne, A. J., & Lavoie, J. G. (2016). Representations of Indigenous peoples and use of pain medication in Canadian news media. The International Indigenous Policy Journal, 7(1), 1–26. https://doi.org/10.18584/iipj.206.7.1.5 Oviedo-­Joekes, E., Guh, D., Brissette, S., et al. (2016). Hydromorphone compared with diacetylmorphine for long-­term opioid dependence: A randomized clinical trial. JAMA Psychiatry, 73(5), 447–455. https://doi.org/10.1001/jamapsychiatry.2016.0109 Padwa, H., Larkins, S., Crevecoeur-­MacPhail, D. A., et al. (2013). Dual diagnosis capability in mental health and substance use disorder treatment programs. Journal of Dual Diagnosis, 9(2), 179–186. https://doi.org/10.1080/15504263.2013.778441. (Seminal). Parappilly, B. P., Garrod, E., Longoz, R., et al. (2020). Exploring the experience of inpatients with severe alcohol use disorder on a managed alcohol program (MAP) at St. Paul’s Hospital. Harm Reduction Journal, 17, 28. https://doi.org/10.1186/s12954-­020-­00371-­6 Payne, R. A., Hrisko, S., & Sninivasan, S. (2018). Treatment approaches for opioid use disorders in late life. Current Treatment Options in Psychiatry, 5(2), 242–254. https://doi.org/10.1007/s40501-­018-­ 0146-­0 Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12, 38–48. https://doi.org/10.4278/0890-­1171-­12.1.38. (Seminal). Rao, V., Micic, D., & Davis, A. (2019). Medical management of opioid-­induced constipation. Jama-­Journal of the American Medical Association, 322(22), 2241–2242. https://doi.org/10.1001/ jama.2019.15852 Ries, R., Fiellin, D. A., Miller, S. C., et al. (2015). The ASAM Essentials of Addiction Medicine (2nd ed.). Wolters Kluwer/Lippincott Williams & Wilkins. Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325–334. https:// doi.org/10.1017/S135246580001643X. (Seminal).

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Rush, B. (2015). Concurrent disorders guidelines: A supplement to the provincial addictions treatments standards. Newfoundland: Department of Health and Community Services. https://www. health.gov.nl.ca/health/mentalhealth_committee/mentalhealth/pdf/ Concurrent_Disorders.pdf Sachdeva, A., Choudhary, M., & Chandra, M. (2015). Alcohol withdrawal syndrome: Benzodiazepines and beyond. Journal of Clinical and Diagnostic Research, 9(9), VE01–VE07. https://doi. org/10.7860/JCDR/2015/13407.6538 Special Advisory Committee on the Epidemic of Opioid Overdoses. (2019). Joint Statement from the Co-­chairs. https://www.canada.ca/en/public-­health/news/2019/12/joint-­ statement-­from-­the-­co-­chairs-­of-­the-­special-­advisory-­committee-­ on-­the-­epidemic-­of-­opioid-­overdoses-­on-­new-­data-­related-­to-­ the-­opioid-­crisis.html Statistics Canada. (2019). Table 13-­10-­0099-­01—Health indicator profile, by Aboriginal identity and sex, age-­standardized rate, four year estimates (2007–2014). https://www150.statcan.gc.ca/t1/tbl1/en/tv. action?pid=1310009901 Strobbe, S. (2014). Prevention and screening, brief intervention and referral to treatment for substance use in primary care. Primary Care Clinic Office Practice, 41, 185–213. https://doi.org/10.1016/j. pop.2014.02.002. (Seminal). Substance Abuse and Mental Health Services Administration (SAMHSA). (2020a). About Screening, Brief Intervention, and Referral to Treatment (SBIRT). https://www.samhsa.gov/sbirt/ about Substance Abuse and Mental Health Services Administration (SAMHSA). (2020b). Recovery and Recovery Support. https://www.samhsa.gov/find-­help/recovery Taber, K., Black, D., Porrino, L., et al. (2012). Neuroanatomy of dopamine: Reward and addiction. Journal of Neuropsychiatry and Clinical Neuroscience, 24(1), 1–4. https://doi.org/10.1176/appi. neuropsych.24.1.1. (Seminal). Ti, L., Milloy, M. J., Buxton, J., et al. (2015). Factors associated with leaving hospital against medical advice among people who use illicit drugs in Vancouver, Canada. PloS One, 10(10), e0141594. https://doi.org/10.1371/journal.pone.0141594 Tobacco Use, & Dependence Guideline Panel. (2008). Treating Tobacco Use and Dependence: 2008 Update. US Department of Health and Human Services. https://www.ncbi.nlm.nih.gov/books /NBK63952/ UBC Continuing Professional Development (UBC CPD). (2020). Addiction Care and Treatment Online Course. https://elearning.ubc cpd.ca/course/view.php?id=164#section-­2 United Nations Office on Drugs and Crime. (2020). Research brief: COVID-­19 and the drug supply chain: from production and trafficking to use. https://www.unodc.org/documents/d ata-­and-­analysis/covid/Covid-­19-­and-­drug-­supply-­chain-­ Mai2020.pdf Urbanowski, K. (2017). Need for equity in treatment of substance use among Indigenous people in Canada. CMAJ, 189(44), E1350– E1351. https://doi.org/10.1503/cmaj.171002 van Boekel, L. C., Brouwers, E. P. M., van Weeghel, J., et al. (2013). Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug and Alcohol Dependence, 131(1), 23–35. https://doi.org/10.1016/j.drugalcdep.2013.02.018. (Seminal). Venkatesan, T., Levinthal, D. J., Li, B., et al. (2019). Role of chronic cannabis use: Cyclic vomiting syndrome vs cannabinoid hyperemesis syndrome. Neurogastroenterology and Motility, 31(Suppl 2), e13606. https://doi.org/10.1111/nmo.13606

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Wilk, P., Maltby, A., & Cooke, M. (2017). Residential schools and the effects on Indigenous health and well-­being in Canada—a scoping review. Public Health Reviews, 38(1), 8. https://doi.org/10.1186/ s40985-­017-­0055-­6 Winkelman, T. N., Admon, L. K., Jennings, L., et al. (2018). Evaluation of amphetamine-­related hospitalizations and associated clinical outcomes and costs in the United States. JAMA Network Open, 1(6) e183758-­e183758. https://doi.org.10.1001/jamanetworkopen.2018.3758 Xiong, G. (2018). Wernicke-­Korsakoff syndrome. Medscape. http://eme dicine.medscape.com/article/288379-­overview

RESOURCES 10 Ways to Reduce Risks to Your Health When Using Cannabis https://www.camh.ca/-­/media/files/pdfs-­-­-­reports-­and-­books-­-­-­ research/canadas-­lower-­risk-­guidelines-­cannabis-­pdf.pdf Canadian Cancer Society: Get Help to Quit Smoking https://www.cancer.ca/en/support-­and-­services/support-­ services/quit-­smoking/?region=bc Canadian Centre on Substance Use and Addiction (CCSA) https://www.ccsa.ca Canadian Drug Policy Coalition https://drugpolicy.ca/ Canadian Institute for Health Information https://www.cihi.ca Canadian Mental Health Association: Addressing Mental Health and Addictions Needs in Primary Care http://ontario.cmha.ca/public_policy/addressing-­mental-­health-­ and-­addictions-­needs-­in-­primary-­care/#.WKVQHTvytPY Canadian Nurses’ Association: Harm Reduction & Illicit Substance Use—Implications for Nursing http://www.cna-­aiic.ca/-­/media/cna/page-­content/pdf-­en/harm-­ reduction-­and-­illicit-­substance-­use-­implications-­for-­nursing.pdf ?la=en&hash=5F5BBCDE16C7892D9C7838CF62C362685CC2D DA7 Canadian Nurses Protective Society https://www.cnps.ca/ Canadian Research Institute on Substance Misuse: Guidance Document on the Management of Substance Use in Acute Care https://crismprairies.ca/wp-­content/uploads/2020/02/Guidance-­ Document-­FINAL.pdf Centre for Addiction and Mental Health https://www.camh.ca/ Clinical Opioid Withdrawal Scale (COWS) https://www.bccsu.ca/wp-­content/uploads/2017/08/Clinical-­ Opiate-­Withdrawal-­Scale.pdf EQUIP Health Care https://equiphealthcare.ca/

Harm Reduction Nurses’ Association–Canada https://www.hrna-­aiirm.ca/ Indigenous Cultural Safety Training https://www.sanyas.ca/ Registered Nurses’ Association of Ontario (RNAO) https://rnao.ca Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline: Engaging Clients Who Use Substances https://rnao.ca/bpg/guidelines/engaging-­clients-­who-­use-­ substances Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline: Integrating Smoking Cessation Into Daily Nursing Practice https://rnao.ca/sites/rnao-­ca/files/Integrating_Smoking_Cessation _into_Daily_Nursing_Practice.pdf Registered Nurses’ Association of Ontario (RNAO): Tobacco https://rnao.ca/category/topics/tobacco Respectful Language and Stigma Regarding People Who Use Substances http://www.bccdc.ca/resource-­gallery/Documents/respectful-­ language-­and-­stigma-­final_244.pdf Stigma Around Drug Use https://www.canada.ca/en/health-­canada/services/substance-­ use/problematic-­prescription-­drug-­use/opioids/stigma.html Trauma-­Informed Practice Guide http://bccewh.bc.ca/wp-­content/uploads/2012/05/2013_TIP-­ Guide.pdf. http://bccewh.bc.ca/wp-­content/uploads/2018/06/ Opioid-­TIP-­Guide_May-­2018.pdf UBC Continuing Professional Development: Addiction Care and Treatment Online Course https://elearning.ubccpd.ca/course/view.php?id=164 Alcoholics Anonymous https://www.aa.org/ Alcohol Use Disorders Identification Test https://auditscreen.org/ International Nurses Society on Addictions https://www.intnsa.org Take Home Naloxone https://towardtheheart.com/naloxone World Health Organization: Mental Health https://www.who.int/mental_health For additional Internet resources, see the website for this book at http: //evolve.elsevier.com/Canada/Lewis/medsurg.

CHAPTER

12

Complementary and Alternative Therapies Ann Mary Celestini

WEBSITE http://evolve.elsevier.com/Canada/Lewis/medsurg • R  eview Questions (Online Only) • Key Points

• A  nswer Guidelines for Case Study • Conceptual Care Map Creator

• A  udio Glossary • Content Updates

LEARNING OBJECTIVES 1. Describe complementary and alternative therapies, including classifications of commonly used therapies such as natural and nonprescription products, mind and body practices, and other related practices. 2. Review natural products such as herbal therapy, including cannabis, while considering the implications for use.

. Investigate the mind and body practices as part of holistic nursing care. 3 4. Highlight the health teachings from Indigenous peoples and traditional Chinese medicine practices. 5. Describe the role of the nurse in integrating complementary and alternative therapies into nursing practice.

KEY TERMS acupuncture complementary and alternative therapies herbal therapy

  

holistic nursing Indigenous health massage therapy

The general health of Canadians is steadily improving, as evidenced by lower mortality rates and increased life expectancy. Biomedical and technological advances have contributed to these improvements. However, conventional therapy has been less helpful in alleviating symptoms of chronic illnesses and associated challenges, which are at an epidemic high. Furthermore, conventional (Western) approaches to health care tend to be depersonalized and often fail to account for all aspects of well-­being, including the individual’s mind, body, and spirit. Increasing access to global perspectives has resulted in greater exposure to healing philosophies from many cultures, offering both consumers and health care providers various new ideas about health and healing (Fontaine, 2019). Complementary and alternative therapies is an umbrella term used to describe a broad range of healing philosophies, therapies, and health care approaches that are often considered unconventional in North America. Several terms have been used to describe these methods of care, which are considered outside the conventional biomedical practices dominant in Canada and other Western cultures; such terms include alternative, complementary, integrative, nontraditional, unconventional, holistic,

prayer therapeutic touch traditional Chinese medicine (TCM)

and natural. According to the US National Center for Complementary and Integrative Health (NCCIH, 2021), complementary care approaches integrate conventional medicine together with unconventional practices. Alternative care approaches replace conventional medicine with unconventional practices. Integrative care further implies a purposeful action of bringing both conventional and unconventional approaches together in a coordinated manner for care. Complementary and alternative therapies support many nursing values, including a view of holistic care, an emphasis on healing, a recognition of the importance of therapeutic care partnerships with patients, and a focus on health promotion and illness prevention (Canadian Nurses Association [CNA], 2017; College & Association of Registered Nurses of Alberta, 2018; College of Nurses of Ontario, 2018). Nursing’s interest in complementary and alternative perspectives is further reflected in the formation of specialty nursing groups. For example, the Canadian Holistic Nurses Association (CHNA, 2021) was established to recognize holistic nursing as a specialty and to ensure that holistic practices are considered within a health maintenance and promotion framework. Despite this, nurses may face

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challenges determining their specific role related to the use of complementary and alternative therapies in practice. In Canada, no national policy or law exists for the regulation of complementary and alternative practitioners, as this power lies within provincial or territorial jurisdictions. To provide direction, the College and Association of Registered Nurses of Alberta (CARNA) (College & Association of Registered Nurses of Alberta, 2018) has published expectations and direction for complementary and alternative health care (CAHC) and use of natural health products (NHPs). The CARNA guideline identifies three standards for registered nurse practice: (a) being responsible and accountable for nursing practice related to CAHC and NHPs; (b) using evidence-­informed approaches in the selection of CAHC and NHPs, while considering the benefits and risks to a patient’s health and safety; and (c) practising ethically when providing care that includes CAHC and NHPs. Provincial and territorial nurse or practitioner licensure and regulations vary for different therapy practices. Practitioners should refrain from performing any therapy that is not within their scope of professional practice and explain this decision to the patient. In 2016, a comprehensive longitudinal national study conducted by the Fraser Institute established that there is a steady increase in the number of people using complementary and alternative therapies in Canada. Approximately 80% of Canadians have used one or more complementary or alternative therapy at some point in their lives (Esmail, 2017). This increasing overall use by consumers raises important questions among health care providers about the effectiveness and safety of complementary and alternative approaches. In response to these inquiries, the Canadian Interdisciplinary Network for Complementary and Alternative Medicine Research (INCAM, 2021) was established to foster excellence in complementary and alternative medicine (CAM) research. Its objectives are to build a sustainable network that facilitates and supports research, promotes knowledge transfer among researchers, and thus avoids the duplication of research efforts (see the Resources at the end of this chapter). Given the vast array of complementary and alternative health practices, categorization becomes difficult. For analytical purposes, the NCCIH (2018) classified these therapies into specific groups: natural products, mind and body practices, and other complementary and alternative practices. Select therapies within each category can be found in Tables 12.1, 12.2, and 12.3. The list of therapies continually changes as practices proven safe and effective become accepted as conventional health care practices.

NATURAL PRODUCTS An interest in natural and nonprescription therapies has increased in countries whose health care practices are dominated by the biomedical model. Interest in these products is related to several factors, including the high cost of and the potential for severe adverse effects associated with pharmaceutical drugs. Remedies that stem from this category are considered “natural” and therefore may be viewed as safer and more appealing to the public. Since they are directly available to consumers, individuals can assume more autonomy regarding their health care. In Canada, the Natural and Non-­prescription Health Products Directorate is the regulating authority that ensures the safety, efficacy, and quality of NHPs and nonprescription drugs that are available. NHPs are substances that occur naturally from plants, animals, microorganisms, or marine sources and are used to restore or maintain good health. Biologically based, or natural, therapies include herbal therapies (phytotherapy),

TABLE 12.1    NATURAL PRODUCTS Examples

Description

Herbal therapy

Use of unrefined plant-­based products to treat, prevent, or cure disease. Effects are slow and less dramatic than effects of pharmaceutical drugs. Vitamin and mineral supplements. The best source of vitamins and minerals is a well-­balanced diet. Special diets for health promotion. Such diets must be studied specifically for their potential benefit. Use of a plants’ extracted essential oils for their beneficial effects on stress management, mood regulation, sleep induction, weight reduction, boosting the immune system, promoting speed recovery, and minimizing illness discomfort. They can be used for many antiviral, antibacterial, antifungal, and antiseptic purposes (Fontaine, 2019). Use of live microorganisms that are similar to those found in the human digestive tract and that aid digestion

Nutraceuticals Nutritional therapy Aromatherapy

Probiotic therapy

nutraceuticals, nutrition therapy, aromatherapy, and probiotic therapy (see Table 12.1) (Fontaine, 2019). For the purposes of classification, cannabis has been grouped with this category, considering the nature of this recently legalized herb in Canada. Natural products come in a wide variety of forms, such as tablets, tinctures, capsules, solutions, creams, ointments, and drops.

Herbal Therapy Herbal therapy, also known as botanical medicine or phytotherapy, is the use of individual herbs or combinations of herbs for therapeutic benefit. An herb is a plant or plant part (bark, roots, leaves, seeds, flowers, or fruit) that produces and contains chemical substances that act on the body. It is estimated that approximately 25 000 plant species are used medicinally throughout the world, and approximately 30% of modern prescription drugs are derived from plants. Botanical medicine is the oldest known form of medicine; archaeological evidence suggests that Neanderthals used plant-­based remedies 60 000 years ago. Today, about 80% of the world’s population relies extensively on plant-­derived remedies (Fontaine, 2019). Clinical Applications of Herbal Therapy.  Medicinal plants work similarly to medications; both are absorbed and trigger biological effects that can be therapeutic. Many medicinal plants have more than one physiological effect and thus can be used for more than one condition. A number of herbs have been determined to be safe and effective for a variety of conditions. Complementary & Alternative Therapies boxes with descriptions of herbs related to specific diseases are found throughout this book. COMPLEMENTARY & ALTERNATIVE THERAPIES Information related to the following complementary and alternative therapies can be found throughout this text. • Acupuncture • Bilberry • Biofeedback • Echinacea • Garlic • Ginger • Ginkgo biloba • Ginseng • Glucosamine • Goldenseal • Guided imagery • Herbs and supplements that affect blood clotting

• Herbs and supplements that affect blood glucose levels • Herbs and supplements used for menopause • Herbs for surgical patients • Herbs that affect healing • Lipid-­lowering agents • Milk thistle • Music therapy • Saw palmetto • Valerian • Zinc

CHAPTER 12  Complementary and Alternative Therapies

191

TABLE 12.2    MIND AND BODY PRACTICES Examples

Description

Relaxation breathing

Slow diaphragmatic breathing, and exercises, used to elicit the relaxation response. See Chapter 8 for further information. General term for a wide variety of methods that promote relaxation in the body and preserve tranquility in the mind. State of being with increased concentration and awareness. Focuses on deepening one’s attention and increasing self-­awareness. Various types of meditation exist, including transcendental, mindfulness, Buddhist, Tibetan, Sufi, and forms of moving meditation, which can be practised individually or in a group. Method of learned self-­control over physiological responses of the body (Fontaine, 2019). Information about one or more physiological functions is received, interventions are used, and a feedback loop allows for voluntary control of certain functions. A noninvasive drug-­free technique whereby electrodes are placed on the scalp to monitor brain activity. Inappropriate brain waveforms are decreased and appropriate waveforms are increased through positive computer-­generated visual or auditory reinforcement. It is used for such conditions as epilepsy, stroke, depression, fibromyalgia, PTSD, and ADHD, often improving quality of life during illness (Luctkar-­Flude et al., 2019). Part of Ayurveda medical system and widely used for its physical, psychological, and spiritual benefits. Numerous schools of yoga or practices exist but typically combine physical postures, breathing techniques, and relaxation or meditation. A state of focused concentration of the mind to generate images that have a calming effect on the body. It involves the use of vision, sound, smell, and taste, as well as movement, position, and the sense of touch. Application of hypnosis to attain a state of attentive, focused concentration during which individuals become highly responsive to suggestion. It may be applied effectively to a wide variety of medical and psychological disorders. Clinical and evidenced-­informed music interventions developed by a credentialed professional to accomplish individualized goals that promote wellness or improve quality of life. Use of specifically selected animals for a variety of therapies that have been successfully used as a motivational, educational, and recreational intervention for people with a variety of physical, psychological. and spiritual issues. Communication with a god, or the sacred. Prayer is a frequently used therapy of various forms that is utilized in all cultures. Therapy that restores and maintains health by proper alignment of the spine through a variety of adjustment and manipulation techniques. Correct spinal alignment facilitates self-­healing and improves health and well-­being. Acupuncture, acupressure, and reflexology are three similar practices of stimulating points on the body, to balance an individual’s life energy within the body. It involves application of pressure or stimulation to specific acupuncture points, as defined by energy meridian charts of the body, to improve energy flow, relieve pain, and stimulate the body’s innate healing abilities. Scientific, purposeful manipulation of soft tissues to improve health, promote healing and help the body heal itself. Outcomes include relaxation, reduced tension, improved immune function, increased flexibility, and pain relief.

Meditation

Biofeedback

Neurofeedback (formally EEG biofeedback)

Yoga

Guided imagery Hypnotherapy Music therapy Animal-­facilitated therapy Prayer Chiropractic therapy Pressure point therapy

Massage therapy

ADHD, attention-­deficit/hyperactivity disorder; EEG, electroencephalography; PTSD, post-­traumatic stress disorder.

TABLE 12.3    OTHER COMPLEMENTARY AND ALTERNATIVE MEDICINE PRACTICES Examples

Description

Whole Medical Systems Indigenous health

Ayurvedic medicine

Traditional Chinese medicine (TCM)

Naturopathy

Homeopathy

Practices based on a domain wherein all things have a “spirit.” Community is valued and plays a role in the healing process. Gratitude to and harmony with nature are central themes. Illness occurs when an imbalance occurs. Healers use herbs, natural medicines, spiritual rituals, and ceremonies to support wellness and promote healing. A holistic system developed in India that bases its practice on the balance of mind, body, and spirit. Disease is viewed as an imbalance between a person’s life force (prana) and basic metabolic condition (dosha). Interventions include breathing exercises, nutrition, detoxification, herbs, meditation, and yoga. One of the world’s oldest, most holistic medical systems. Based on restoring and maintaining the balance of vital energy (qi). Interventions include acupressure, acupuncture, Chinese herbology, cupping, moxibustion, nutrition, meditation, tai chi, and qigong. Therapy based on promotion of health rather than on symptom management. Focus is on enhancing the body’s natural healing response through a variety of individualized interventions such as nutrition, herbology, homeopathy, physical therapies, and counselling. Naturopathic physicians are graduates of accredited naturopathic medical schools, and licensing varies by province or territory. Therapy based on the adage “like cures like.” Remedies are specially prepared from the same substance that causes the symptom or health problem. Extremely small amounts of the substance are used for the remedy, which are believed to work through a transfer in energy.

Energy Healing Therapies Hand-­mediated biofield energies

Manipulation of energy fields: bioelectromagnetics

Designed to balance the body’s biofield, or energy field, and increase the flow of energy within an individual by channeling and directing healing energy through the hands of a practitioner. Practices include therapeutic touch, healing touch, and Reiki. Magnet therapy is based on the principle that every animal, plant, and mineral has an electromagnetic field that allows other objects to interact with it as part of one unified energy system (Fontaine, 2019). Magnets are frequently used to reduce pain, relieve swelling and inflammation, and promote healing of soft tissue and bone.

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SECTION 1  Concepts in Nursing Practice

TABLE 12.4    PATIENT & CAREGIVER TEACHING GUIDE Herbal Therapies When teaching patients and caregivers about herbal therapies, the nurse should: • Ask the patient about use of herbal therapies. Document a complete history of herbal use, including amounts, brand names, and frequency of use. Ask the patient about allergies. • Investigate whether herbs are used instead of or in addition to traditional medical treatments. Find out whether herbal therapies are used to prevent disease or to treat an existing problem. • Instruct the patient to inform health care providers of any intention to take herbal treatments before doing so. • Make the patient aware of the risks and benefits associated with herbal use, including reactions when herbs are taken in combination with other medications. • Advise the patient using herbal therapies to be aware of any adverse effects while taking herbal treatments and to immediately report them to the health care provider. • Make the patient aware that moisture, sunlight, and heat may alter the components of herbal products. • Inform the patient of the need to be aware of the reputation of the manufacturers of herbal products and the safety of the product before buying herbal treatments. • Encourage the patient to read labels of herbal therapies carefully. Advise the patient not to take more of an herb than is directed. • Inform the patient that most herbal therapies should be discontinued at least 2 to 3 weeks before surgery. • Inform the patient that the employees of health food stores may not have any educational background in the actions, interactions, and efficacies of the herbal therapies sold in the store they are working in. It is the responsibility of the patient to ensure that the information received comes from someone who has the appropriate background and education to be providing that information.

Although most herbal therapies can safely be used without professional assistance, nurses should assess for their use to mitigate adverse effects and interactions with prescription drugs. Adverse effects resulting from the use of herbal remedies may be underreported, which can promote the impression that herbal remedies are completely safe to use. Because consumers tend not to discuss their use of herbal therapies with their primary health care provider, herb–drug interactions may also be underreported (Fontaine, 2019). For safety, patients who are scheduled for surgery should be advised to stop taking herbal remedies 2 to 3 weeks before surgery. Patients who are being treated with conventional drug therapy should be advised to discontinue herbal remedies that produce similar pharmacological effects, because the combination may lead to an excessive reaction or to unknown interaction effects. General patient teaching guidelines related to use of herbal therapy are presented in Table 12.4. Patients who take herbal therapies should be advised to adhere to the suggested dosage. If taken in high doses, herbal preparations can be toxic. The potency of a particular herbal remedy can vary widely because of factors such as where and how it was grown, how it was harvested, and how it was processed. Herbal medicines should be purchased only from reputable manufacturers. Health Canada (2021b) advises Canadians to use only herbal products that have been approved for sale under the Natural Health Products Regulations. If the product has been assessed, it will have a drug identification number (DIN) or natural products number (NPN) on its label. This certifies that the product has passed a review of formulation, labelling, and instructions for use. Because of the potential for adverse effects, pregnant women, nursing mothers, and older persons with liver or cardiovascular disease should use caution in consuming herbal products. Commonly used herbs are listed in Table 12.5, and commonly used dietary supplements are found in Table 12.6. 

Cannabis Cannabis, or Cannabis sativa, contains hundreds of chemical substances. Over 100 of these are known as cannabinoids, which are produced and stored in trichomes, or tiny clear hairs that protrude from the plant flowers and leaves. Cannabinoids have effects on cell receptors in the brain and body that can change how these cells behave and communicate with each other.

Delta-­9-­tetrahydrocannabinol (THC), cannabidiol (CBD), and terpenes are three primary cannabinoids in cannabis. THC, the most researched of the three, is responsible for the physiological response, including the “high” and intoxicating effects of cannabis. THC has both therapeutic and harmful effects that can vary depending on dose, potency, and individual user characteristics. The potency of THC in cannabis, shown in percentage, has increased from 3% in the 1980s to around 15% today, with some strains averaging as high as 30% or greater. Cannabis containing very low amounts of THC (less than 0.3%) is classified as hemp. CBD, unlike THC, does not produce a similar “high” or intoxication. Equal or higher amounts of CBD may block or lower some of the THC effects on the mind while offering the possibility of various therapeutic uses. Finally, terpenes are chemicals made and stored in the trichomes of the cannabis plant, with the cannabinoids giving it a distinctive smell and flavour (Health Canada, 2021a). Cannabis, often known as marijuana, is used for medical, recreational, or religious purposes. Most cannabis products come from or can be made using the flowers and leaves of the cannabis plant. Depending on the plant strain, these products can have a range of potencies of THC and CBD that come in different forms for consumption, such as fresh or dried herbs, oil, concentrated extracts (e.g., hash oil/shatter/budder/wax), physically concentrated extracts (e.g., hash/kief), edibles, tinctures, sprays, and creams (Health Canada, 2021a). Cannabis can be administered by inhalation, oral ingestion, sublingually, topically, and rectally. In Canada, synthetic forms of cannabis such as nabilone and dronabinol are also available through prescriptions (Pratt et al., 2019). 

Clinical Applications of Cannabis Over the last decade there has been increased medical use of cannabis in North America. In Canada, the Cannabis Act, which came into effect on October 17, 2018, permitted the legal purchase of cannabis for recreational use. Further, in October 2019, an amendment for cannabis-­infused edibles was made to this Act. These recent developments highlight the increasing need for nurses to become familiar with their implications for health and well-­being. A Web link to information for health care providers regarding the potential therapeutic uses, dosing, warnings, and adverse effects can be found in the Resources section of this chapter.

CHAPTER 12  Complementary and Alternative Therapies

193

TABLE 12.5    COMMONLY USED HERBS* Name

Uses Informed by Scientific Evidence

Comments

Aloe

Laxative, skin conditions, osteoarthritis, fever

Black cohosh

Decrease menopausal and menstrual related symptoms

Echinacea

Treat upper respiratory tract infections, wound and skin conditions

Evening primrose

Treat eczema, skin conditions, rheumatoid arthritis, premenstrual or menopausal symptoms, breast pain Prevent migraine headaches. Used to treat menstruation problems, rheumatoid arthritis, asthma, tinnitus, dizziness, nausea, vomiting, intestinal parasites, and toothaches or as skin cleanser Can decrease hypertension cholesterol and low-­ density lipoproteins Potential anticancer properties Ease nausea and vomiting May help with osteoarthritis, rheumatoid arthritis Treat symptoms of intermittent claudication, tinnitus, dementia, eye problems Improve mental and physical performance, enhance immune system May lower blood glucose level in type 2 diabetes mellitus Treat mild to moderate heart failure, digestive and kidney problems, anxiety Treat anxiety

• May lead to abdominal cramping, diarrhea • Can cause electrolyte imbalances • May lower blood glucose level • May cause upset stomach or rash • Can cause liver problems • May increase bleeding • May lead to digestive symptoms • Rash may result from allergic reactions • Only short-­term use is recommended • Contraindicated in individuals on blood thinners and in pregnant and lactating women • May cause mild gastrointestinal upset or headache • May cause gastrointestinal adverse effects • Could increase risk of bleeding • Stopping long-­term use may lead to withdrawal symptoms • Avoid use during pregnancy as it can affect uterine contractions • May increase risk of bleeding • Avoid prior to surgery • Could interfere with effectiveness of some medications • Use cautiously with gallstone disease • May increase risk of bleeding • Can increase risk of bleeding and certain cancers • Could be poisonous if ingesting raw or roasted seeds • Could increase or decrease blood pressure • May lower blood glucose levels • Can increase risk of bleeding

Feverfew

Garlic

Ginger Ginkgo biloba Ginseng (Panax species, including Asian and American ginseng) Hawthorn Kava

Milk thistle St. John’s wort

Treat liver disorders, high cholesterol, and gallbladder problems Treat mild depression, menopausal symptoms

Zinc

Treat upper respiratory tract infections

• May cause dizziness, nausea, and gastrointestinal problems • Could interact harmfully with cardiac medications • Should be used only under the supervision of a health care provider • Associated with a risk of liver damage • Risk of heart problems and eye irritation with heavy consumption • May lower blood glucose levels • May lead to serious interactions with herbs, supplements, OTC drugs, or prescription drugs, thus it is important to consult and notify health care provider • Could lead to photosensitivity, anxiety, dry mouth, sexual problems • Not for use with other antidepressants • Not for children • Can cause copper deficiency with long-­term use • May interact with antibiotics

OTC, over-­the-­counter. *Advise patients who are pregnant or lactating to consult a health care provider before they use any herbs. Scientific evidence for the use of most herbs during pregnancy or lactation is limited. Source: National Center for Complementary and Integrative Health. (2019). Health topics A–Z. https://nccih.nih.gov/health/atoz.htm

The flowers and leaves of the cannabis plant are primarily used for their ability to cause short-­term positive effects on the mind, including feeling high (euphoria), a sense of well-­being, relaxation, and heightened sensory experiences including sight, taste, smell, and sound. Medical cannabis has been used effectively in treating and managing a wide range of health conditions, most notably anxiety, eating disorders, epilepsy, chronic pain management, glaucoma, inflammatory bowel disease, post-­traumatic stress disorder, multiple sclerosis, sleep difficulties, and symptom management of several chronic illnesses (NCCIM, 2019; Pratt et al., 2019). However, despite the diversity of successful applications, certain individuals may experience some of the short-­term negative effects on the brain, including confusion; sleepiness (fatigue); impaired ability to remember, concentrate, react quickly, or pay attention; and anxiety, panic, or fear. Short-­term effects may also include damaged blood vessels caused by smoking; reduced blood pressure causing people to faint; and increased heart

rate, which can be dangerous for those with heart conditions, increasing their risk for a heart attack. Occasionally, cannabis use can result in psychotic episodes characterized by paranoia, delusions, and hallucinations. Long-­term effects of cannabis consumption may develop gradually with daily or near-­daily use that continues over months or years. Frequent, excessive use can harm an individual’s memory, concentration, intelligence, and ability to think and make decisions. Long-­term extreme use may potentially lead to a condition involving recurrent, severe vomiting. If cannabis is smoked, the risks to lung health may be similar to the effects of tobacco smoke. Similar to cautions with medication administration, pregnant or breastfeeding mothers must be aware of the impact cannabis use can have on the fetus or newborn. Health effects of cannabis use during pregnancy and breastfeeding have been associated with lower infant birth weights (Health Canada, 2021a). With the rising popularity of cannabis-­infused edibles, the inherent risks involved should be discussed with users. Responsible use,

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TABLE 12.6    COMMONLY USED DIETARY SUPPLEMENTS* Name

Uses Informed by Scientific Evidence

Comments

Chondroitin sulphate

Treat osteoarthritis

Coenzyme Q10

Treat hypertension and heart disease and prevent migraines Treat hypertension or hypertriglyceridemia Prevent cardiovascular disease and relieve symptoms of rheumatoid arthritis

• May interact with anticoagulant • Long-­term use could damage kidneys • Should be used with caution in patients who have bleeding disorders or are taking anticoagulants • May decrease blood glucose levels

Fish oil/omega-­3 fatty acids

Glucosamine

Treat osteoarthritis

Melatonin

Treat jet lag Decrease sleep latency

Probiotics (live bacteria or yeast)

Re-­establish gut flora (especially after prolonged antibiotic therapy) Influence immune system

• May increase risk of bleeding • Might increase blood glucose levels in patients with diabetes • Could increase low-­density lipoprotein (LDL) level • Can potentiate reaction if allergic to fish or shellfish • May increase intraocular pressure • Could increase blood glucose and insulin levels and impact effectiveness of diabetes medication • Can increase risk of bleeding • May cause problems in those with shellfish allergies • May increase risk of bleeding • Might alter blood pressure • Should be used with caution in patients with diabetes or hypoglycemia • Should be used with caution by patients with seizure disorder • Should be used with caution in patients with compromised immune system or gastrointestinal disorders

*Advise patients who are pregnant or lactating to consult a health care provider before they use any supplements. Scientific evidence for use during pregnancy or lactation is limited. Source: National Center for Complementary and Integrative Health. (2019). Health topics A–Z. https://nccih.nih.gov/health/atoz.htm

which includes safe storage, should be stressed, to avoid accidental ingestion of cannabis by children or pets (Charlebois et al., 2020). Nurses should be aware of facility policies regarding CBD administration. 

MIND–BODY PRACTICES Mind–body interventions include a variety of techniques designed to facilitate the mind’s capacity to affect bodily function. These include behavioural, psychological, social, and spiritual approaches to health. Massage, yoga, meditation, pressure point therapies, relaxation techniques such as breathing exercises, guided imagery, hypnotherapy, biofeedback, neurofeedback, animal-­facilitated therapy, chiropractic manipulation, and prayer are examples of mind–body therapies and approaches (see Table 12.2).

Massage Therapy Massage therapy includes a range of techniques that the practitioner uses to manipulate the soft tissues and joints of the body (Figures 12.1 and 12.2). Involving touch and movement, massage is typically delivered with the hands, although elbows, forearms, or feet may be also used. Massage techniques are used in body work, sports training, physiotherapy, nursing, chiropractic therapy, osteopathy, and naturopathy. Clinical Applications of Massage Therapy.  Until the 1970s, nurses were taught to perform “p.m. care,” which consisted of a back rub and other measures to promote relaxation and sleep. After that time, p.m. care and back rubs became the exception rather than the rule. Yet today, with the increased focus on providing holistic care, nurses are again recognizing the benefits of massage. Massage promotes health and wellness and has been shown to improve quality of life (Angelopoulou et  al., 2020; Yeun, 2017). The role of the nurse in massage differs from that of the registered massage therapist. Whereas massage therapists can provide more comprehensive massage therapies, nurses can

use specific massage techniques as part of nursing care when indicated by findings in patient assessment. For example, a back massage can be used to help promote sleep. For a bedridden patient, gentle massage can stimulate circulation. When a nurse determines that massage may be indicated in meeting a patient goal, the nurse must first assess the patient’s preference regarding touch and massage. The nurse should consider cultural and social beliefs and discuss potential benefits with the patient. The indicated plan of care (e.g., hand massage, back massage) can then be implemented, and reassessment can be performed after the massage. 

Prayer Prayer has been identified as one of the most common and universally used mind–body interventions shared among many cultures, faiths, and religions globally. While prayer may have different implications and meanings within the context of these various perspectives, all have similar intentions of establishing a connection with God, or Creator, to either seek help or give thanks and praise. Prayer has been most simply defined as a form of intentional communication with a higher God, or deity. Health challenges or serious illness that arise throughout life may specifically prompt people to look to prayer for guidance, intervention, and healing during these difficult times. Prayer can be initiated on an individual or communal basis, while following a scripted or personalized format in either a public or private forum. Directed and nondirected prayer are two types that exist. In directed prayer, an individual will ask for a specific outcome, in contrast to nondirected prayer, which is not focused on the attainment of any specific outcome but on achieving an optimal result considering the circumstances. Further, prayer can be classified according to form, such as meditative, ritualistic, colloquial, and intercessory (or petitionary). Meditative or contemplative prayer, like meditation, requires a process of focusing the mind on an aspect of God over a specified period of time. Ritualistic prayer includes repeated words, phrases, or

CHAPTER 12  Complementary and Alternative Therapies

A

B

FIG. 12.1  Massage. A, Using effleurage to relax the back. B, Using pétris-

sage to relax arm muscles. Source: Lori Karhu, RMT, RN, San Antonio, Texas.

B A

C

195

D

FIG. 12.2  A, Hand massage. B, Technique of hand massage: Bend the wrist

backward and forward to relax the wrist, then massage the wrist and top of the hand, using circular movements. C, Massage the palm of the hand with the cushions of the thumbs, using circular movements. D, Massage each finger from the base to the tip. Source: Lori Karhu, RMT, RN, San Antonio, Texas.

rituals commonly associated with formal liturgy. Colloquial prayer involves a casual and spontaneous talk with the divine. Petitionary or intercessory prayer involves praying for someone else (Fontaine, 2019). Clinical Applications of Prayer.  Regardless of the method used, prayer supports spiritual health by allowing for the reflective expression of an individual’s fears, beliefs, faith, forgiveness, courage, and compassion. Spiritual health problems or crisis may stem from both physical and emotional sources, motivating people to question or search for the meaning or purpose of life. During times of illness, prayer can have positive effects, such as diminishing causes of depression, stress, anxiety, and concern, while in many cases supporting an improvement in the physical functioning and coping patterns among believers (Gonçalves et al., 2015; Mahmodi & Sayehmiri, 2018; Prado Simão et al., 2016). Dr. Issam Nemeh, M.D., a medical physician of unshakable faith,

FIG. 12.3  Dr. Issam Nemeh, M.D., a medical physician with an unshakable

faith in God’s divine intervention and ability to heal through prayer. Source: Path to Faith, Westlake, Ohio.

is globally known for the miraculous recoveries experienced by numerous people after either attending one of his healing services or following treatment in his medical office. With prayer, Dr. Nemeh has and continues to touch many people’s lives, from all denominations of faith, with healing, while modestly accrediting these miracles to an intercession from God (Figure 12.3). Nurses are committed to spiritual care as part of their holistic practice. Nurses need cross-­ cultural knowledge about prayer practices, awareness of patients’ spiritual needs, and engagement in rigorous research that examines the effects of prayer and faith on healing. However, the role of a nurse in supporting the spiritual health of patients is not meant to replace but supplement clergy services. Regardless of personal religious or spiritual beliefs, nurses can promote an atmosphere that accepts and encourages various forms of spiritual expression for patients. Such promotion requires respecting the patient’s denominational beliefs and traditions while ensuring that the nurse not force or impose their own views on the patient. Supporting this practice involves fostering self-­awareness and education among nurses regarding the clinical relevance of faith and prayer to health, healing, recovery, and even death. Through the development of a caring–healing therapeutic relationship with patients, nurses can honour the inner wisdom of others and promote a deeper level of understanding of their needs. Providing an opportunity and quiet space for holding sacred prayer or rituals can be arranged if needed within a health care organization with the nurse’s assistance. If comfortable with prayer, the nurse could offer to pray silently together with the patient (Casterline, 2018). Further, spiritual tools and assessments can guide nurses in identifying patients’ needs while establishing the influence and connection of spirituality to their health. Various formal formats or tools for assessment may be useful for nurses to help guide the process, such as the HOPE formatted spiritual assessment questions (Anandaraih & Hight, 2001). The initial letter H identified in this spiritual assessment tool requires a nurse to gather information specific to an individual’s source of hope, meaning, comfort, strength, peace, love, and connection to others. The letter O necessitates the nurse to inquire into any affiliation a patient may have with an organized religion. Next, questions specific to the letter P can help the nurse focus on capturing

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SECTION 1  Concepts in Nursing Practice

g s as er gr p t t e h ee w Ke orth te ig w ee irit e N Whi Y: Nter E: S der K Sp th : DA in IN El R of LO OF : W IC E: O E ON ED LIF C IM S M F d Sh T EA NT O in er a’ S LA GE : M De Sp ng P TA CE L: CO of irit ab S LA A M T I L the K i P N Sp ’h SE IME OR Ea eep A TI iri an P M A O : Y st er of t K on E PL ST LAN SO F D ello N: A w g AN S OF CO the ee A P T Y ST T E D LO W per Balance AN LAC GE ME Spr : M es AG M AS AY R IM E: OF DI ing or t E EDI ON : E : Bl C ni A ng L: Spi LIF INE PL OF CIN : A ven ack Ea rit E: : AC LI E utu ing T B g o AN E FE : S mn le ab ba ng y IM : Ph : A age cc o AL ys du no per a l h t i : B ca e ut w e d ea l a K o e t r Sh piri he S R: R oon er S f t O ern m r o OL ft m da C : A Su Ce uth n AY : : Yo io D ON NE : ot te F AS ICI IFE Em oyo O E SE ED F L E: : C M M O C L TI T E LA IMA AN TAG P AN L P S on

in at

W

any other personal spirituality and related practices used by the patient to support health and healing. Finally, E of the HOPE acronym focuses on obtaining patient input about any effect on medical care and end-of-life issues that need to be considered during care. Following any type of spirituality assessment, the nurse may also offer to contact a chaplain or a personal spiritual leader for the patient if necessary. 

ab

g

Indigenous Health Indigenous health is viewed as involving a balance of spiritual, emotional, physical, mental, and social aspects of life. To achieve this harmony with all things, maintaining this balance with oneself is a priority. Illness or disease occurs when this crucial equilibrium of life aspects is upset. Most illness is perceived as beginning in the mind; therefore, getting rid of thoughts that contribute to illness is considered key to preventing disease. Disease can also develop as a result of what has been termed soul loss, or the loss of one’s ability to be generous (Fontaine, 2019). While the term Indigenous is used to be inclusive of First Nations, Métis, and Inuit peoples in Canada, each group has a distinctly different healing system. Nonetheless, some commonalities among them can be generalized to gain a better understanding of these main principles. Medicine Wheel teachings are among the oldest of Indigenous peoples and represent the entirety of Indigenous life, which emphasizes a holistic approach to maintain balance and equilibrium. This circular wheel is specifically balanced in shape, indicating constant movement and change. Generations of various Indigenous communities have utilized divergent versions of the Four Directions in the Medicine Wheel to symbolize their interpretations of the cycles of life and specific dimensions of health. Each of these Four Directions is represented typically by a different colour, such as red, yellow, white, and black (Figure 12.4), which in some Indigenous communities symbolize various races of people in humanity. Each of the Four Directions can also signify (a) stages of life—birth, youth, adult (or elder), and death; (b) seasons of the year—spring, summer, winter, and fall; (c) aspects of life—spiritual, emotional, intellectual, and physical; (d) elements of nature—fire (or sun), air, water, and earth; (e) animals—eagle, bear, wolf, and buffalo; (f) ceremonial plants—tobacco, sweet grass, sage, and cedar; and (g) food groups—fruits and vegetables, meat and fish, wheat and breads, milk and milk products. Movement is circular and typically clockwise within the Medicine Wheel to help align it with the forces of nature, such as gravity and the rising or setting of the sun (Northern College Indigenous Council on Education,

on

Alternative medical systems are complete methods of health-­ related theory and practice that were developed outside of the Western biomedical model, often in other cultures. For some countries, these are used as their conventional health care systems. Indigenous health care practices, traditional Chinese medicine (TCM), Ayurvedic, homeopathic, and naturopathic medicine are some of the primary types of whole or alternative systems of care. Within each of these approaches, many individual complementary methods such as healing touch, massage, herbs, and prayers are used in varying combinations to promote or maintain health and treat disease. 

an

OTHER COMPLEMENTARY AND ALTERNATIVE PRACTICES Alternative Systems of Care

FIG. 12.4  The Medicine Wheel represents teaching that everything is creat-

ed equal. Source: Anishnaabe Kwewag Gamig: Alderville First Nation Women’s Shelter. (2020). Medicine Wheel. https://akgshelter.ca/medicine-­wheel/

2020). While variants in teachings and representations exist, the underlying themes remain focused on appreciating the continuing interrelatedness of all things. Four sacred medicines have been described by Indigenous peoples as including tobacco, sweetgrass, sage, and cedar. These four medicines are believed to be sacred because they are provided by the Creator, thus are used in everyday life and ceremonies. All of them can be used to smudge with, although sage, cedar, and sweetgrass also have many other uses. Traditionally, tobacco is burned to communicate with the spirits and thus is offered first to express gratitude toward the land prior to picking medicines or before requesting advice or help of Elders or healers. Tobacco is known to be the main activator of sweetgrass, sage, and cedar. Sweetgrass is usually braided, dried, or burned and is used in prayer, smudging, and purifying ceremonies to attract positive energies. Sage is medicinally stronger than sweetgrass, supporting its use for removing negative energy from homes and sacred items, and in preparing people for ceremonies or teachings. Similarly, cedar has many restorative medicinal uses and can be used in healing baths, to purify the home, or as a form of protection for sweat lodge ceremonies (Northern College Indigenous Council on Education, 2020). The healing properties of plants are acknowledged by Indigenous people. Plants such as those found in the Canadian Boreal Forest have been found to be effective for the management of chronic pain (Uprey et al., 2016). Clinical Applications of Indigenous Health Practices.  Smudging involves a process of cleansing or purifying people and sacred objects using smoke from the burning of sacred herbs, most commonly tobacco, sage, cedar, and sweetgrass in Indigenous health practices. Smoke signifies a prayer to the Creator and is often used in ceremonies or as part of a daily devotion. Negativity can be cleared and the energy field of either people or places can be restored through this form of healing (Fontaine, 2019).

CHAPTER 12  Complementary and Alternative Therapies Sweat lodge is an Indigenous sacred ceremony or ritual that purifies the body, mind, heart, and spirit. Typically, a sweat lodge occurs in a heated enclosed, dome-­ shaped covered structure with a small door flap to seal the inside from outer air and light (Fontaine, 2019). Intense heat or steam, referred to as the Breath of Spirit, is generated from pouring water onto heated rocks outside of the lodge to promote the sweating out of toxins and negative energy by individuals seated within it. A variety of herbs can be burned on these heated rocks to treat a range of ailments. Sacred songs and prayer are also used to prevent illness or bring healing. Sweat lodges can be used alone or as part of other ceremonies, each being unique depending on the purpose and context for its use (National Library of Medicine, n.d.). 

Traditional Chinese Medicine Traditional Chinese medicine (TCM) is one of the world’s oldest and most comprehensive medical systems. It has evolved over several thousand years of cultural and philosophical developments, as well as extensive clinical observation and testing. Several major concepts constitute Chinese medicine. The principle of yin and yang is a core tenet of Chinese art, philosophy, and science, as well as of TCM. Various states are associated with yin energies (feminine energy—cold, heavy, moist, negative) and yang energies (masculine energy—hot, dry, light, positive). Yin and yang are viewed as dynamic, interacting, and interdependent energies, neither of which can exist without the other, each containing some part of the other within it. These energies are a part of everything in nature and must be maintained in a harmonious state of balance to achieve optimal health. Imbalance is associated with illness. TCM modalities are used to restore balance between yin and yang energies (Fontaine, 2019). Strengths of TCM include its individualized system of diagnosis, treatment, and focus on prevention. Assessment tools include a comprehensive health history, tongue examination, and pulse examination. TCM includes an array of modalities, the most common of which are acupuncture and Chinese herbal medicine. These modalities are used together to replenish and smooth the flow of qi (pronounced “chee”) throughout the body. When yin and yang are in balance, qi, or the fundamental life force, flows evenly through the body, leading to good health. Qi is a form of energy found in all life; when it is disrupted, illness and pain can occur. Other TCM interventions include acupressure, moxibustion, cupping, Chinese massage, meditative physical exercise (e.g., tai chi and qigong), and nutrition counselling. Tai chi and qigong are slow-­movement exercises that focus on breathing (Fontaine, 2019). Clinical Applications of Traditional Chinese Medicine.  TCM has been used to treat an extensive diversity of medical conditions including respiratory, digestive, blood, urogenital, gynecological, cardiovascular, neurological, and psychiatric disorders (Di et al., 2019). Effectiveness of healing varies individually with health condition and the modality used (NCCIM, 2019).  Acupuncture Acupuncture is the primary treatment modality used by TCM practitioners. In 1983, the Chinese Medicine and Acupuncture Association of Canada was federally incorporated in order to unite TCM and acupuncture practitioners in Canada. In acupuncture, fine needles are inserted into the circulation of qi underneath the skin’s surface. The insertion points depend on

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the diagnosis and the nature of the health issue. With proper point selection and manipulation, acupuncture corrects disruptions in the flow of qi. Clinical Applications of Acupuncture.  Clinical studies have indicated that acupuncture is effective in reducing pain, fighting inflammation, accelerating wound healing, and promoting nerve regeneration (Liu et al., 2019; Swanson et al., 2015). Acupuncture is considered a safe therapy when the practitioner has been appropriately trained and uses disposable needles. Patients should review the credentials of their practitioners. 

ENERGY-­B ASED THERAPIES Energy-­based therapies are those that involve the manipulation of energy fields. They focus on energy fields originating within the body (biofields, or human energy fields) or those from other sources (electromagnetic fields). Examples of biofield therapies include therapeutic touch, healing touch, Reiki, and bioelectromagnetic, or magnet, therapy. Energy-­based therapies (see Table 12.3) are based on the theory that energy systems in the body need to be balanced and repatterned to enhance healing. Some forms of energy therapy manipulate biofields by applying pressure or manipulating the body by placing the hands in, or through, these fields.

Therapeutic Touch Therapeutic touch is a method of detecting, balancing, and repatterning the human energy field. It is a contemporary interpretation of several ancient healing practices. It involves the conscious use of the hands to direct or modulate human energy fields. Therapeutic touch was developed in the 1970s by a nurse, Dolores Krieger, and a traditional healer, Doris Kunz. According to Krieger (1997), therapeutic touch is based on the assumptions that a human being is an open energy system, a balanced flow of energy underlies good health, and illness is a reflection of an imbalance in an individual’s energy field. During the actual treatment, trained nurses or practitioners use their hands to assess the patient’s energy field for bilateral similarities or differences in the flow of energy. The practitioner then clears imbalances and smooths the patient’s energy field to promote healing and well-­being. Clinical Applications of Therapeutic Touch.  Research has been conducted on the effectiveness of therapeutic touch for a wide range of conditions, including wound healing, sleep promotion, enhancement of immune function, and reduction of anxiety, agitation, postoperative pain, tension headache, and stress. The research findings have been inconclusive, which indicates the need for further research. Specialized instruction is needed to perform therapeutic touch. Some individuals can “feel” the energy field more readily than others. However, with patience, determination, and a desire to help others, anyone (including family members) can learn to use therapeutic touch. 

AGE-­RELATED CONSIDERATIONS Older persons with non–life-­threatening, chronic conditions often use complementary and alternative therapies. For older persons, safety concerns involve herb–drug interactions or toxicity from polypharmacy and age-­related changes in pharmacokinetics (Touhy et al., 2019). Decreased renal and liver function may slow metabolism and excretion of herbs and dietary supplements. Because older patients are a more vulnerable population,

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the nurse must discuss the risks and benefits of using herbal products and also encourage patients to inform their health care provider of any herbal product or dietary supplement that they are taking. 

NURSING MANAGEMENT COMPLEMENTARY AND ALTERNATIVE THERAPIES The role of the nurse with regard to complementary and alternative therapies is evolving. Roles of the nurse may include (a) assessing patients’ use of complementary and alternative therapies, and their risk for complications or adverse interactions with conventional therapies (Table 12.7); (b) serving as a resource about complementary or alternative therapies, including teaching patients about these options, providing information about evidence concerning effectiveness, and making referrals to qualified practitioners; (c) serving as a provider of therapies for which the nurse obtains training and certification, such as therapeutic touch or acupuncture; and (d) conducting research about complementary and alternative approaches. The nurse must be able to perform these roles nonjudgementally. If patients believe they are being judged because of their use of complementary or alternative therapies, they may stop communicating and withhold this vital information from their health care providers. Collection of data on patients’ use of complementary and alternative therapies is part of a thorough nursing assessment. It is especially important because most patients do not voluntarily tell their health care provider about their use of these therapies. However, they usually share this information with a nurse when asked. Nurses must ask general, open-­ended questions, while remaining nonjudgemental and respectful of the patient’s response. Along with assessing use, the nurse needs to document the effectiveness of interventions that the patient uses.

TABLE 12.7    NURSING ASSESSMENT Complementary and Alternative Therapies . What are you doing to maintain or improve your health and well-­being? 1 2. How involved are you in planning and carrying out your health-­ related care? 3. What is your view of the ideal relationship between yourself and your primary health care provider? 4. Do you have any conditions that have not responded to conventional medicine? If so, have you tried any other approaches? 5. Are you using any vitamin, mineral, dietary, or herbal supplements or energy-­based therapies? 6. Are you interested in obtaining information about alternative or complementary approaches?

Holistic nursing practice is based on the philosophies of holism and humanism, which recognize the entire person while acknowledging the interdependence of differing facets within that whole. A holistic nurse integrates these mind–body–spirit principles into the development of caring and therapeutic relationships with patients that support healing and well-­being. With a relationship based on openness, mutuality, and equality, a holistic nurse uses several modalities to deliver care and support focused on restoring power and responsibility to patients, which in turn encourages self-­care practices (Jasemi et al., 2017). Professional nursing has historically considered holistic practice crucial to patient care. However, the influence of a Western, biomedical model rooted in curing has led to a fragmented emphasis on the physical characteristics of an individual’s health, missing essential psychological and spiritual aspects of life and well-­being. In Canada, a growing trend in the use of complementary and alternative therapies provides an ideal opportunity for nurses to return to their foundations of holistic nursing practice, which honours cultural diversity in the health and well-­being of others.

CASE STUDY Abdominal Distress Patient Profile

Discussion Questions

J. C., a 21-­year-­old university student (pronouns they/them), was seen in the student health centre for increasing episodes of abdominal fullness and discomfort with alternating diarrhea and constipation. 

. A 1  ssess what J. C. is currently doing to help alleviate their symptoms. 2. Explain the psychological stressors that may be contributing to J. C.’s abdominal discomfort. 3. Describe how J. C.’s current diet may be affecting them, both physiologically and psychologically. 4. What complementary or alternative therapy (or therapies) would be appropriate for J. C.? 5. How could the nurse recommend complementary therapies to J. C.’s physician? What arguments could support their use?

Subjective Data • Reports that irritable bowel syndrome was diagnosed several years ago • Was told to eat more fibre, drink at least eight glasses of water per day, and consume foods such as peas, prunes, and oatmeal • States they have tried to change their diet but due to a limited budget cannot afford fresh fruits and vegetables • Consumes mainly fast foods because of their busy schedule • Drinks six to eight colas per day because they do not like water • Has not been able to effectively reduce abdominal distress • Is taking a heavy course load this semester • Has to work 20 hours each week for a work–study contract 

Answers are available at http://evolve.elsevier.com/Canada/Lewis/medsurg.

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 REVIEW QUESTIONS

REFERENCES Anandarajh, G., & Hight, E. (2001). Spirituality and medical practice: Using the HOPE questions as a practical tool for spiritual assessment. American Family Physician, 63(1), 81–89. https://www.aafp. org/afp/2001/0101/p81.html Angelopoulou, E., Anagnostouli, M., Chrousos, P., et al. (2020). Massage therapy as a complementary treatment for Parkinson’s disease: A systematic literature review. Complementary Therapies in Medicine, 49, 1–8. https://doi.org/10.1016/j.ctim.2020.102340. Canadian Holistic Nurses Association (CHNA). (2021). About us. http://www.chna.ca/about-­us/. Canadian Nurses Association (CNA). (2015). Framework for the practice of registered nurses in Canada. https://www.cna-­aiic.ca/∼/media /cna/page-­content/pdf-­en/framework-­for-­the-­pracice-­of-­registered-­nurses-­in-­canada.pdf?la=en. (Seminal). Canadian Nurses Association (CNA). (2017). Code of ethics for registered nurses. https://www.cna-­aiic.ca/∼/media/cna/page-­ content/pdf-­en/code-­of-­ethics-­2017-­edition-­secure-­interactive.pdf?la=en. Casterline, G. (2018). Healing, wholeness, & connection through prayer: A guide for nurses. American Holistic Nurses Association, 1, 8–9. http://www.ahna.org/Portals/66/Docs/Education/Provider/Be ginnings/Articles/Beginnings_CNE_2018_issue_1.pdf?ver=2018-­ 02-­19-­145220-­550. Charlebois, S., Music, J., Sterling, B., et al. (2020). Edibles and Canadian consumers’ willingness to consider recreational cannabis in food or beverage products: A second assessment. Trends in Food Science and Technology, 98, 25–29. https://doi.org/10.1016/j. tifs.2019.12.025. College & Association of Registered Nurses of Alberta. (2018). Complementary and alternative health care and natural health products standards. https://www.nurses.ab.ca/docs/defau lt-­source/document-­library/standards/complementary-­and-­ alternative-­health-­care-­and-­natural-­health-­products.pdf?sfvrsn=2 480176b_34.

e. Holistic nursing incorporates mind–body–spirit principles. 4. Which of the following clients is most likely to benefit from treatment by a traditional Chinese medicine practitioner? a. A client with pneumonia b. A client with mental illness c. A client with chronic back pain d. A postoperative client with low blood pressure 5. Which of the following best describes the role of the nurse involved with complementary and alternative therapies? a. Caring for clients rather than caring for self b. Prescribing the appropriate herbal therapies for a client c. Serving as a resource to guide clients in the safe use of therapies d. Advocating for use of complementary and alternative therapies instead of conventional health care 1. d; 2. c, d, e; 3. c, e; 4. c; 5. c.

The number of the question corresponds to the same-­numbered objective at the beginning of the chapter. 1. Which of the following statements best describes complementary and alternative therapies? a. They are used as a primary form of treatment. b. They contradict the values of nursing. c. They are based on extensive scientific research. d. They were developed outside the Western biomedical model. 2. Which herbs can increase a client’s risk of bleeding? (Select all that apply.) a. Aloe b. Kava c. Garlic d. Ginger e. Feverfew 3. Which of the following statements describes holistic nursing? (Select all that apply.) a. Holistic nursing focuses on physical health. b. Holistic nursing is practised only by experienced nurses. c. Holistic nursing promotes self-­care and self-­responsibility. d. Holistic nursing is based on the biomedical model of health care.

For even more review questions, visit http://evolve.elsevier.com/Canada/ Lewis/medsurg.

College of Nurses of Ontario (CNO). (2018). Complementary therapies. http://www.cno.org/en/learn-­about-­standards-­ guidelines/educational-­tools/ask-­practice/complementary­therapies/. Di, Y. M., Yang, L., Shergis, J. L., et al. (2019). Clinical evidence of Chinese medicine therapies for depression in women during perimenopause and menopause. Complementary Therapies in Medicine, 79, 1–9. https://doi.org/10.1016/j.ctim.2019.03.019. Esmail, N. (2017). Complementary and alternative medicine: Use and public attitudes 1997, 2006, and 2016. https://www.fraserinstitute. org/sites/default/files/complementary-­and-­alternative-­medicine-­ 2017.pdf. Fontaine, K. L. (2019). Complementary and alternative therapies for nursing (5th ed.). Pearson Education. Gonçalves, J. P. B., Lucchetti, G., Menezes, P. R., et al. (2015). Religious and spiritual interventions in mental health care: A systematic review and meta-­analysis of randomized controlled clinical trials. Psychological Medicine, 45, 2937–2949. https://doi.org/10.1017/ S0033291715001166 (Seminal). Health Canada. (2021a). Health effects of cannabis. https://www.canada.ca/en/health-­canada/services/drugs-­ medication/cannabis/health-­effects/effects.html. Health Canada. (2021b). Information on homeopathic products. https://www.canada.ca/en/health-­canada/services/drugs-­health-­ products/natural-­non-­prescription/regulation/information-­ homeopathic-­products.html. (Seminal). Interdisciplinary Network for Complementary and Alternative Medicine Research (INCAM). (2021). About the Interdisciplinary Network for Complementary and Alternative Medicine Research. www.iscmr.org/content.aspx?page_id=22&club_id=869917&modu le_id=477001. (Seminal). Jasemi, M., Valizadeh, L., Zamanzadeh, V., et al. (2017). A concept analysis of holistic care by hybrid model. Indian Journal of Palliative Care, 23(1), 71–80. https://doi.org/10.4103/0973­1075.197960.

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Krieger, D. (1997). Therapeutic touch inner workbook: Ventures in transpersonal healing. Santa Fe, NM: Bear (Seminal). Liu, F., You, J., Li, Q., et al. (2019). Acupuncture for chronic pain-­ related insomnia: A systematic review and meta-­analysis. Evidence-­Based Complementary and Alternative Medicine, 1–10. https://doi.org/10.1155/2019/5381028. Luctkar-­Flude, M., Tyerman, J., & Groll, D. (2019). Exploring the use of neurofeedback by cancer survivors: Results of interviews with neurofeedback providers and clients. Asia-­Pacific Journal of Oncology Nursing, 6(1), 35–42. https://doi.org/10.4103/apjon. apjon_34_18. Mahmodi, Z., & Sayemiri, K. (2018). The effect of attitude and prayer-­ related behaviours on depression: A systematic review. International Journal of Epidemiologic Research, 5(1), 34–39. https://doi. org/10.15171/ijer.2018.08. National Center for Complementary and Integrative Health. (2019). Traditional Chinese medicine: What you need to know. https://nccih .nih.gov/health/whatiscam/chinesemed.htm. National Center for Complementary and Integrative Health. (2021). Complementary, alternative, or integrative health. What’s in a name?. https://nccih.nih.gov/health/integrative-­health. National Library of Medicine. (n.d.). Medicine ways: Traditional healers and healing. https://www.nlm.nih.gov/nativevoices/exhibition/ healing-­ways/medicine-­ways/medicine-­wheel.html. Northern College Indigenous Council on Education. (2020). Four sacred medicines. http://www.northernc.on.ca/indigenous/four-­ sacred-­medicines/. Prado Simão, T., Caldeira, S., & Campos de Carvalho, E. (2016). The effect of prayer on patients’ health: Systematic literature review. Religions, 7, 1–11 https://doi.org/10.3390/rel7010011 (Seminal). Pratt, M., Stevens, A., Thuku, M., et al. (2019). Benefits and harms of medical cannabis: A scoping review of systematic reviews. Systematic Reviews, 8(320), 1–35. https://doi.org/10.1186/s13643019-1243-x. Swanson, B., Keithley, J. K., Johnson, A., et al. (2015). Acupuncture to reduce HIV-­associated inflammation. Evidence-­based Complementary and Alternative Medicine, 5, 1–6 https://doi. org/10.1155/2015/908538 (Seminal work). Touhy, T. A., Jett, K. F., Boscart, B., et al. (2019). Ebersole and Hess’ gerontological nursing and healthy aging (2nd Canadian ed.). Toronto: Elsevier. Uprety, Y., Lacasse, A., & Asselin, H. (2016). Traditional uses of medical plants from the Canadian Boreal Forest for the management of chronic pain syndromes. Pain Practice, 16(54), 459–466. https:// doi.org/10.11111/paper.12284.

Yeun, Y. (2017). Effectiveness of massage therapy for shoulder pain: A systematic review and meta-­analysis. The Journal of Physical Therapy Science, 29(2), 365–369 https://doi.org/10.1589/ jptd.29.365 (Seminal).

RESOURCES Acupuncture Canada https://www.acupuncturecanada.org Canadian Association for Parish Nursing Ministry http://www.capnm.ca Canadian Association of Naturopathic Doctors (CAND) http://www.naturopathicassoc.ca Canadian Chiropractic Association http://www.ccachiro.org Canadian Holistic Nurses Association https://www.chna.ca Canadian Indigenous Nurses Association http://indigenousnurses.ca/ Canadian Interdisciplinary Network for Complementary and Alternative Medicine Research (INCAM) https://iscmr.org/content.aspx?page_id=22&club_id=869917&mo dule_id=372144 Chinese Medicine and Acupuncture Association of Canada http://www.cmaac.ca/public/tcm-­regulation-­in-­canada College of Traditional Chinese Medicine & Pharmacology Canada https://www.ctcmpc.ca Healing Touch Canada https://www.healingtouchcanada.net Massage.ca http://massage.ca/professional_development.html Natural Health Practitioners of Canada https://www.nhpcanada.org Registered Nurses’ Association of Ontario (RNAO) Complementary Therapies Nurses’ Interest Group (CTNIG) http://www.rnao-­ctnig.org Healing Beyond Borders https://www.healingbeyondborders.org National Center for Complementary and Integrative Health (NCCIH) https://nccih.nih.gov For additional Internet resources, see the website for this book at http://evolve.elsevier.com/Canada/Lewis/medsurg.

CHAPTER

13

Palliative and End-­of-­Life Care Sara Olivier, Kathryn Nichol, and Laura Wilding  Originating US chapter by Denise M. McEnroe-­Petitte

WEBSITE • • • •

http://evolve.elsevier.com/Canada/Lewis/medsurg • R  eview Questions (Online Only) • Key Points • Student Case Study

 hronic Myelogenous Leukemia Including End-­of-­Life Care C Conceptual Care Map Creator Audio Glossary Content Updates

LEARNING OBJECTIVES . Describe the philosophy of a palliative approach to care. 1 2. Describe nursing management of common physical manifestations at the end of life. 3. Describe nursing management of common psychosocial manifestations at the end of life. 4. Explain the process of grief and bereavement. 5. Discuss variables that affect end-­of-­life care.

. Discuss key ethical and legal issues related to hospice palliative care. 6 7. Explore the special needs of family caregivers of a dying patient. 8. Discuss the special needs of nurses who care for dying patients and their families. 9. Understand medical assistance in dying as an end-­of-­life option.

KEY TERMS advance care planning advance directives bereavement certification of death Cheyne-­Stokes respiration

  

death end-­of-­life care grief hospice palliative care integrated palliative approach

HOSPICE PALLIATIVE CARE The World Health Organization (WHO) describes palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with a life-­ threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (WHO, 2021). Specific goals of palliative care are listed in Table 13.1. In Canada, the term hospice palliative care describes the convergence of hospice and palliative care into one movement that has the same principles of practice and that continues to evolve in an effort to reflect changes in people’s experience with illness and dying (Canadian Hospice Palliative Care Association [CHPCA], 2013a). A national strategy promotes standardization and consistency through a shared vision for the delivery of care and for the organizational development,

Medical Assistance in Dying (MAiD) pronouncement of death spirituality

education, and advocacy relating to hospice palliative care across the country (CHPCA, 2013b). Advances in medical treatments have helped people live longer with chronic illnesses. The course of an illness and timing of death are becoming harder to predict as more treatments become available to extend life. Hospice palliative care is available to individuals and families throughout the illness experience. At the beginning of the illness, there is increased focus on treatment and management. Over time, as illness progresses, the role for a palliative approach to care increases to relieve suffering and improve quality of life. Over the course of an illness, the patient’s and family’s concerns, their goals of care, and treatment priorities should always be taken into consideration (CHPCA, 2013b) (Figure 13.1). Chochinov’s model of dignity-­ conserving care can be used to guide care that specifically targets the maintenance of dignity for those nearing the end of life (Chochinov, 2002).

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TABLE 13.1    GOALS OF PALLIATIVE CARE • Provide relief from symptoms, including pain • Regard dying as a normal process • Affirm life and neither hasten nor postpone death • Support holistic patient care and enhance quality of life • Offer support to patients to live as actively as possible until death • Offer support to the family during the patient’s illness and in their own bereavement Source: Reprinted from Cancer, WHO, WHO Definition of Palliative Care, Copyright 2018.

Therapy to modify disease

Focus of care

Presentation/ diagnosis Illness Acute

Hospice palliative care Therapy to relieve suffering and/or improve quality of life

Patient’s death

Time Chronic

Advanced Life-threatening Bereavement

End-of life care FIG. 13.1  The role of hospice palliative care during illness. Source: Ca-

nadian Hospice Palliative Care Association. (2013). A model to guide hospice palliative care. Canadian Hospice Palliative Care Association. https://www.chpca.ca/wp-content/uploads/2019/12/norms-of-practice-engweb.pdf

Integrated Hospice Palliative Care Approach The Canada Health Act (1984) is the overarching legislation covering Canada’s national medicare program (Madore, 2005). This publicly funded health care system is administered on a provincial or territorial basis; however, developing an integrated palliative approach to care is a priority for Canada (CHPCA, 2013b). In an effort to develop a national standard of palliative care, the CHPCA has produced “The Way Forward” as a national vision (CHPCA, 2013b) (Table 13.2). Hospice palliative care is best provided as an integral part of health care and should be available in all settings of care, including acute and long-­ term care facilities, retirement homes, private residences, hospices, palliative care units, and shelters (Quality End-­of-­Life Care Coalition of Canada [QELCCC], 2010). An integrated palliative approach to care focuses on meeting a patient’s and family’s full range of needs—physical, psychosocial, and spiritual—at all stages of illness, not just at the end of life. It is a shared-­care model—one that shifts hospice palliative care from being a specialized service to a more generalized, integrated service available to people with life-­limiting conditions, regardless of where they live and receive care (CHPCA, 2013b). Health care providers—physicians, nurses, home care nurses, personal support workers, long-­term care staff, and hospital staff—continue to provide care with support of the expert palliative care team. The expert palliative care team takes the lead only when a patient’s and family’s needs become increasingly complex and require specialized care (CHPCA, 2015). The Edmonton Symptom Assessment System (ESAS) (Hui & Bruera, 2017) and Palliative Performance Scale (PPS) (see Resources at the end of this chapter) are standardized tools that support comprehensive assessments and ensure consistent language when providing care and communicating within the health care team.

TABLE 13.2    SUCCESS FACTORS FOR AN

INTEGRATED PALLIATIVE APPROACH TO CARE

Vision • Commitment to person-­centred care • Focus on building capacity in the community • Focus on changing organizational structure • Senior management support

People • Dedicated coordinators • Interprofessional teams • Strong role of and more support for family physicians • Support for health care providers in long-­term care facilities • Key roles for nurses • Relationships, partnerships, and networks

Delivery of Care • Integration of primary, secondary, and tertiary care • Cultural sensitivity • Single access point and case management • Around-­the-­clock community support and care • Advance care planning

Supportive Tools • Common frameworks, standards, and assessment tools • Flexible approaches to education • Shared records • Research, evaluation, and quality improvement Source: Canadian Hospice Palliative Care Association (CHPCA). (2013). Innovative models of integrated hospice palliative care. The Way Forward Initiative: An integrated palliative approach to care. http://www.hpcintegration.ca/media/40546/T WF-­innovative-­models-­report-­Eng-­webfinal-­2.pdf

End-­of-­Life Care.  End-­of-­life care refers to care provided during the last months, weeks, and days for a person with a life-­limiting illness. In June 2000, the Senate of Canada issued a report, “Quality End-­of Life Care: The Right of Every Canadian” (Carstairs, 2000), containing recommendations ensuring access to high-­ quality end-­of-­life care for all Canadians. The QELCCC (2012) supported these recommendations safeguarding the rights of Canadians “to die with dignity, free of pain, and surrounded by their loved ones, in a setting of their choice.” Despite these efforts, well-­documented gaps remain between the end-­of-­life care that Canadians prefer and the care that they receive (Conlon et al., 2019). Seriously ill individuals in hospitals and their family members have identified the following features of quality end-­of-­life care: trust in the treating physician, avoidance of unwanted life support, effective communication, continuity of care, and death with dignity (Cook et al., 2013). While most Canadians (75%) state they would prefer to die at home, they also report feeling they would not be able to devote the time required to care for a loved one in a home setting (CHPCA, 2013a). In Canada, caregiver benefits are now available to financially support most individuals who wish to take time away from work to provide care and support a person needing end-­of-­life care (Government of Canada, 2021). In some cases, the needs of a patient and their family exceed the resources that can be provided in the home, resulting in admission to hospital at the end of life. Residential hospices and palliative care units are alternative settings for patients who are unable to remain at home for the end of their life but do not require an acute-care setting.  

PHYSICAL MANIFESTATIONS OF THE END OF LIFE During the dying process metabolism is altered and body systems gradually slow down until they no longer function.

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TABLE 13.3    PHYSICAL MANIFESTATIONS OF APPROACHING DEATH System Sensory system • Hearing • Taste and smell • Sight

Cardiovascular system

Respiratory system

Urinary system

Manifestations • Usually last sense to disappear • Decreased with disease progression • Blurring of vision • Sinking and glazing of eyes • Blink reflex absent • Eyelids may remain half open • Increased heart rate; later slowing and weakening of pulse • Irregular rhythm • Decrease in blood pressure • Delayed absorption of drugs administered subcutaneously • Peripheral edema • Increased respiratory rate • Cheyne-­Stokes respiration (irregular pattern of respiration characterized by alternating periods of apnea and deep breathing) • Inability to cough or clear upper airway secretions, which results in gurgling, noisy, or congested breathing (terminal secretions) • Irregular breathing, gradually slowing down to terminal gasps (may be described as “guppy breathing”) • Gradual decrease in urinary output • Incontinent of urine • Inability to urinate

Respiratory changes are common. Breath sounds may become wet and noisy, both audibly and on auscultation. These terminal secretions are caused by mouth breathing and accumulation of mucus in the airways that cannot to be cleared by coughing or repositioning. Cheyne-­Stokes respiration is an irregular pattern of breathing characterized by alternating periods of apnea and deep breathing. Dying is a multisystem process that can exhibit a variety of manifestations. Presentation of these changes may vary depending on the comorbidities of the individual. Physical manifestations of approaching death are listed in Table 13.3. Identification and explanation of these changes by the nurse is key in supporting patients and families through the dying process.

Death Death occurs when all vital organs and body systems cease to function. It is the irreversible cessation of cardiovascular, respiratory, and brain function. When circulation and breathing stop and no attempts are made to restore circulation, after approximately 2 to 5 minutes, cessation of breathing and circulation is permanent and the individual may be determined to be dead. 

PSYCHOSOCIAL MANIFESTATIONS OF THE END OF LIFE A variety of feelings and emotions can affect the patient and family at the end of life. They may experience a wide range of emotions and reactions (Table 13.4). Many people struggle with the news of a terminal diagnosis and the realization that there is no cure or further treatment options. The patient and family may feel overwhelmed, fearful, powerless, and fatigued.

System

Manifestations

Gastrointestinal (GI) system

• Loss of appetite and thirst sensations • Slowing or cessation of GI function (opioid medications may contribute to slowed GI transit) • Accumulation of gas and abdominal distension • Nausea • Loss of sphincter control, which may cause incontinence • Bowel movement before imminent death or at time of death • Increasing weakness • Gradual loss of ability to move • Sagging of jaw as a result of loss of facial muscle tone • Difficulty speaking • Difficulty swallowing • Difficulty maintaining body posture and alignment • Loss of gag reflex • Mottling of hands, feet, arms, and legs • Cold, clammy skin • Cyanosis of nose, nail beds, and knees • “Waxlike” skin when death is very near

Musculoskeletal system

Integumentary system

TABLE 13.4    PSYCHOSOCIAL MANIFESTATIONS

OF APPROACHING DEATH

• Altered decision making • Anxiety about unfinished business • Decreased socialization • Fear of loneliness • Fear of meaninglessness of one’s life • Fear of pain

• Helplessness • Life review • Peacefulness • Restlessness • Saying goodbyes • Unusual communication • Vision-­like experiences • Withdrawal

Alternatively, there may be feelings of peace and acceptance if closure has been achieved. A patient-­centered approach to understand and support the psychosocial needs of the patient and their family is essential. 

GRIEF AND BEREAVEMENT Bereavement refers to the state of loss, and grief refers to the reaction to loss, although the terms are often used interchangeably. Grief is a normal reaction to loss and may manifest itself in both psychological and physiological ways. It is a powerful emotional state affecting all aspects of a person’s life. Psychological responses may include anger, guilt, anxiety, sadness, depression, despair, or a combination of these. Physiological reactions may include disruption in sleep, changes in appetite, and illness. Elisabeth Kübler-­Ross (1969) was a pioneer in the recognition and description of grief. In her model of grief, she described five stages observed in people who were grieving,

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TABLE 13.5    KÜBLER-­ROSS’S MODEL OF GRIEF Stage Denial

Anger

No, not me. It cannot be true.

Why me?

Bargaining

Yes, me, but…

Depression

Yes, me, and I am sad.

Acceptance

Worden’s tasks of mourning

What a Person May Say Characteristics

Yes, me, but it is okay.

Denying the loss has taken place and possibly withdrawing. This response may last minutes to months. Possibly being angry at the person who inflicted the hurt (even after death) or at the world for letting it happen. Possibly being angry with self for letting an event (e.g., car accident) take place, even if nothing could have stopped it. Making bargains with God, asking, “If I do this, will you take away the loss?” Feeling numb, although anger and sadness may remain subconsciously. Tapering off of anger, sadness, and mourning; accepting the reality of the loss.

Source: From On Death and Dying, by Dr. Elisabeth Kubler-­Ross. Copyright © 1969 by Elisabeth Kubler-­Ross; copyright renewed © 1997 by Elisabeth Kubler-­Ross. Reprinted with the permission of Scribner, a division of Simon & Schuster, Inc. All rights reserved.

but also acknowledged hope interwoven in the experience and suggested that some meaning can be taken from the experience (Table 13.5). As other theorists built on this work, they realized that the stages are not linear. Indeed, not every person experiences all the stages of grieving. It is not uncommon to reach a stage and then revert to an earlier stage. William Worden further developed Kübler-­Ross’s work and began talking about “grief work.” He developed a counselling model to assist people in the work of grief. Worden’s (2009) model outlines “four tasks of mourning” that must be accomplished in grief work (Figure 13.2). The way a person grieves depends on factors such as the relationship with the person who has died (e.g., spouse, parent), physical and emotional coping resources, concurrent life stresses, cultural beliefs, and personality. Other factors that affect the grief response include mental and physical health, economic resources, religious influences or spiritual beliefs, family relationships, social support, and time spent preparing for the death. Anticipatory grief is a form of grieving that takes place before the actual death. Patients nearing the end of life, as well as their family, may experience anticipatory grief. As a patient approaches the end of life, it is common for loved ones to begin to think of what life will be like when the person has died. The extent to which they have explored and experienced anticipatory grief has an influence on their grief after the actual death (National Cancer Institute, 2020). Working in a positive way through the grief process helps to adapt to the loss. Grief that helps the person accept the reality of death is called adaptive grief. It is a healthy response. It may be associated with grieving before death occurs or when the inevitability of the death is known. Indicators of adaptive grief include the ability to see some good resulting from the death and positive memories of the deceased person.

Task #1 To accept the reality of the loss

Task #2 To work through the pain of grief

Task #3

To find an enduring connection with the deceased while embarking on a new life

To adjust to an environment in which the deceased is missing

Task #4

FIG. 13.2  Worden’s tasks of mourning. Source: Worden, J. W. (2009). Grief

counselling and grief therapy: A handbook for the mental health practitioner. http://www.whatsyourgrief.com/wordens-­four-­tasks-­of-­mourning/

Dysfunctional reactions to loss can occur, and the physical and psychological impact of the loved one’s death may persist for years. Prolonged grief disorder, formerly called complicated grief, is a term used to describe prolonged and intense mourning. Prolonged grief disorder can include symptoms such as recurrent and severe distressing emotions and intrusive thoughts related to the loss of a loved one, self-­neglect, and denial of the loss for longer than 6 months. It is estimated that 1 out of 10 bereaved adults is at risk for prolonged grief disorder (Lundorff et  al., 2017). Those with prolonged grief disorder have a higher risk for illness and may have work and social impairments. Bereavement is the period after the death of a loved one during which grief is experienced and mourning occurs. The time spent in bereavement depends on a number of factors, including cultural norms, the nature of the relationship with the deceased person, and the degree to which the surviving person was able to prepare for the loss before death. Bereavement and grief counselling are core components of patient­and family-­ centered hospice palliative care. Bereavement programs offer support to assist a loved one’s transition to a life without the deceased person. An environment in which patients and families can share feelings of anger, sadness, and fear supports individuals as they work through the grieving process. 

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SPIRITUAL NEEDS

TABLE 13.6    SPIRITUAL ASSESSMENT

Assessment of spiritual needs in end-­of-­life care is a key consideration (Table 13.6). Spirituality is defined as the beliefs, values, and practices that relate to the search for existential meaning and purpose (O’Brien, 2018). Spiritual needs do not necessarily equate to religion or belief in a higher power. A person may not be part of a particular religion but may be deeply spiritual. The nurse needs to assess the patient’s and family’s preferences regarding spiritual guidance or pastoral care services and make appropriate referrals. Deep-­seated spiritual beliefs may surface for some patients when they deal with their progressing illness and related issues. Spiritual distress may arise as they question their beliefs about a higher power, their journey through life, religion, and existence of an afterlife. Characteristics of spiritual distress may include anger toward God or a higher being, change in behaviour and mood, desire for spiritual assistance, or displaced anger toward clergy (Caldeira et al., 2013). A sense of spirituality has also been associated with decreased despair in patients at the end of life. Some dying patients are secure in their faith about the future. It is common to see patients relinquish material possessions of life and focus on values that they believe will lead them on to another place. Many turn to religion because it gives order to the world even in the presence of physical decline, social losses, suffering, and impending death. Religion may offer an existential meaning that provides a sense of peace and recognition of one’s place in the broader cosmic context (O’Brien, 2018). 

1. Who or what provides you strength and hope? 2. Do you use prayer in your life? 3. How do you express spirituality? 4. How would you describe your philosophy of life? 5. What type of spiritual or religious support do you desire? 6. What is the name of your clergy, minister, chaplain, pastor, rabbi? 7. What does suffering mean to you? 8. What does dying mean to you? 9. What are your spiritual goals? 10. Is there a role of a church, synagogue, mosque, or temple in your life? 11. Has belief in God been important in your life? 12. How does your faith help you cope with illness? 13. How do you keep going day after day? 14. What helps you get through this health care experience? 15. How has illness affected you and your family?

CULTURALLY COMPETENT CARE At the End of Life Although death is universal, the ways in which people understand and experience death vary across cultures. Variations in rituals within cultural groups, religious faiths, and individuals are reminders of the importance of not overgeneralizing culturally attributed qualities. Some cultural and religious experiences and expressions of death are subdued and intensely private, whereas for others the experience may involve their entire community and be a very public affair with public expressions of grief. Some cultures shield or protect the dying from information about their illness. Effective nurses seek to understand the cultural or religious practices and attitudes toward end-­of-­life care and death that are specific to each patient (Ganz & Sapir, 2019). This understanding should also include practices or rituals concerning the care of the body upon and immediately after death, including accommodations regarding the patient’s language, diet, and cultural beliefs and practices. Families with non–English-­speaking members are at risk for receiving less information about their family member’s illness and prognosis (Hagerty et al., 2016). When appropriate, the nurse should access interpreter services so that the patient’s wishes are known. In Canada the Indigenous population consists of First Nations, Inuit, and Métis peoples. Leaders within these groups have expressed the importance of culturally appropriate palliative care for their communities (Health Canada, 2019). Ongoing work of Health Canada and national Indigenous organizations is focused on developing a palliative care framework that reflects the specific and unique priorities of Indigenous people.

Source: © Joint Commission Resources: Provision of Care, Treatment, and Services (PC) (Critical Access Hospitals/Critical Access Hospitals). Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, 2018. Reprinted with permission.

In an effort to increase access of Indigenous communities to health care services, Indigenous navigator programs have been developed throughout Canada to support patients and their families navigate the health care system, remove barriers, and increase cultural sensitivity among health care providers. The role of extended family, family gatherings, community leaders, healers, and medicine men and women within Indigenous culture should be explored and integrated into care. Furthermore, it is important to understand the connection to the spirit world, to ceremony, and to sacred ceremonial items such as feathers, tobacco, sweet grass, cloth, and stones and how these elements can be respectfully incorporated into a patient’s plan of care (Hampton et al., 2010). (Further considerations around culturally competent care are discussed in Chapter 2.) 

LEGAL AND ETHICAL ISSUES AFFECTING END-­O F-­L IFE CARE Patients and families struggle with many questions related to a life-­limiting illness and the dying experience. Many people decide that the outcomes for their care should be based on their own wishes and values. It is important to provide information to help patients with these decisions. The decisions may involve the choice for (1) organ and tissue donations, (2) advance directives (e.g., medical power of attorney), (3) resuscitation, and (4) medical assistance in dying. Throughout the COVID-­19 pandemic, care settings were required to restrict visitors in order to maintain the safety of patients and staff. This practice brought to light the need for care settings to consider the effects of social isolation on dying patients and to implement safe, compassionate, and inclusive visitation policies allowing those nearing the end of life to say goodbye to their loved ones (CHPCA, 2020).

Advance Care Planning and Advance Directives Legislation pertaining to advance care planning (ACP) in Canada is specific to each province or territory. However, the principles underlying ACP are common across the country: the intrinsic value and uniqueness of each person, the person’s right to self-­determination, and autonomous decision making.

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ETHICAL DILEMMAS

TABLE 13.7    DEVELOPING AN ADVANCE CARE

PLAN

End-­of-­Life Care Case Study R. S. (pronouns she/her) is a 50-­year-­old person with metastatic breast cancer. She has developed severe bone pain that is not adequately controlled by her current dosage of intravenous (IV) morphine. She moans at rest and verbalizes severe pain from any movement to reposition her. Even though she appears to sleep at intervals, R. S. requests pain medicine frequently, and her family is demanding additional pain medicine for her. At the interprofessional team conference, the nurses discuss the need for more effective pain control but are concerned that additional medications could hasten her death. 

Important Points for Consideration • A  dequate pain relief is an important outcome for all patients, but especially for patients at the end of life. The principle of beneficence imposes the obligation to provide the necessary care to benefit the patient. • One goal of treatment is to provide adequate pain and symptom management to alleviate suffering. This goal is based on the principle of nonmaleficence: preventing or reducing harm to the patient. The concern of hastening death should be acknowledged. However, the intent behind adequate management of refractory symptoms is to control the suffering and is a nurse’s ethical obligation. • Adequate pain relief at the end of life continues to be a major concern of health care providers and patients and their families. • Opportunities for debriefing should be offered to alleviate the potential moral distress of the nurses. 

Clinical Decision-­Making Questions 1. In R. S.’s situation, what type of discussion needs to occur between the health care team, the patient, and the family as the terminally ill phase of the care approaches? 2. Distinguish between palliative sedation and medical assistance in dying, and the promotion of comfort and relief of pain in dying patients.

Health care providers should always speak with patients about their wishes for care and treatment. The intent of an advance care plan is that when the patient is no longer able to give direction or consent, the patient’s substitute decision maker (SDM) or advance care plan, or both, will ensure that the patient’s wishes are known. Each province and territory has legislation outlining who may be designated an SDM. Advance care planning is the process of thinking about and sharing one’s wishes for future health and personal care. It is a means by which an individual can tell others what would be important if they were ill and unable to communicate. An individual may choose an SDM and identify this person through a written document such as a power of attorney (or similar document). An individual may express their wishes or directions as generally or specifically as they wish through an advance care plan (formerly known as a living will). When advance directives—legal documents specifying an individual’s decisions regarding care—are written, they should be made available to the health care providers and the SDM. The CHPCA has led a national initiative promoting and educating the general public and health care providers on the importance of ACP. The CHPCA website lists a variety of tools, workbooks, and other information regarding ACP (see Resources section at the end of this chapter). In all cases, an SDM must act on a patient’s prior expressed wishes, if known, and in a manner that would be consistent with what the patient would have done when capable.

Steps

Important Considerations

Learn about your condition and medical treatment: Some may improve your quality of life, whereas others may only keep you alive longer. Think about you: What are your values, wishes, beliefs, and understanding about your care and specific medical treatments? Talk about your wishes: It is important to discuss your wishes with your loved ones, your family physician, and your health care team. Choose a substitute decision maker: Choose someone who would honour and follow your wishes if you cannot speak for yourself. Record your wishes: It is a good idea to write down or make a recording of your wishes. Give a copy to your health care provider and substitute decision maker.

• What makes each day worthwhile? • What makes you happy? • How do your decisions about your illness, your care, and your treatment affect your loved ones? Does this change the way you feel about treatment? • Do you have fears or worries regarding your treatment? • Do you have a preference regarding location of care (for example, at home, in a health care institution) if your condition gets worse? • Is there anything that feels “undone” about your life? • Whom can you rely on to help you through any challenges? • Do your religious, cultural, or personal beliefs affect your decisions?

Source: Based on Advance Care Planning National Task Group. (2015). Five steps of advance care planning (Speak Up campaign video). https://www.youtube.com/watc h?v=mPtu-­FpY1Kw

Nurses play an important role in educating individuals about their health condition and helping them understand the information they have been given. Patients are encouraged to consider this information in the development of an advance care plan (Table 13.7). 

Resuscitation Do-­not-­resuscitate (DNR) decisions are unique instructions that have developed in acute care hospitals since the 1970s. Because cardiopulmonary resuscitation (CPR) is the default response to respiratory or cardiac arrest, a DNR decision requires informed consent (Bester & Kodish, 2019). This is a very specific example of an event that can often be anticipated and addressed in an advance care directive. A physician’s DNR order is required and should be specific enough to reflect the patient’s expressed wishes, whether through direct discussion with the patient, through the advance directive, or from the patient’s SDM. Physicians can reflect this understanding of the patient’s wishes with written orders for care that focus on comfort, meaning that treatments associated with pain and symptom management are carried out, but the natural physiological progression to death is not delayed or interrupted. Allow natural death (AND) is a term increasingly being used to replace DNR. The use of this type of language means that care is not withheld but rather is supportive while allowing nature to take its course. It is meant to promote comfort and dignity at the end of life. Templates such as the “Goals of Care Designations” from Alberta Health Services are designed to facilitate conversations and documentation of an individual’s values and wishes regarding medical care, resuscitative care, and comfort care that is valid across the entire province in all care settings (see Resources section at the end of this chapter).

CHAPTER 13  Palliative and End-of-Life Care Medical Assistance in Dying.  Medical Assistance in Dying (MAiD), legal in Canada since June 2016, involves prescribing or administering medications to intentionally end the life of an adult, at their request. In Canada, federal legislation—Bill C-­14— governs who is eligible and the processes under which MAiD can be legally and safely delivered to a patient (Government of Canada, 2016). Specifically, adults who have a serious and incurable illness, disease, or disability; who are in an advanced state of irreversible decline in capability; whose illness, disease, or disability causes them to endure suffering that is intolerable to them and that cannot be relieved under conditions they find acceptable; and whose natural death has become reasonably foreseeable may be eligible to receive MAiD (Government of Canada, 2016). Both nurse practitioners and physicians can assess and provide MAiD in Canada. In order to pursue MAiD, people must be informed of their treatment options, including palliative care, and must make a written request for MAiD that is witnessed by two independent witnesses who meet specific criteria. Mandatory reporting to Health Canada provides oversight of this practice (Government of Canada, 2018). Each province and territory is accountable for the service delivery model of MAiD, which varies considerably across Canada. It is imperative that nurses follow the professional policies and standards for the jurisdiction where they practice. The choice to pursue MAiD is personal and complex. Psychosocial support for the person, their loved ones, as well as for the health care providers involved in the care of the person is paramount. MAiD-­specific grief and bereavement resources may support a positive experience for the patient and family, while mentorship and resiliency resources have been identified as essential components for the wellness of health care providers (Li et al., 2017). The introduction of Bill C-­7, in February 2020, proposed further changes to Canada’s law on MAiD (Government of Canada, 2020). However, MAiD remains inaccessible to those under the age of 18 years, to those whose sole underlying medical condition is mental illness, or through an advanced directive. 

Palliative Sedation MAiD should not be confused with palliative sedation. Palliative sedation is an infrequent and extraordinary intervention that necessitates interprofessional expertise. Rigorous guidelines are strictly followed to intentionally produce sedation in the last days of a patient’s life (Alberta Health Services, 2018) and where the intent is to control refractory symptoms and suffering, not to shorten life or to hasten death (Abarshi et al., 2014). Promoting the relief of suffering is a nurse’s ethical obligation, and it may include appropriate administration of medications that have the potential to cause sedation. The principle of double effect justifies the use of medications that cause sedation as an adverse effect—an unintended harm—as its primary role is to relieve suffering and is not intended to hasten death. Careful titration of medication, which is based on the patient’s response, can improve the likelihood that the patient will receive appropriate doses of medications to manage symptoms and minimize adverse effects. The use of opioids for symptom management at the end of life is often misunderstood and feared by patients, families, and some health care providers. For this reason, many patients do not receive adequate medication, which may lead to physical and emotional suffering from uncontrolled pain and symptoms. This presents an opportunity for the nurse to educate the patient and family and address concerns about physical dependence

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and tolerance of medications. Patients at the end of life should not be concerned with physical dependence when the goal of treatment is comfort until death. (Pain management is discussed in Chapter 10.) 

Organ and Tissue Donation In Canada, oversight and administration of health services, including organ donation, are the responsibility of provincial and territorial governments. Deceased donor services are managed by organ procurement organizations and living donor services are managed by individual hospitals. All people who are 16 years of age or older and are competent may choose organ and tissue donation. Only patients who have sustained a nonrecoverable injury and are on life support may donate organs. However, all patients have the potential to donate tissue (e.g., eyes, bones, heart valves, and skin) after death (Ontario Trillium Gift of Life Network, n.d.). Patients who choose MAiD may also be considered for organ and tissue donation. Nurses should be aware of ethical and legal issues and the patient’s wishes. Advance directives and organ donor information should be in the patient’s medical record and identified on that record or in the nursing care plan. All caregivers responsible for the patient need to know the patient’s wishes. In addition, nurses are responsible for becoming familiar with provincial or territorial, local, and facility policies regarding documentation of end-­of-­life care. (Altered immune response and transplantation are discussed in Chapter 16.) 

NURSING MANAGEMENT END OF LIFE Nurses spend more time than any other health care providers with patients nearing the end of life. Nursing care is holistic and encompasses all psychosocial and physical needs. It focuses on what is important for the patient and family, such as respect, dignity, and comfort. Although there is no cure for the person’s disease, the treatment plan still consists of assessment, planning, implementation, and evaluation, with the main focus on management of the symptoms of the disease, rather than on the disease itself. In addition, nurses need to recognize their own needs when dealing with grief and dying. NURSING ASSESSMENT Assessment of a patient at the end of life varies with the patient’s diagnosis, life expectancy, and rate of decline. Depending on the reason for admission, the assessment might be comprehensive or limited to essential data. Nurses must be sensitive and not impose repeated, unnecessary assessments. When possible, health history data that are available in the medical record should be used in the nursing assessment. The nurse documents the specific event or change in condition that caused the patient to enter the health care facility. The patient’s medical diagnoses, medication profile, and allergies are recorded. A comprehensive symptom assessment according to the acronym OPQRSTUV (onset, provoking/palliating, quality, region/radiation, severity, treatment, understanding/impact on person, and values) and a physical assessment should be completed so that prompt interventions can be initiated. In addition, comorbid conditions or acute episodes of health conditions should be evaluated and managed according to the established goals of care. The nurse should elicit information about the patient’s abilities, food and fluid intake, patterns of

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sleep and rest, and response to the stress of the illness; assess the patient’s ability to cope with the diagnosis and prognosis of the illness; and determine the family’s capacity to manage care and cope with the illness and its consequences. (Health history and physical assessment are discussed in Chapter 3.) The physical assessment for patients at the end of life is abbreviated and focuses on changes that accompany the specific disease process (Hui et al., 2015). The frequency of assessment depends on the patient’s stability, but a full assessment is completed at least every shift in the institutional setting. For patients cared for in their homes, assessment may occur less frequently. As changes occur, assessment and documentation may be completed more often. If the patient is in the final hours of life, the physical assessment may be limited to gathering essential data. Key elements of a social assessment include evaluating the goals of the patient and family, assessing what the patient and family know and want to know about the dying process, and determining the relationships and patterns of communication among the family members. If multiple family members are present, the nurse should listen to concerns from different members. Differences in expectations and interpersonal conflict can result in family disruptions during the dying process and after the death of the loved one. As a member of the interprofessional team, the nurse plays a key role in patient and family education, helping them understand what is happening, validating their questions, and advocating for respect of the patient’s wishes (Canadian Nurses Association [CNA] et al., 2015). As the patient nears death, the nurse should monitor multiple systems that often fail at the end of life. This requires vigilance and attention to physical changes that are often subtle. Neurological assessment is especially important and includes evaluation of level of consciousness, presence of reflexes, and pupil responses. Evaluation of vital signs, skin colour, and temperature helps detect changes in circulation. The nurse should monitor and describe respiratory status, character and pattern of respirations, and characteristics of breath sounds. Nutritional and fluid intake, urine output, and bowel function should also be monitored because they provide assessment data for renal and gastrointestinal functioning. Skin condition should be assessed on an ongoing basis because skin becomes fragile and may easily break down. In the last hours of life, assessments should be limited to only those that are needed to determine the patient’s comfort. Assessment of pain and respiratory status may be most important during this time. It may be more peaceful and comforting to the patient and family to refrain from overstimulation that may occur from certain types of assessments, such as measuring blood pressure or checking for pupillary response. As the patient’s death approaches, the nurse’s efforts may be better spent providing emotional support to the patient and family. (Tools for nursing practice can be found at the Canadian Virtual Hospice and Pallium Canada websites, listed in the Resources section at the end of this chapter.)  NURSING DIAGNOSES Several nursing diagnoses concern psychosocial manifestations (Table 13.8) and physical manifestations (Table 13.9) associated with end-­of-­life care.  PLANNING The patient and family need to be involved in planning and coordinating end-­of-­life care. In some cases, a family conference may be helpful to develop a coordinated plan of care. The nurse develops a comprehensive plan to support, teach, and evaluate

TABLE 13.8    NURSING DIAGNOSES Psychosocial Manifestations of the End of Life • A  nxiety, death • C  onfusion, acute • C  onfusion, chronic • C  oping, inadequate • D  enial • F  amily processes, interrupted • F  ear • G  rieving, potential for complicated • G  rieving, complicated • H  opelessness

• L  oneliness, potential for • S  leep pattern, disturbed • S  ocial interaction, altered • S  ocial isolation • S  orrow, chronic • S  piritual distress • S  piritual well-­being, potential to improve • V  erbal communication, altered

TABLE 13.9    NURSING DIAGNOSES Physical Manifestations of the End of Life • A  irway clearance, reduced • A  spiration, potential for • B  ed mobility, reduced • B  owel incontinence • B  reathing pattern, altered • C  ardiac output, decreased • C  onstipation • D  iarrhea • F  atigue • G  as exchange, inadequate • Infection, potential for • Injury, potential for • N  ausea • N  utrition, altered: less than body requirements

• O  ral mucous membrane, altered • P  ain, acute • P  ain, chronic • M  obility, reduced • S  elf-­care deficits • S  kin integrity, potential for altered • S  kin integrity, altered • S  wallowing, altered • T  hermoregulation, altered • T  issue integrity, potential for altered • T  issue integrity, altered • T  issue perfusion, reduced • Incontinence, functional urinary

patients and families. Nursing care goals during the last stages of life involve comfort and safety measures and care of the patient’s emotional and physical needs. These goals should also include determining where the patient would prefer to die and whether this is possible. Many factors contribute to the decision of the patient and family; for example, the patient may prefer to die at home, but the family may not be in favour of this because of inadequate support. End-­of-­life care should always be interprofessional and may include the physician, nurse, social worker, chaplain, and other members of the palliative care team. The nurse should advocate for the patient so that their wishes are met as much as possible (CNA, 2017).  NURSING IMPLEMENTATION Psychosocial and physical care are interrelated for both the dying patient and the family. Support and education are important components of end-­of-­life care. Patients and families need ongoing information regarding the disease, the dying process, and any care that will be provided. They need information on how to cope with the many issues during this period of their lives. Anxiety and grief may be barriers to learning and understanding at the end of life for both the patient and their family. PSYCHOSOCIAL CARE.  As the patient’s death approaches, the nurse should encourage the family to respond appropriately to the psychosocial manifestations of the end of life. Table 13.10 presents management of psychosocial manifestations near death. Anxiety and Depression.  Patients often exhibit signs of anxiety and depression during the end-­of-­life period. Anxiety is an uneasy feeling whose cause is not easily identified. Anxiety is frequently a result of fear.

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TABLE 13.10    NURSING MANAGEMENT Psychosocial Care at the End of Life Characteristic

Nursing Management

Withdrawal A patient near death may seem withdrawn from the physical environment; however, the patient may be able to hear but unable to respond.

• Converse as though the patient were alert, using a soft voice and gentle touch.

Unusual Communication This may indicate that an unresolved issue is preventing the dying person from letting go. The patient may become restless and agitated or perform repetitive tasks (may also indicate terminal delirium).

• Encourage the family to talk with and reassure the dying person.

Vision-­Like Experiences The patient may talk to people who are not there or see places and objects not visible. Vision-­like experiences assist the dying person in coming to terms with meaning in life and transition from it.

• Affirm the dying person’s experience as a part of transition from this life.

Saying Goodbyes It is important for the patient and family to acknowledge their sadness, mutually forgive one another, and say goodbye.

• Encourage the dying person and family to verbalize their feelings of sadness, loss, and forgiveness and to touch, hug, and cry. • Allow the patient and family privacy to express their feelings and comfort one another.

Spiritual Needs The patient or family may request spiritual support, such as the presence of a spiritual care provider.

Causes of anxiety and depression may include uncontrolled pain and dyspnea, psychosocial factors related to the disease process or impending death, altered physiological states, and medications. Encouragement, support, and teaching decrease some of the anxiety and depression. Management of anxiety and depression may include both medications and nonpharmacological interventions. Relaxation strategies including breathing techniques, muscle relaxation, music, and imagery may be useful. (Complementary and alternative therapies are discussed in Chapter 12.)  Anger.  Anger is a common and normal response in the grief process. A grieving person cannot be forced to accept loss. The surviving family members may be angry with the dying loved one who is leaving them. The nurse should encourage the expression of feelings, but at the same time realize how difficult it is to come to terms with loss. The nurse may be the target of the anger; however, it is critical to understand the source of the expressed emotion and not to react on a personal level.  Hopelessness and Powerlessness.  Feelings of hopelessness and powerlessness are common during the end-­of-­life period. The nurse should encourage realistic hope within the limits of the situation. The patient and family should be allowed to deal with what is within their control, and the nurse should help them to recognize what is beyond their control. The nurse should support the patient’s involvement in decision making about care, when possible, to foster a sense of control and autonomy.  Fear.  Fear is a common emotion associated with dying. Four specific fears associated with dying are fear of pain, fear of shortness of breath, fear of loneliness and abandonment, and fear of meaninglessness. Fear of Pain.  Many people assume that pain always accompanies dying and death. Physiologically, there is no absolute indication that death is always painful. Psychologically, pain may result from the anxieties and separations related to dying. Patients can participate in their own pain control by discussing pain relief measures and their effects. Patients who experience

• Assess spiritual needs. Allow patient to express their spiritual needs. • Encourage visit by appropriate spiritual care service provider such as a chaplain, priest, rabbi, or family member.

physical pain should have pain-­relieving medications available around the clock (Pereira, 2016). Nurses must assure the patient and family that medications will be given promptly when needed and that adverse effects can and will be managed. Reassessment of pain after medications are given is an important nursing action. Most patients want their pain relieved without the adverse effects of grogginess or sleepiness. Pain relief measures do not have to deprive the patient of the ability to interact with others.  Fear of Shortness of Breath.  Respiratory distress and dyspnea occur in some patients near the end of life. The sensation of breathlessness often results in anxiety for both the patient and family. Current therapies may include opioids, bronchodilators, and oxygen, depending on the cause of the dyspnea. Anxiety-­reducing medications (anxiolytics) may help produce relaxation.  Fear of Loneliness and Abandonment.  Most dying patients fear loneliness and do not want to be alone. Many are afraid that loved ones who are unable to cope with the patient’s imminent death will abandon them. The simple presence of someone provides support and comfort. Holding hands, touching, and listening are important nursing interventions. Providing companionship allows the dying person a sense of security.  Fear of Meaninglessness.  Fear of meaninglessness leads most people to review their lives. They review their intentions during life, examining actions and expressing regrets about what might have been. Life review helps patients recognize the value of their lives. Nurses can assist patients and their families in identifying the positive qualities of the patient’s life. Practical ways of helping may include looking at photo albums or collections of important mementos. Sharing thoughts and feelings may enhance spirituality and provide comfort for the patient. A patient may wish to leave a legacy through writing letters to read or making a video to be viewed at future events when they will no longer be present. Nurses must respect and accept the practices and rituals associated with the patient’s life review while remaining nonjudgemental. 

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COMMUNICATION.  No two conversations are the same, inasmuch as they are shaped by the unique circumstances, coping styles, and personalities of the individuals involved. Difficult discussions include any information that adversely affects one’s expectations for the future. How the person experiences and processes difficult news is dependent on not only the words used but also how the message is delivered (Boles, 2015). Nurses may use several approaches to difficult conversations that share common features. Suggested approaches are “ask–tell–ask,” “tell me more,” responding to emotions with the NURSE protocol (naming, understanding, respecting, supporting, and exploring) and the SPIKES six-­step protocol (setup, perception, invitation, knowledge, empathize, and summarize and strategize) (Back et al., 2005). Effective communication techniques used in conversations among the interprofessional team, patient, and family are essential. Empathy and active listening are key communication components in end-­of-­life care. Empathy is the identification with and understanding of another person’s situation, feelings, and motives. Active listening, an active process required in the development of empathy toward another person’s feeling, is paying attention to what is said, observing the patient’s nonverbal cues, and not interrupting. There may also be silence. Silence is frequently related to the overwhelming feelings experienced at the end of life. Silence can also allow time to gather thoughts. Listening to the silence sends a message of acceptance and comfort. The nurse’s communication also must show respect for the patient’s ethnic, cultural, and religious backgrounds. Patients and family members may have difficulties expressing themselves emotionally. The nurse must allow time for them to express their feelings and thoughts, making time to listen and interact in a sensitive way. A family conference is one way to create an environment more conducive to large group conversations. Family members need to be prepared for changes in emotional and cognitive function that occur at end of the patient’s life. Unusual communication by the patient may take place at the end of life. The patient’s speech may become confused, disoriented, or garbled. Patients may speak to or about family members or others who have predeceased them, give instructions to those who will survive them, or speak of projects yet to be completed. Active, careful listening allows for the identification of specific patterns in the dying person’s communication and decreases the risk of inappropriate labelling of behaviours.  PHYSICAL CARE.  Nursing management related to physical care at the end of life focuses on symptom management and comfort rather than treatments for cure (Table 13.11). The priority is meeting the patient’s physiological and safety needs. Physical care addresses the needs for oxygen, nutrition, pain relief, mobility, elimination, and skin care. People who are dying deserve and require the same physical care as that of patients who are expected to recover. If possible, it is important to discuss with the patient and family the goals of care before treatment begins. Documentation of the discussion regarding wishes and preferences may take the form of an advance directive or simply be recorded in the medical chart to clearly communicate with the interprofessional team.  POSTMORTEM CARE.  The pronouncement of death is not a reserved act or a delegated medical function and is within the scope of nursing practice for an expected death related to a terminal illness (Canadian Medical Protective Association, 2019).

Although the death is anticipated, the pronouncement of death should be made with certainty and compassion. Death is considered to have occurred when cardiac and respiratory functions have ceased. The pronouncement of death is verification of the absence of an apical pulse and respirations, and the presence of fixed and dilated pupils. A certification of death—a legal medical document stating that the patient is dead—is usually required within 24 hours of a death. This function is in the purview of a physician, nurse practitioner, or medical examiner, who is required to both sign the document and indicate the cause of death (Canadian Medical Protective Association, 2019). After death is pronounced, the nurse prepares or delegates preparation of the body for immediate viewing by the family, with consideration for cultural customs and in accord with employer policies and procedures. In some cultures, it may be important to allow the family to prepare or assist in caring for the body. In general, the nurse should close the eyes, replace dentures, wash the body as needed (placing pads under the perineum to absorb urine and feces), and remove tubes and dressings (if appropriate). The body is straightened, the pillow is positioned to support the head, and a small rolled towel is placed under the chin to hold the mouth closed. The family should be allowed privacy and as much time as they need with the deceased person. In the case of an unexpected death, preparation of the patient’s body for viewing or release to a funeral home depends on provincial law and employer policies and procedures. The deceased person should never be referred to as “the body.” Care of and discussion related to the person should continue to be respectful even after death. 

SPECIAL NEEDS OF CAREGIVERS IN END-­O F-­L IFE CARE Special Needs of Family Caregivers Family caregivers are important in meeting the patient’s physical and psychosocial needs. The role of caregivers includes working and communicating with the patient and family members, supporting the patient’s concerns, and helping the patient resolve any unfinished business. Families often face emotional, physical, and economic consequences as a result of caring for a family member who is dying. The caregiver’s responsibilities do not end when the person is admitted to an acute care, hospice, or long-­term care facility. Being present during a family member’s dying process can be highly stressful. The nurse should recognize signs and behaviours among family members who may be at risk for abnormal grief reactions and be prepared to intervene, if necessary. Warning signs of abnormal grief may include dependency and negative feelings about the dying person, inability to express feelings, sleep disturbances, a history of depression, difficult reactions to previous losses, perceived lack of social or family support, low self-­esteem, multiple previous losses, alcoholism, or substance misuse. Caregivers with concurrent life crises (e.g., divorce) may be especially at risk. Family caregivers and other family members need encouragement to continue their usual activities where possible in order to maintain some control over their lives. The nurse should inform caregivers about appropriate resources for support, including respite care. Resources such as community counselling and local support may assist some people in working through their grief. The nurse should encourage caregivers to accept support from extended family, friends, and community. 

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CHAPTER 13  Palliative and End-of-Life Care TABLE 13.11    NURSING MANAGEMENT Physical Care at the End of Life Characteristics

Nursing Management

Pain • May be a major symptom associated with terminal illness and is the one most feared • Can be acute or chronic • Possible causes of bone pain: metastases, fractures, arthritis, and immobility • Aggravated by physical and emotional stressors

• Assess pain thoroughly and regularly to determine the quality, intensity, location, and contributing and alleviating factors. • Minimize possible irritants such as wet skin, heat or cold, and pressure. • Administer medications around the clock in a timely manner and on a regular basis to provide constant relief, rather than waiting until the pain is unbearable and then trying to relieve it. • Provide complementary and alternative therapies such as guided imagery, massage, and relaxation techniques as needed (see Chapter 12). • Evaluate effectiveness of pain relief measures frequently to ensure that the patient is on a correct, adequate drug regimen. • Do not delay or deny pain relief measures to a terminally ill patient.

Delirium • A state characterized by confusion, disorientation, restlessness, clouding of consciousness, incoherence, fear, anxiety, excitement, and often hallucinations • May be misidentified as depression, psychosis, anger, or anxiety • May be caused by use of opioids or corticosteroids, as well as by their withdrawal • May be exacerbated by underlying disease process • Generally considered a reversible process

• Perform a thorough assessment for reversible causes of delirium, including pain, constipation, and urinary retention. • Provide a room that is quiet, well lit, and familiar to reduce the effects of delirium. • Reorient the dying person with delirium to person, place, and time with each encounter. • Administer ordered benzodiazepines and sedatives as needed. • Stay physically close to a frightened patient. Reassure in a calm, soft voice with touch and slow strokes of the skin. • Provide family with emotional support and encouragement in their efforts to cope with the behaviours associated with delirium.

Anxiety/Restlessness • May occur as death approaches and cerebral metabolism slows • May occur with tachypnea, dyspnea, or sweating

• Assess for previous anxiety disorder. • Assess for spiritual distress or concerns related to death as causes of restlessness and agitation. • Assess for urinary retention and stool impaction. • Do not restrain. • Use soothing music; slow, soft touch; and a calm, soft voice. • Limit the number of people at the patient’s bedside.

Dysphagia • May occur because of extreme weakness and changes in level of consciousness • Difficulty swallowing • Aspiration of liquids or solids, or both • Drooling/inability to swallow secretions

• Identify the least invasive alternative routes of administration for drugs needed for symptom management. • If necessary, use alternative (rectal, buccal, transdermal) medication routes. • Suction orally as needed. • Modify diet as tolerated or desired (soft, pureed, chopped meats). • Hand-feed small meals. • Elevate the patient’s head for meals and for at least 30 minutes after. • Discontinue nonessential medications. • Discuss risk of aspiration with patient and family.

Weakness and Fatigue • Expected at the end of life • Exacerbated by metabolic demands related to disease process

• Assess the patient’s tolerance for activities. • Time nursing interventions to conserve the patient’s energy. • Help the patient identify and complete valued or desired activities. • Provide support as needed to maintain the patient’s positions in bed or a chair. • Provide frequent rest periods for the patient.

Dehydration • May occur during the last days of life • Hunger and thirst are rare in the last days of life • Tendency for dying patients to take in less food and fluid

• Assess mucous membranes frequently for dryness, which can lead to discomfort. • Maintain complete, regular oral care to provide for comfort and hydration of mucous membranes. • Encourage consumption of ice chips and sips of fluids or use moist cloths to provide moisture to the mouth. • Use moist cloths and swabs for an unconscious patient to prevent aspiration. • Apply lubricant to the lips and oral mucous membranes as needed. • Do not force the patient to eat or drink. • Teach the family that hunger and thirst are rare in the last days of life. • Reassure the family that cessation of food and fluid intake is a natural part of the process of dying.

Continued

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TABLE 13.11    NURSING MANAGEMENT Physical Care at the End of Life—cont’d Characteristics

Nursing Management

Dyspnea • Subjective symptom • Accompanied by fear of suffocation and anxiety • Can be exacerbated by underlying disease process • Progressive difficulty with coughing and expectorating secretions

• Assess respiratory status regularly. • Elevate the patient’s head or position the patient on one side to improve chest expansion. • Use a fan or air conditioner to facilitate movement of cool air. • Teach and encourage the use of pursed-­lip breathing. • Administer supplemental oxygen as ordered. • Suction as necessary to remove accumulation of mucus from the airways. Suction cautiously when a patient is in the terminal phase. • Administer expectorant as ordered.

Myoclonus • Mild to severe jerking or twitching, sometimes associated with use of high dose of opioids • Possible reports of involuntary twitching of extremities

• Assess for initial onset, duration, and any discomfort or distress experienced by patient. • If myoclonus is distressing or becoming more severe, discuss possible medication therapy modifications with the health care provider. • Changes in opioid medication may alleviate or decrease myoclonus.

Skin Breakdown • Difficulty maintaining skin integrity at the end of life • Risk for development increased by immobility, urinary and bowel incontinence, dry skin, nutritional deficits, anemia, friction, and shearing forces • Skin integrity possibly impaired by disease and other processes • As death approaches, decrease of circulation to the extremities; they become cool, mottled, and cyanotic

• Assess skin for signs of breakdown. • Implement protocols to prevent skin breakdown by controlling drainage and odor and by keeping the skin and any wound areas clean. • Perform wound assessments as needed. • Follow appropriate nursing management policy for dressing wounds. • Follow appropriate nursing management policy for a patient who is immobile but consider realistic outcomes of skin integrity in relation to maintenance of comfort. • Follow appropriate nursing management to prevent skin irritations and breakdown from urinary and bowel incontinence. • Use blankets to cover for warmth. Never apply heat. • Prevent the effects of shearing forces.

Bowel Patterns • Constipation possibly caused by immobility, use of opioid medications, depression, lack of fibre in the diet, and dehydration • Diarrhea possible as muscles relax or as a result of fecal impaction related to the use of opioids and immobility

• Assess bowel function. • Assess for and remove fecal impactions. • Encourage movement and physical activities as tolerated. • Encourage fibre in the diet if appropriate. • Encourage fluid intake if appropriate. • Use suppositories, stool softeners, laxatives, or enemas if ordered. • Assess patient for confusion, agitation, restlessness, and pain, which may be signs of constipation.

Urinary Incontinence • May result from disease progression or changes in level of consciousness • Relaxation of perineal muscles soon before death

• Assess urinary function. • Use absorbent pads for urinary incontinence. • Follow appropriate nursing protocol for the consideration and use of in-­ dwelling or external catheters. • Follow appropriate nursing management to prevent skin irritations and breakdown from urinary incontinence.

Anorexia, Nausea, and Vomiting • May be caused by complications of disease process • Nausea exacerbated by drugs • All exacerbated by constipation, impaction, and bowel obstruction

• Assess patient for reports of nausea or vomiting. • Assess possible contributing causes of nausea or vomiting. • Have family provide the patient’s favorite foods. • Discuss modifications to the drug regimen with the health care provider. • Provide antiemetics before meals if ordered. • Offer and provide frequent meals with small portions of favorite foods. • Offer culturally appropriate foods. • Provide frequent mouth care, especially after the patient vomits. • Ensure uninterrupted mealtimes. • If ordered, administer medications (e.g., megestrol, corticosteroids) to increase appetite. • Teach family that appetite naturally decreases at the end of life.

Candidiasis • White, cottage cheese–like oral plaques • Fungal overgrowth in the mouth as a result of chemotherapy, immunosuppression, or both

• Administer oral antifungal nystatin if ordered. • Clean dentures and other dental appliances to prevent reinfection. • Provide oral hygiene and use a soft toothbrush.

CHAPTER 13  Palliative and End-of-Life Care Special Needs of Nurses Many nurses who care for dying patients do so because they are passionate about providing high-­quality end-­of-­life care. Caring for patients and their families at the end of life is challenging and rewarding but also intense and emotionally charged (Larkin et al., 2019). A bond or connection may develop between the nurse and the patient or family. The nurse should be aware of how grief personally affects them. When the nurse provides care for dying patients, the nurse is not immune to feelings of loss. It is common to feel helpless and powerless when dealing with death. The nurse may need to express feelings of sorrow, guilt, and frustration. It is important to recognize one’s own values, attitudes, and feelings about death (Zheng et al., 2018).

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Interventions are available that may help ease the nurse’s physical and emotional stress. The nurse should be aware of what they can and cannot control. Recognizing personal feelings allows openness in exchanging feelings with the patient and family. Realizing that it is okay to cry with the patient or family may be important for the nurse’s well-­being. To meet the nurse’s personal needs, they should focus on interventions that will help decrease stress. The nurse can get involved in hobbies or other interests, schedule time for themselves, ensure time for sleep, maintain a peer support system, and develop a support system beyond the workplace. Specialized hospice palliative care teams can help the nurse cope through professionally assisted groups, informal discussion sessions, and flexible time schedules.

 REVIEW QUESTIONS c. Physician and substitute decision maker d. Physician and nursing staff 7. When a male client was diagnosed with renal failure, his new wife asked his children from a previous marriage to help with their father’s care. Each of the children refused to help and his wife cared for him without help until his death. Which factors may predispose the children to an abnormal grief reaction? (Select all that apply.) a. Negative feelings about the deceased person b. Lack of experience with other deaths in the family c. Difficulties with substance misuse d. Residing geographically far away 8. A nurse has been working full-­time with clients with advanced illnesses for 3 years. The nurse has been experiencing irritability and mixed emotions when expressing sadness since four clients died on the same day. What should the nurse change to optimize the quality of her nursing care? a. Full-­time work schedule b. Past feelings toward death c. Patterns for dealing with grief d. Demands for involvement in care 9. What is an important moral argument supporting medical assistance in dying? a. Respect for self-­determined choice b. Mercy and respect for beneficence c. Dignity in dying d. All of the above 1. d; 2. d; 3. a; 4. d; 5. a, d; 6. c; 7 a, b, c, d; 8. c; 9. d

The number of the question corresponds to the same-­numbered objective at the beginning of the chapter. 1. What is the purpose of palliative care? a. To provide psychological support b. To prolong life c. To hasten death d. To improve quality of life 2. A client with metastatic lung cancer is imminently dying. On assessment, it is noted that she has alternating periods of apnea and deep, rapid breathing. Which of the following is the correct terminology to use in documenting this assessment data? a. Tachypnea b. Stertorous respirations c. Dyspnea d. Cheyne-­Stokes respirations 3. The client has inoperable pancreatic cancer. Until recently, he has been very active in a book club but no longer wants to attend. Which common end-­of-­life psychological manifestation is he demonstrating? a. Decreased socialization b. Decreased disease progression c. Decreased sense of helplessness d. Decreased perception of pain and touch 4. A client died 2 years ago but his wife refuses to donate his belongings to charity. She often sits in the bedroom, crying and talking to her deceased husband. What type of grief is his wife experiencing? a. Adaptive grief b. Disruptive grief c. Anticipatory grief d. Prolonged grief 5. A female client with end-­stage renal disease experiences choking when given food or fluids. The family is concerned that she is starving. What is the most helpful response from the nurse? (Select all that apply.) a. “Allow me to show you how to moisten her mouth.” b. “If you give her food, she will choke to death.” c. “I can order you a tray and you can try to feed her if you like.” d. “People who are dying usually don’t experience hunger or thirst.” 6. A client did not have an advance directive when he suffered a serious stroke. Who is responsible for identifying end-­of-­life measures to be instituted when he cannot communicate his specific wishes? a. Adult children b. Notary and attorney

For even more review questions, visit http://evolve.elsevier.com/Cana da/Lewis/medsurg.

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CHAPTER 13  Palliative and End-of-Life Care O’Brien, M. E. (2018). Spirituality in nursing (6th ed.). Jones & Bartlett Learning. Ontario Trillium Gift of Life Network. (n.d.). Organ and tissue donation: Frequently asked questions for health professionals. www .giftoflife.on.ca/resources/pdf/FAQ_for_HP_(fact_sheet)_EN.pdf Pereira, J. L. (2016). The Pallium palliative pocketbook: A peer reviewed reference resource (2nd ed.). Pallium Canada. Quality End-­of-­Life Care Coalition of Canada (QELCCC). (2010). Blueprint for action 2010 to 2020. https://www.chpca.ca/wp-­conten t/uploads/2020/01/eng_progress_report_20102012-­07-­10_2.pdf. (Seminal). Quality End-­of-­Life Care Coalition of Canada (QELCCC). (2012). Executive summary (Seminal) https://www.chpca.ca/wp-­content/uplo ads//2020/01/microsoft_word_-­_3_executive_summary_2012.pdf Worden, J. W. (2009). Grief counseling and grief therapy: A handbook for the mental health practitioner (4th ed.). Springer (Seminal). World Health Organization. (2021). Palliative care. http://www.who.in t/cancer/palliative/definition/en/ Zheng, R., Lee, S., & Bloomer, M. (2018). How nurses cope with patient death: A systematic review and qualitative meta-­synthesis. Journal of Clinical Nursing, 27(1-­2), E39–E49. https://doi. org/10.1111/jocn.13975

RESOURCES Advance Care Planning https://www.advancecareplanning.ca Alberta Health Services: Goals of Care Designations https://myhealth.alberta.ca/health/Pages/HealthVideoPlayer.aspx ?List=fde13c02%2D8aa3%2D41ec%2D920d%2Ded3c17022ba8& ID=762&Web=c310c9f6%2D9976%2D4384%2Db2af%2Dd167d9 8d0966

Canadian Cancer Society https://www.cancer.ca Canadian Home Care Association https://www.cdnhomecare.ca/ Canadian Hospice Palliative Care Association https://www.chpca.net Canadian Virtual Hospice http://www.virtualhospice.ca Dignity in Care https://dignityincare.ca Life and Death Matters https://www.lifeanddeathmatters.ca/reflecting-­on-­death-­first-­ nations-­people/ Pallium Canada https://www.pallium.ca Trillium Gift of Life Network http://www.giftoflife.on.ca Casey House Hospice https://www.caseyhouse.com Temmy Latner Centre for Palliative Care http://www.tlcpc.org/ Victoria Hospice http://www.victoriahospice.org Victoria Hospice: Palliative Performance Scale https://victoriahospice.org/how-­we-­can-­help/clinical-­tools/ Worldwide Hospice Palliative Care Alliance http://www.thewhpca.org For additional Internet resources, see the website for this book at http://evolve.elsevier.com/Canada/Lewis/medsurg.

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Pathophysiological Mechanisms of Disease

Source: © CanStock Photo/ronniechua

Chapter 14: Inflammation and Wound Healing Chapter 15: Genetics Chapter 16: Altered Immune Response and Transplantation Chapter 17: Infection and Human Immunodeficiency Virus Infection Chapter 18: Cancer Chapter 19: Fluid, Electrolyte, and Acid–Base Imbalances

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CHAPTER

14

Inflammation and Wound Healing Kevin Woo Originating US chapter by Catherine R. Ratliff

WEBSITE http://evolve.elsevier.com/Canada/Lewis/medsurg • • • •

 eview Questions (Online Only) R Key Points Answer Guidelines for Case Study Student Case Study

• • • •

 ressure Injuries P Customizable Nursing Care Plans Fever Pressure Injury

• A  udio Glossary • Content Updates

LEARNING OBJECTIVES 1. Explain the mechanisms that enable the cell to adapt to sublethal injury. 2. Describe the causes and mechanisms of lethal cell injury. 3. Differentiate among types of cell necrosis. 4. Describe the components and functions of the mononuclear phagocyte system. 5. Describe the inflammatory response, including vascular and cellular responses and exudate formation. 6. Explain local and systemic manifestations of inflammation and their physiological bases. 7. Describe the pharmacological, dietary, and nursing management of inflammation.

8. Differentiate between healing by primary, secondary, and tertiary intention. 9. Describe the factors that delay wound healing and common complications of wound healing. 10. Describe the risk assessment process for pressure injuries. 11. Discuss measures to prevent the development of pressure injuries. 12. Explain the causes and clinical manifestations of pressure injuries. 13. Discuss interprofessional and nursing management of a patient with pressure injuries.

KEY TERMS adhesions anaplasia apoptosis atrophy dehiscence dry gangrene dysplasia evisceration fibroblasts

  

fistula hyperplasia hypertrophic scar hypertrophy inflammatory response integrins keloid lethal injury metaplasia

CELL INJURY Cell injury can be sublethal or lethal. Sublethal injury alters function without causing cell destruction. The changes caused by this type of injury are potentially reversible if the harmful stimulus is removed. Lethal injury is an irreversible process that causes cell death.

Cell Adaptation to Sublethal Injury While cell adaptations to sublethal injuries are common and are part of many normal physiological processes, they may also

necrosis pressure injury regeneration repair selectins shearing force sublethal injury wet gangrene

result from pathological changes. For example, prolonged exposure to sunlight stimulates melanin production, which provides protection of deeper skin layers; increased melanin production causes tanning of the skin. Lack of muscular activity can lead to atrophy and decreased tone of muscles. Adaptive processes of the cell include hypertrophy, hyperplasia, atrophy, and metaplasia. Other responses, which are considered maladaptive, are dysplasia and anaplasia. Hypertrophy.  Hypertrophy is an expansion in the size of cells, which results in increased tissue mass without cell

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SECTION 2  Pathophysiological Mechanisms of Disease

division. Physiological hypertrophy results from increased workload on an organ or tissue that is not caused by disease. Examples include an increase in the muscle mass that occurs during weight training, uterine expansion during pregnancy from hormonal stimulation, and enlargement of the sex organs during puberty. Pathological hypertrophy occurs as a result of disease—for example, enlargement and thickening of the heart ventricle in a person with severe hypertension in response to increased cardiac workload. Compensatory hypertrophy occurs in response to increased workload caused by reduced function. For example, when a kidney is removed, the remaining kidney enlarges as a result of increased work demand.  Hyperplasia.  Hyperplasia is a multiplication of cells as a result of increased cellular division. Physiological hyperplasia is an adaptive response to normal body changes. For example, cells of the uterus undergo hyperplasia during pregnancy, and the female breast undergoes hyperplasia during puberty and lactation. Examples of pathological hyperplasia are endometrial hyperplasia, caused by excessive estrogen secretion, and acromegaly, caused by excessive production of growth hormone. Compensatory hyperplasia is a process whereby cells of certain organs regenerate. For example, if portions of the liver are removed, the remaining cells undergo increased mitosis to compensate.  Atrophy.  Atrophy is a decrease in the size of a tissue or organ as a result of a reduction in the number or size of individual cells. It is frequently caused by disease (e.g., musculoskeletal disease), lack of blood supply (e.g., thrombus formation), the natural aging process (e.g., atrophy of ovaries after menopause), inactivity (e.g., decreased muscle size), or nutritional deficiency.  Metaplasia.  Metaplasia is the transformation of one cell type into another in response to a change in physiological condition or an external irritant. An example of physiological metaplasia is the change of circulating monocytes to macrophages as

they migrate into inflamed tissues. An example of pathophysiological metaplasia is the change of normal pseudostratified columnar epithelium of the bronchi to squamous epithelium in response to chronic cigarette smoking. These squamous cells can later become cancerous.  Dysplasia.  Dysplasia is an abnormal differentiation of dividing cells that results in changes in their size, shape, and appearance. Minor dysplasia is found in some areas of inflammation. Dysplasia is potentially reversible if the stimulus for the change is removed. Dysplasia is frequently a precursor of malignancy, as in cervical dysplasia.  Anaplasia.  Anaplasia is cell differentiation to a more immature or embryonic form. Malignant tumours are often characterized by anaplastic cell growth. 

Causes of Lethal Cell Injury Many different agents and factors can cause lethal cell injury (Table 14.­1). The mechanisms of actual cell death may include deterioration of the nucleus, such as pyknosis (nuclear condensation and shrinking), karyolysis (dissolution of nucleus and contents), disruption of cell metabolism, and rupture of the cell membrane. Microbial invasion often results in cell injury and death. Infection occurs when pathogens invade and multiply in body tissue.  Cell Apoptosis and Necrosis Apoptosis and necrosis are the two fundamental types of cell death. Programmed cell death, or apoptosis, is a normal, anticipated event that occurs in some regenerating tissues to create homeostasis, such as bone marrow, skin, and gut epithelium. In contrast, necrosis is tissue death that occurs as a result of a traumatic injury, infection, ischemia, or exposure to a toxic chemical that causes a local inflammatory response, which results from the release of intracellular contents after

TABLE 14.1    CAUSES OF LETHAL CELL INJURY Cause

Effect on Cell

Hypoxia or ischemic injury Physical agents • Heat • Cold

Compromised cell metabolism, acute or gradual cell death

• Radiation • Electrothermal injury • Mechanical trauma

Chemical injury Microbial injury • Viruses • Bacteria Immunological* • Antigen–antibody response • Autoimmune response Neoplastic growth Normal substances (e.g., digestive enzymes, uric acid)

Denaturation of protein, acceleration of metabolic reactions (see Chapter 27) Decreased blood flow from vasoconstriction, slowed metabolic reactions, thrombosis of blood vessels, freezing of cell contents that forms crystals and can cause cell to burst (see Chapter 71) Alteration of cell structure and activity, alteration of enzyme systems, mutations (see Chapter 18) Interruption of neural conduction, fibrillation of cardiac muscle, coagulative necrosis of skin and skeletal muscle (see Chapter 27) Transfer of excess kinetic energy to cells, causing rupture of cells, blood vessels, tissue; examples include the following: Abrasion: scraping of skin or mucous membrane Laceration: severing of vessels and tissue Contusion (bruise): crushing of tissue cells, causing hemorrhage into skin Puncture: piercing of body structure or organ Incision: surgical cutting Alteration of cell metabolism, interference with normal enzymatic action within cells (see Chapter 27) Taking over of cell metabolism and synthesis of new particles that may cause cell rupture; cumulative effect may produce clinical disease Destruction of cell membrane or cell nucleus, production of lethal toxins Release of substances (histamine, complement) that can injure and damage cells Activation of complement, which destroys normal cells and produces inflammation (see Chapter 16) Cell destruction from abnormal and uncontrolled cell growth (see Chapter 18) Release into abdomen, causing peritonitis and crystallization of excess accumulation in joints and renal tissue

*See Chapter 16 for a more detailed discussion.

CHAPTER 14  Inflammation and Wound Healing the rupture of the outer membrane of the dead cells. Various types of tissue necrosis occur in different organs or tissues (Table 14.­2; Figure 14.1). Dry gangrene can result from degenerative changes that occur with certain chronic diseases, such as atherosclerosis or diabetes, when the blood supply to the lower extremities is gradually reduced (see Figure 14.1). Wet gangrene, which can quickly become fatal, occurs as the result of a sudden rapid elimination of blood flow, such as that seen in a severe burn or traumatic crush injury. It is malodorous because of extensive tissue liquefaction, which makes the affected area soft, and the odour is often indicative of a bacterial infection. 

DEFENCE AGAINST INJURY To protect against injury and infection, the body has various defence mechanisms: (a) the skin and mucous membranes (see Chapter 25); (b) the mononuclear phagocyte system; (c) the inflammatory response; and (d) the immune system (see Chapter 16).

Mononuclear Phagocyte System The mononuclear phagocyte system consists of monocytes and macrophages and their precursor cells. In the past, the mononuclear phagocyte system was called the reticuloendothelial system. However, it is not a body system with distinctly defined tissues and organs. Rather, it consists of phagocytic cells located in

FIG. 14.1  Gangrene of the toes. Gangrenous necrosis 6 weeks after frostbite injury. Source: Courtesy of Cameron Bangs, MD. From Auerbach, P. S. (2007). Wilderness medicine (6th ed., p. 201). Elsevier.

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various tissues and organs. The phagocytic cells are either fixed or free (mobile). The macrophages of the liver, spleen, bone marrow, lungs, lymph nodes, and nervous system are fixed phagocytes. The monocytes in blood and the macrophages found in connective tissue are mobile, or wandering, phagocytes. Monocytes and macrophages originate in the bone marrow. Monocytes spend a few days in the blood and then enter tissues and change into macrophages. Tissue macrophages are larger and more phagocytic than monocytes. The functions of the macrophage system include recognition and phagocytosis of foreign material such as microorganisms, removal of old or damaged cells from circulation, and participation in the immune response (see Chapter 16). 

Inflammatory Response The inflammatory response is a biological response to cell injury caused by pathogens, irritants, or chronic health conditions (e.g., arthritis). Through this response, the inflammatory agent is neutralized and diluted, necrotic materials are removed, and an environment suitable for healing and repair is established. The term inflammation should not be confused with infection. Infections almost always cause inflammation, but not all inflammations are caused by infections. Furthermore, neutropenic individuals may not mount an inflammatory response to infection. An infection involves invasion of tissues or cells by microorganisms such as bacteria, fungi, and viruses. Inflammation can also be caused by heat, radiation, trauma, chemicals, allergens, or an autoimmune reaction (see Table 14.­1). Under these conditions, the presence of an infection represents a superimposed invasion of microorganisms. The mechanism of inflammation is basically the same regardless of the injuring agent. The intensity of the response depends on the extent and the severity of injury and on the reactive capacity of the injured person. The inflammatory response can be divided into a vascular response, a cellular response, formation of exudate, and healing. Figure 14.2 illustrates the vascular and cellular responses to injury. Vascular Response.  After cell injury, arterioles in the area briefly undergo transient vasoconstriction, which is stimulated by the sympathetic nervous system. Platelets adhere to vessels and aggregate to seal the injured area, forming a fibrin-­platelet clot, and they release proinflammatory mediators such as histamine, which cause vasodilation. This results in hyperemia (increased blood flow in the area) in which filtration pressure increases, causing endothelial cell retraction and an increase in capillary permeability. These vascular changes will facilitate movement of fluid from capillaries into tissue spaces. Initially

TABLE 14.2    TYPES OF NECROSIS Type

Description

Coagulative necrosis

Caused by ischemia. Ischemia results in decreased levels of adenosine triphosphate (ATP), increased levels of cytosolic Ca2+, and free radical formation, each of which eventually causes membrane damage. A myocardial infarct is an example of a localized area of coagulative necrosis. Usually caused by focal bacterial infections because they can attract polymorphonuclear leukocytes (PMNs). The enzymes in the PMNs are released to fight the bacteria but also dissolve the tissues nearby, which causes pus to accumulate and the tissue to liquefy. An abscess is an example of a liquefactive necrotic process. A distinct form of coagulative necrosis that occurs in mycobacterial infections (e.g., tuberculosis) or in tumour necrosis, in which the coagulated tissue no longer resembles the cells but is in chunks of unrecognizable debris. Necrosis of an appendage (usually the limbs). The term may also be used to describe necrosis of an appendix or gallbladder. This form of necrosis applies to ischemic necrosis, usually with superimposed bacterial action (wet gangrene) but sometimes in toes without bacterial effects (dry gangrene or mummification).

Liquefactive necrosis

Caseous necrosis Gangrene

Source: Adapted from Krafts, K. (2012). A quick summary of six types of necrosis. http://www.pathologystudent.com/?p=5770

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PATHOPHYSIOLOGY MAP Cell injury

Vascular response

Momentary vasoconstriction

Cell injury/death

Cellular response

Chemotaxis

Release of chemical mediators (histamine, kinins, prostaglandins)

Migration of leukocytes to the site of injury

• Local vasodilation • Hyperemia

Neutrophils

• Capillary permeability • Local edema

Margination and diapedesis of blood leukocytes

Tissue macrophages

Monocytes

Lymphocytes

Macrophages

Immune response

Phagocytosis

Inflammatory exudates • Fluid exudate • Cell exudate FIG. 14.2  Vascular and cellular responses in inflammation.

composed of serous fluid, this inflammatory exudate later contains plasma proteins, primarily albumin, which exerts oncotic pressure that further draws fluid from blood vessels, and the tissue become edematous. As the plasma protein fibrinogen leaves the blood, it is activated by the products of the injured cells to become fibrin. Fibrin strengthens the blood clot formed by platelets. In tissue, the clot functions to minimize blood loss, trap bacteria, prevent their spread, and serve as a framework for the healing process. Platelets release growth factors that begin the healing process.  Cellular Response.  Phagocytes produce nitric oxide, whose role in the inflammatory response is to inhibit vascular smooth muscle contraction and growth, platelet aggregation, and leukocyte adhesion to endothelium. Cytokines are released by macrophages, which causes endothelial cells to express cellular adhesion molecules: selectins (cell surface carbohydrate-­ binding proteins that mediate cell adhesion, involved in leukocyte extravasation during the immune response) and integrins (cell receptors that mediate attachment between endothelial cells and surrounding tissues, also involved in leukocyte extravasation during the immune response). The blood flow through capillaries in the area slows as fluid is lost and viscosity increases. Neutrophils and monocytes move to the inner surface of the capillaries (margination) and then, in ameboid manner, through the capillary wall (diapedesis) to the site of injury.

Chemotaxis is the directional migration of white blood cells (WBCs) along a concentration gradient of chemotactic factors, which are substances that attract WBCs to the site of inflammation. Chemotaxis is the mechanism for ensuring accumulation of neutrophils and monocytes at the site of injury. Neutrophils.  Neutrophils are the first leukocytes to arrive at the site of inflammation (within 6 to 12 hours). They phagocytize (engulf) bacteria, other foreign material, and damaged cells. Because of their short lifespan (24 to 48 hours), dead neutrophils soon accumulate. In time, a mixture of dead neutrophils, digested bacteria, and other cell debris collect as a creamy substance (pus). To keep up with the demand for neutrophils, the bone marrow releases more neutrophils into circulation. This results in an elevated WBC count, especially the neutrophil count. Sometimes the demand for neutrophils increases to the extent that the bone marrow releases immature forms of neutrophils (bands) into circulation. (Mature neutrophils are called segmented neutrophils.) The finding of increased numbers of band neutrophils in circulation is called a shift to the left and is commonly observed in patients with acute bacterial infections. (See Chapter 32 for a discussion of neutrophils.)  Monocytes.  Monocytes are the second type of phagocytic cells that migrate from circulating blood. They are attracted by chemotactic factors and usually arrive at the site within 3 to 7 days after the onset of inflammation. On entering the tissue

CHAPTER 14  Inflammation and Wound Healing

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TABLE 14.3    MEDIATORS OF INFLAMMATION Mediator

Source

Mechanisms of Action

Histamine

Stored in granules of basophils, mast cells, platelets

Serotonin

Stored in platelets, mast cells, enterochromaffin cells of GI tract

Kinins (e.g., bradykinin)

Produced from precursor factor kininogen as a result of activation of Hageman factor (XII) of clotting system Anaphylatoxic agents generated from complement pathway activation Produced from activation of the clotting system Produced from arachidonic acid

Causes vasodilation and increased vascular permeability by stimulating contraction of endothelial cells and creating widened gaps between cells Causes vasodilation and increased vascular permeability by stimulating contraction of endothelial cells and creating widened gaps between cells; stimulates smooth muscle contraction Cause contraction of smooth muscle and dilation of blood vessels; result in stimulation of pain

Complement components (C3a, C4a, C5a) Fibrinopeptides Prostaglandins and leukotrienes Cytokines

Secreted by white blood cells and other cells For more information on cytokines, see Table 16.3.

Stimulate histamine release; stimulate chemotaxis Increase vascular permeability; stimulate chemotaxis for neutrophils and monocytes Prostaglandins E1 and E2 cause vasodilation; leukotriene B4 stimulates chemotaxis Act as messengers between cell types; instruct cells to alter their proliferation differentiation, secretion, or activity

GI, gastrointestinal.

spaces, monocytes transform into macrophages. Together with the tissue macrophages, they assist in phagocytosis of the inflammatory debris. The macrophage role is important in cleaning the area before healing can occur. Macrophages have a long lifespan; they may stay in the damaged tissues for weeks and multiply, and they are important in orchestrating the healing process. In some cases, macrophages perform tasks other than phagocytosis. They may accumulate and fuse to form a multinucleated giant cell. The giant cell attempts to phagocytize particles too large for macrophages and is then encapsulated by collagen, which leads to the formation of a granuloma. A classic example of this process occurs in tuberculosis of the lung. Although the Mycobacterium bacillus is walled off, a chronic state of inflammation exists. The granuloma formed is a cavity of necrotic tissue.  Lymphocytes.  Lymphocytes arrive later at the site of injury. Their primary role is related to humoral and cell-­mediated immunity (see Chapter 16).  Eosinophils and Basophils.  Eosinophils and basophils have a more selective role in inflammation. Eosinophils are released in large quantities during an allergic reaction. They release chemicals that act to control the effects of histamine and serotonin. They are also involved in phagocytosis of the allergen-­antibody complex. Eosinophils contain highly caustic chemicals that are capable of destroying a parasite’s cell surfaces. The histamine and heparin that basophils carry in their granules are released during inflammation.  Chemical Mediators.  Mediators of the inflammatory response are listed in Table 14.­3. Complement System.  The complement system is an enzymatic cascade consisting of pathways to mediate inflammation and destroy invading pathogens. Major functions of the complement system are enhanced phagocytosis, increased vascular permeability, chemotaxis, and cellular lysis. All of these activities are important in the inflammatory response. When the complement system is activated, the components are generated in the sequential order of C1, C4, C2, C3, C5, C6, C7, C8, and C9. The numbering reflects the order of their discovery. Some components have subparts designated by

lowercase letters, such as C3a, C3b, and C5a. The primary pathway for activation of the complement system is through fixation of component C1 to an antigen–antibody complex. Immunoglobulins G and M are responsible for fixing complement. Each activated complex can act on the next component, which creates a cascade effect. In an alternative pathway, C3 is activated without prior antigen–antibody fixation. Bacterial products, lipopolysaccharides, and neutrophil proteases can stimulate the complement sequence, beginning with C3 and with activation of C5 through C9. Complement activation increases phagocytosis through opsonization and chemotaxis. Opsonization occurs when the antigen, in combination with complement factor C3b and immunoglobulin, sticks to the surface of the foreign particle such as pathogens that are targeted for destruction. This leads to more ready and rapid phagocytosis. In addition, complement component C5a promotes chemotaxis. The components C3a, C5a, and C4a are termed anaphylatoxins and bind to receptors on mast cells and basophils, thus triggering histamine release. Histamine causes smooth muscle contraction, vasodilation, and an increase in vascular permeability. The entire complement sequence of C1 to C9 must be activated for cell lysis to occur. The final components (C8, C9) act on the cell surface, causing rupture of the cell membrane and lysis. In autoimmune disorders, healthy tissue can be damaged by complement activation and the resulting inflammatory response. Examples of this include rheumatoid arthritis and systemic lupus erythematosus.  Prostaglandins and Leukotrienes.  Prostaglandins are substances that can be synthesized from the phospholipids of cell membranes of most body tissues, including blood cells. On stimulation by chemotactic factors or phagocytosis or after cell injury, phospholipids can be converted to arachidonic acid, which is then oxidized by two different pathways. The cyclo-­oxygenase metabolic pathway leads to the production of prostaglandins of the D, E, F, and I series and of thromboxanes (formed on activation of platelets). Prostaglandins of the E and I series are potent vasodilators and inhibit

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TABLE 14.4    TYPES OF INFLAMMATORY EXUDATE Type

Description

Examples

Serous

Results from fluid that has low cell and protein content; seen in early stages of inflammation or when injury is mild Found during the midpoint in healing after surgery or tissue injury. Composed of RBCs and serous fluid, which is semi-­clear pink and may have red streaks. Found in tissues in which cells produce mucus; mucus production is accelerated by inflammatory response Occurs with increasing vascular permeability and fibrinogen leakage into interstitial spaces; excessive amounts of fibrin coating of tissue surfaces may cause tissues to adhere Consists of WBCs, microorganisms (dead and alive), liquefied dead cells, and other debris Results from rupture or necrosis of blood vessel walls; consists of RBCs that escape into tissue

Skin blisters, pleural effusion

Serosanguinous

Catarrhal Fibrinous

Purulent (pus) Hemorrhagic

Runny nose in association with upper respiratory tract infection Adhesions

Furuncle (boil), abscess, cellulitis (diffuse inflammation in connective tissue) Hematoma

RBCs, red blood cells; WBCs, white blood cells.

platelet and neutrophil aggregation. Prostaglandin E2 (PGE2) can sensitize pain receptors in response to stimuli that would normally be painless. PGE2 is also a potent pyrogen, acting on the temperature-­regulating area of the hypothalamus. Thromboxane A2 is a potent vasoconstrictor and platelet-­aggregating agent. Prostaglandins are generally considered proinflammatory, contributing to increased blood flow, edema, and pain. Metabolism of arachidonic acid by the lipoxygenase pathway leads to the production of leukotrienes. Leukotriene B4 is a potent chemotactic factor. Leukotrienes C4, D4, and E4 form the slow-­reacting substance of anaphylaxis, which constricts smooth muscles of bronchi and increases capillary permeability. Medications that inhibit prostaglandin synthesis are useful clinically. Nonsteroidal anti-­inflammatory drugs (NSAIDs) are used to treat many acute and chronic inflammatory conditions. Acetylsalicylic acid blocks platelet aggregation; it also has anti-­ inflammatory action. Prostacyclin (prostaglandin I2) has been used to prevent platelet deposition in extracorporeal systems, such as hemodialysis and heart–lung bypass oxygenators. Another group of medications that inhibit prostaglandins is the corticosteroids. They are valuable in the treatment of asthma because they inhibit leukotriene production and thus prevent bronchoconstriction. (Other mediators of the inflammatory response are described in Table 14.­3.)  Exudate Formation.  Exudate consists of fluid and leukocytes that move from the circulation to the site of injury. The nature and quantity of exudate depend on the type and the severity of the injury and the tissues involved (Table 14.­4). Clinical Manifestations.  The local manifestations of inflammation include redness, heat, swelling, and pain (Table 14.­5). Systemic manifestations of inflammation include leukocytosis with a shift to the left, malaise, nausea and anorexia, increased pulse and respiratory rate, and fever. The causes of these systemic changes may be related to complement activation and the release of cytokines from stimulated WBCs. Three of these cytokines—interleukin-­1, interleukin-­6, and tumour necrosis factor—are important in causing the generalized symptoms of inflammation, such as malaise, as well as inducing fever. A rise in body temperature is accompanied by increased metabolism that is evident by an increase in pulse and respiration. (Cytokines are discussed in Chapter 16.) Fever.  The release of cytokines initiates metabolic changes in the temperature-­regulating centre of the hypothalamus, thus causing fever (Figure 14.3). The synthesis of PGE2 is the most

TABLE 14.5    LOCAL MANIFESTATIONS OF

INFLAMMATION

Manifestations

Cause

Redness Heat Pain

Hyperemia from vasodilation Increased metabolism at inflammatory site Change in pH; nerve stimulation by chemicals (e.g., histamine, prostaglandins); pressure from fluid exudate Fluid shift to interstitial spaces; fluid exudates accumulation

Swelling

critical metabolic change because it acts directly to increase the thermostatic set point. The hypothalamus then activates the autonomic nervous system to stimulate increased muscle tone and shivering and decreased perspiration and blood flow to the periphery. Epinephrine released from the adrenal medulla increases the metabolic rate. The net result is fever. With the physiological thermostat fixed at a higher-­than-­ normal temperature, the rate of heat production is increased until the body temperature reaches the new set point. As the set point is raised, the hypothalamus signals an increase in heat production and conservation to raise the body temperature to the new level. At this point, the affected individual feels chilled and shivers. The shivering response is the body’s way of raising its temperature until the new set point is reached. The body is hot, and yet the individual paradoxically piles on blankets and may go to bed to get warm. When the circulating body temperature reaches the set point of the core body temperature, the chills and warmth-­seeking behaviour cease (Dinarello & Porat, 2015). The febrile response is classified into four stages, described in Table 14.­6. The released cytokines and the fever they trigger activate the body’s defence mechanisms. Beneficial aspects of fever include increased killing of microorganisms, increased phagocytosis by neutrophils, and increased proliferation of T cells. Higher body temperatures may also enhance the activity of interferon, the body’s natural virus-­fighting substance (see Chapter 16).  Types of Inflammation.  The basic types of inflammation are acute, subacute, and chronic. In acute inflammation, the healing occurs in 2 to 3 weeks and usually leaves no residual damage. Neutrophils are the predominant cell type at the site of inflammation. A subacute inflammation has the features of the acute process but lasts longer. For example, infective endocarditis is a

CHAPTER 14  Inflammation and Wound Healing

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TABLE 14.7    REGENERATIVE ABILITY OF

PATHOPHYSIOLOGY MAP

DIFFERENT TYPES OF TISSUES

Temperature-regulating centre

Tissue Type

Activation of monocytes/macrophages

Regenerative Ability

Epithelial Skin, linings of blood vessels, mucous membranes

Cells readily divide and regenerate.

Connective Tissue Production of PGE2 raised thermostatic set point

Release of IL-1, IL-6, and TNF

Autonomic nervous system

Bone Cartilage Tendons and ligaments Blood

Muscle Smooth Cardiac

Heat conservation • Cutaneous vasoconstriction • Decreased sweating

Heat generation • Increased muscle contraction • Shivering reflex

FEVER

Skeletal

TABLE 14.6    STAGES OF THE FEBRILE

RESPONSE

Stage

Characteristics

Prodrome

Nonspecific reports such as mild headache, fatigue, general malaise, muscle aches Cutaneous vasoconstriction, “goose pimples,” pale skin; feeling of being cold; generalized, shaking chill; shivering that causes body to reach new temperature set by control centre in hypothalamus Sensation of warmth throughout body; cutaneous vasodilation; warming and flushing of skin Sweating; decrease in body temperature

Chill

Flush Defervescence

smouldering infection with acute inflammation, but it persists for weeks or months (see Chapter 39). Chronic inflammation lasts for weeks, months, or even years. The injurious agent persists, causing repeated tissue injuries. The predominant cell types present at the site of inflammation are lymphocytes and macrophages. Examples of chronic inflammation include rheumatoid arthritis, osteomyelitis, and tuberculosis. The prolongation and chronicity of any inflammation may be the result of an alteration in the immune response (e.g., autoimmune disease). C-­reactive protein is an acute-­phase protein whose plasma concentration increases in response to inflammation, and thus it can be a useful inflammatory marker.  Healing Process.  The final phase of the inflammatory response is healing. Healing includes two major components: regeneration and repair. Regeneration is the replacement of lost cells and tissues with cells of the same type. Repair is healing as

Regeneration is usually possible (particularly in GI tract). Damaged muscle is replaced by connective tissue. Connective tissue replaces severely damaged muscle; in moderately damaged muscle, some regeneration occurs.

Nerve Neurons

FIG. 14.3  Production of fever. When monocytes or macrophages are ac-

tivated, they secrete cytokines such as interleukin-­1 (IL-­1), interleukin-­6 (IL-­6), and tumour necrosis factor (TNF), which reach the hypothalamic temperature-­regulating centre. These cytokines promote the synthesis and secretion of prostaglandin E2 (PGE2) in the anterior hypothalamus. PGE2 increases the thermostatic set point, and the autonomic nervous system is stimulated, which results in shivering, muscle contraction, and peripheral vasoconstriction.

Active tissue heals rapidly. Regeneration is possible but slow. Regeneration is possible but slow. Cells actively regenerate.

Glial

Cells of these tissues are generally nonmitotic; they do not replicate or replace themselves if irreversibly damaged. Cells regenerate; scar tissue often forms when neurons are damaged.

GI, gastrointestinal.

a result of lost cells being replaced by connective tissue. Repair is the more common type of healing and usually results in scar formation. Regeneration.  The ability of cells to regenerate depends on the cell type (Table 14.­7). Labile cells—such as cells of the skin, lymphoid organs, bone marrow, and mucous membranes of the gastrointestinal, urinary, and reproductive tracts—divide constantly. Injury to these organs is followed by rapid regeneration. Stable cells retain their ability to regenerate but do so only if the organ is injured. Examples of stable cells are liver, pancreas, kidney, and bone cells. Permanent cells such as neurons of the central nervous system and cardiac muscle cells do not regenerate. Damage to these cells can lead to permanent loss. Healing occurs by repair with scar tissue.  Repair.  Repair is a more complex process than is regeneration. Most injuries heal by connective tissue repair. Repair healing occurs by primary, secondary, or tertiary intention (Figure 14.4). Primary Intention.  Primary intention healing takes place when wound margins are neatly approximated, as in a surgical incision or a paper cut. A continuum of processes is associated with primary healing (Table 14.­8). These processes include three phases: the initial (inflammatory) phase, the granulation (proliferative/reconstructive) phase, and the maturation phase and scar contraction. Initial (Inflammatory) Phase.  The initial phase lasts for 3 to 5 days. The edges of the incision are aligned and sutured (or stapled) in place. The incision area fills with blood from the cut blood vessels, and blood clots form and platelets release growth factors to begin the healing process. This forms a matrix for WBC migration and an acute inflammatory reaction occurs.

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SECTION 2  Pathophysiological Mechanisms of Disease

A Incision with blood clot

Edges approximated with suture

Fine scar

Irregular, large wound with blood clot

Granulation tissue fills in wound

Large scar

Contaminated wound

Granulation tissue

Delayed closure with suture

B

C FIG. 14.4  Types of wound healing. A, Primary intention. B, Secondary intention. C, Tertiary intention.

TABLE 14.8    PHASES IN PRIMARY

INTENTION HEALING

Phase

Activity

Initial (3 to 5 days)

Approximation of incision edges; migration of epithelial cells; clot serving as meshwork for starting capillary growth Migration of fibroblasts; secretion of collagen; abundance of capillary buds; fragility of wound Remodelling of collagen; strengthening of scar

Granulation (5 days to 4 weeks) Scar contracture (7 days to several months)

The area of injury is composed of fibrin clots, erythrocytes, neutrophils (dead and dying), and other debris. Macrophages ingest and digest cellular debris, fibrin fragments, and red blood cells. Extracellular enzymes from macrophages and neutrophils help digest fibrin. As the wound debris is removed, the fibrin clot serves as a framework for future capillary growth and migration of epithelial cells.  Granulation (Proliferative/Reconstructive) Phase.  The granulation phase is the second step and lasts from 5 days to 3 weeks. The components of granulation tissue include proliferating fibroblasts; proliferating capillary sprouts (angioblasts); various types of WBCs; exudate; and loose, semifluid, ground substance. Fibroblasts are immature connective tissue cells that migrate into the healing site and secrete collagen. In time, the collagen is organized and restructured to strengthen the healing site. At this stage, it is termed fibrous or scar tissue. During the granulation phase, the wound is pink and vascular. Numerous red granules (young budding capillaries) are

present. Surface epithelium at the wound edges begins to regenerate. In a few days, a thin layer of epithelium migrates across the wound surface in a one-­cell thick layer until it contacts cells spreading from the opposite direction. The epithelium thickens and begins to mature, and the wound now closely resembles the adjacent skin. In a superficial wound, re-­epithelialization may take 3 to 5 days.  Maturation Phase and Scar Contraction.  The maturation phase, in which scar contraction occurs, overlaps with the granulation phase. It begins 7 days after the injury and continues for several months or years, during which time collagen fibres are further organized, and the remodelling process occurs. Fibroblasts disappear as the scar becomes stronger. The active movement of the myofibroblasts causes contraction of the healing area, helping to close the defect and bring the skin edges closer together to form a mature scar. In contrast to granulation tissue, a mature scar is virtually avascular and pale.  Secondary Intention.  Wounds with wide or irregular wound margins that cannot be approximated will heal by secondary intention. Examples include chronic wounds, such as venous leg ulcers, and wounds caused by trauma or pressure. In some instances, a surgical incision may become infected, resulting in dehiscence, and healing by secondary intention must then take place. The process of healing by secondary intention is essentially the same as that of healing by primary intention. The major differences are the larger defect and the gaping wound edges. The inflammatory reaction that occurs is often greater than in primary healing, which creates more debris, cells, and exudate. The debris may have to be cleaned away (debrided) before healing can take place. Healing and granulation take place from the edges inward and from the bottom of the wound upward until the defect is filled. There is more granulation tissue, and the result is a much larger scar.  Tertiary Intention.  Tertiary intention (delayed primary intention) healing occurs when a wound is intentionally left open because if the wound is closed immediately, healing could be impaired by contamination (e.g., animal bite or foreign body), infection or high risk of infection, edema, or poor circulation. The wound is later closed surgically after the issue is controlled or resolved. Healing by tertiary intention usually results in a larger and deeper scar than does healing by primary or secondary intention.  Wound Classification.  Correctly classifying a wound requires identifying the underlying cause. Wounds can be categorized by cause (surgical or nonsurgical), underlying pathology (vascular, pressure, diabetes related), duration (acute or chronic), level of contamination, or type of tissue affected (superficial, partial thickness, or full thickness). A superficial wound involves only the epidermis. Partial-­thickness wounds extend into the dermis. Full-­thickness wounds cause destruction to the deepest layer of tissue because they involve the subcutaneous tissue and sometimes even extend into the fascia and underlying structures such as muscle, tendon, or bone (see Figure 27.3). Pressure injuries are the only type of wound that are described and classified using the staging system (European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance [EPUAP/NPIAP/PPPIA], 2019); see Table 14.­13 later in this chapter). Another system that is sometimes used clinically to categorize open wounds is based on the colour of the wound bed (red, yellow, black) rather than on the level of tissue destruction

CHAPTER 14  Inflammation and Wound Healing

A

B

C

D

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FIG. 14.5  Wounds classified by colour assessment. A, Black wound. B, Yellow wound. C, Red wound. D, Mixed-­colour

wound. Source: Courtesy Molnlyche Health Care, Eddystone, PA. In Potter, P. A., & Perry, A. G. (2009). Fundamentals of nursing (8th ed., p. 1285). Elsevier.

(Figure 14.5). It can be used to describe any wound allowed to heal by secondary or tertiary intention. When a wound contains two or three colours at the same time, it should be classified according to the least desirable colour present (e.g., if there is any black in the wound, the wound is deemed “black”).  Delay of Healing.  In a healthy person, wounds heal at a normal, predictable rate. Little can be done to accelerate this process. However, some factors may delay wound healing. These are summarized in Table 14.­9.  Complications of Healing.  Complications of wound healing may include adhesions, contractures, dehiscence and evisceration, excess granulation tissue, fistula formation, infection/ biofilm, hemorrhage, and formation of hypertrophic scars and keloids. Adhesions.  Adhesions are bands of scar tissue that form between or around organs. They may develop in the abdominal cavity or between the lungs and pleura. Adhesions in the abdomen may cause an intestinal obstruction. Those between the lungs and the pleura necessitate decortication, or stripping of pleura, to enable normal ventilation.  Contractures.  Wound contraction is an important part of healing. This process may become abnormal when contraction is excessive, which results in deformity, or contracture. Shortening of muscle or scar tissue, especially over joints, results from excessive fibrous tissue formation. Contractures frequently occur in burn injuries, when extensive skin and subcutaneous tissue are lost (see Chapter 27).  Dehiscence and Evisceration.  Dehiscence is the separation and disruption of previously joined wound edges. It usually occurs when a primary healing site bursts open (Figure 14.6). Dehiscence has three possible contributing causes. First, an infection may cause an inflammatory process. Second, the

FIG. 14.6  Dehiscence after a cholecystectomy. Source: Bale, S., & Jones, V. (2006). Wound care nursing: A patient-­centered approach (2nd ed., p. 20). Mosby.

granulation tissue may not be strong enough to withstand the forces imposed on the wound—for example, if a fluid pocket (seroma or hematoma) develops between the tissue layers. Third, individuals with obesity are at a high risk for dehiscence because adipose tissue has less blood supply, which can slow healing. Evisceration occurs when wound edges separate to the extent that intestines protrude through the wound.  Excess Granulation Tissue.  Excess granulation tissue or hypergranulation tissue (“proud flesh”) may protrude above the surface of the healing wound, affecting keratinocyte migration. Hypergranulation tissue may be cauterized or cut off to promote normal healing. 

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SECTION 2  Pathophysiological Mechanisms of Disease

TABLE 14.9    FACTORS DELAYING WOUND HEALING Factor Nutrition • Vitamin C deficiency • Protein deficiency • Zinc deficiency Inadequate blood supply Smoking Corticosteroid medications Infection Anemia Advanced age Obesity Diabetes mellitus Poor general health Mechanical friction on wound Cold temperature Excessive moisture

Effect on Wound Healing Delays formation of collagen fibres and capillary development Decreases supply of amino acids for tissue repair Impairs epithelialization Decreases supply of nutrients to injured area, decreases removal of exudative debris, inhibits inflammatory response Nicotine is a potent vasoconstrictor and impedes blood flow to healing areas, which results in tissue ischemia and impairs wound healing Impair phagocytosis by WBCs, inhibit fibroblast proliferation and function, depress formation of granulation tissue, inhibit wound contraction Increases inflammatory response and tissue destruction Reduces supply of oxygen to tissues Slows collagen synthesis by fibroblasts, impairs circulation, imposes need for longer time for epithelialization of skin, alters phagocytic and immune responses Decreases blood supply in fatty tissue Decreases collagen synthesis, retards early capillary growth, impairs phagocytosis (result of hyperglycemia), reduces supply of O2 and nutrients as a result of vascular disease Causes generalized absence of factors necessary to promote wound healing Destroys granulation tissue, prevents apposition of wound edges Decreases cellular activity and fibroblast proliferation Promotes formation of hypergranulation tissue, which prevents the migration of epithelial cells

WBCs, white blood cells.

Fistula Formation.  A fistula is an abnormal passage that forms between organs or a hollow organ and the skin. For example, a connection between the bowel and the skin would be referred to as an enterocutaneous fistula; it allows intestinal content or stool to leak through the skin. A connection between the bowel and the bladder would be referred to as an enterovesical fistula.  Infection.  A wound has an increased risk of infection when it contains necrotic tissue, when the blood supply is decreased, when the immune function is depressed, or if a patient is malnourished, has multiple stressors, or is diabetic. Aggregation of microorganisms produce biofilm that can delay wound healing.  Hemorrhage.  Bleeding is normal immediately after tissue injury and ceases with clot formation. Hemorrhage occurs as abnormal internal or external blood loss caused by suture failure, clotting abnormalities, dislodged clot, infection, or erosion of a blood vessel by a foreign object (tubing, drains) or infection process.  Formation of Hypertrophic Scars and Keloids.  Hypertrophic keloid scars form when the body produces excess collagen. A hypertrophic scar is inappropriately large, red, raised, and hard (Figure 14.7). However, it remains confined to the wound edges and regresses in time. In contrast, a keloid is a protrusion of scar tissue that extends beyond the wound edges and may form tumour-­like masses of scar tissue (Figure 14.8). Keloids are permanent, without any tendency to subside. A person with keloids often feels tenderness, pain, and hyperesthesia in the area of the scar, particularly in the early stages of development. Keloid formation is thought to be hereditary and occurs more often in dark-­skinned people, particularly Black individuals. Neither complication is life-­ threatening, but both can have serious cosmetic implications. 

NURSING MANAGEMENT INFLAMMATION AND HEALING NURSING IMPLEMENTATION HEALTH PROMOTION.  The best management of inflammation is the prevention of infection, trauma, surgery, and contact with potentially harmful agents. This is not always possible;

FIG. 14.7  Hypertrophic scarring. Source: Courtesy Dr. C. Lawrence, Wound

Healing Research Unit, Cardiff, Wales, UK. In Bale, S., & Jones, V. (2006). Wound care nursing: A patient-­centered approach (2nd ed., p. 16). Mosby.

for example, a simple mosquito bite causes an inflammatory response. Because occasional injury is inevitable, concerted efforts to minimize inflammation and infection are needed. Adequate nutrition is essential so that the body has the necessary factors to promote healing when injury occurs. Individuals at risk for wound-­healing complications are those with malabsorption problems (e.g., Crohn’s disease, gastrointestinal surgery, liver disease), deficient intake or high energy demands (e.g., malignancy, major trauma or surgery, sepsis, fever), or diabetes. An individual should always be considered at risk for delayed wound healing if the following have occurred: (a) loss of 20% or more of total body weight in the preceding 6 months or (b) 10% loss of total body weight in the preceding 2 months. Special nutritional measures facilitate wound healing. Fluid intake must be high to replace fluid loss from perspiration and exudate formation. An increased metabolic rate intensifies water loss. For every 1°C increase in body temperature above 37.8°C, metabolism increases by 13%. A diet high in protein, carbohydrate,

CHAPTER 14  Inflammation and Wound Healing

FIG. 14.8  Keloid scarring. Source: Courtesy Dr. C. Lawrence, Wound Healing Research Unit, Cardiff, Wales, UK. In Bale, S., & Jones, V. (2006). Wound care nursing: A patient-­centered approach (2nd ed., p. 17). Mosby.

and vitamins with moderate fat intake is necessary to promote healing. Protein is needed to correct the negative nitrogen balance that results from the increased metabolic rate. Protein is also necessary for synthesis of immune factors, leukocytes, fibroblasts, and collagen. Carbohydrate is needed for the increased metabolic energy required for inflammation and healing. If carbohydrate intake is deficient, the body breaks down protein for the needed energy. Fats are also a necessary component in the diet to help in the synthesis of fatty acids and triglycerides, which are part of the cellular membrane. Vitamin C is needed for capillary synthesis, capillary formation, and resistance to infection. The B-­complex vitamins are necessary as coenzymes for many metabolic reactions. If a vitamin B deficiency develops, metabolism of protein, fat, and carbohydrate is disrupted. Vitamin A is also needed in healing because it aids in the process of epithelialization. It increases collagen synthesis and tensile strength of the healing wound. Patients are sometimes given vitamin A to counteract the effects of steroids on wound healing. If the patient is unable to eat, enteral feedings and supplements should be the first choice if the gastrointestinal tract is functional. Parenteral nutrition is indicated when enteral feedings are contraindicated or not tolerated. (Enteral nutrition and parenteral nutrition are discussed in Chapter 42.) The manifestations of inflammation and infection must be recognized early so that appropriate treatment can begin. Treatment may be rest, medication therapy, or specific care of the injured site. Immediate treatment may prevent the extension and complications of prolonged inflammation.  Acute Intervention Observation and Vital Signs.  The ability to recognize the clinical manifestations of inflammation is important. In a patient who is immunosuppressed (e.g., taking corticosteroids or receiving chemotherapy), the classic manifestations of inflammation may be masked. In such a patient, early symptoms of inflammation may be malaise or “just not feeling well.” Observation and recording of wound characteristics are essential. The amount, consistency, colour, and odour of any drainage should be recorded and reported if abnormal. Staphylococcus and Pseudomonas organisms commonly cause purulent drainage. Exudate from wounds colonized with Pseudomonas often has a distinctive bright “highlighter” yellow or green appearance.

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Vital signs are important to note with any inflammation, especially when an infectious process is present. When infection is present, temperature may rise, and pulse and respiration rates may increase. If a wound infection develops in a postoperative patient, vital signs change within 3 to 5 days after surgery.  Fever.  Although fever is usually regarded as harmful, an increase in body temperature is an important host defence mechanism. Steps are frequently taken to lower body temperature to relieve the anxiety of the patient and medical personnel. Because a mild fever does little harm, imposes no great discomfort, and may benefit host defence mechanisms, antipyretic medications are rarely essential for patient welfare. Moderate fevers (up to 39.5°C) usually produce few problems in most patients. However, if the patient is very young or very old, is extremely uncomfortable, or has a significant medical condition (e.g., severe cardiopulmonary disease, brain injury), the use of antipyretics should be considered. Fever in an immunosuppressed patient should be treated rapidly and antibiotic therapy begun because infections can rapidly progress to septicemia. (Neutropenia is discussed in Chapter 33.) Fever (especially if the temperature exceeds 40°C) can be damaging to body cells, and delirium and seizures can occur. At temperatures higher than 41°C, regulation by the hypothalamic temperature control centre becomes impaired, and many cells, including those in the brain, can be damaged. Older persons have a blunted febrile response to infection (El Chakhtoura et al., 2017). The body temperature may not rise to the level expected for a younger adult, or the onset of fever may be delayed. The blunted response can delay diagnosis and treatment. By the time fever (as defined for younger adults) is present, the illness may be severe. Several medications are commonly used to lower the body temperature set point in the hypothalamus (Table 14.­10). Aspirin specifically blocks prostaglandin synthesis in the hypothalamus and elsewhere in the body. Acetaminophen acts on the heat-­regulating centre in the hypothalamus. Some NSAIDs (e.g., ibuprofen [Motrin, Advil]) have antipyretic effects. Corticosteroids are antipyretic through the dual mechanisms of inhibiting interleukin-­1 production and preventing prostaglandin synthesis. The action of these medications results in dilation of superficial blood vessels, increased skin temperature, and sweating. Antipyretics should be given around the clock to prevent acute swings in temperature. These agents cause a sharp decrease in temperature. When the antipyretic wears off, the body may initiate a compensatory involuntary muscular contraction (i.e., chill) to raise the body temperature back up to its previous level. To prevent this unpleasant adverse effect, these agents should be administered regularly at 2-­to 4-­hour intervals. Although sponge baths increase evaporative heat loss, there is no evidence that they decrease the body temperature unless antipyretic medications have been given to lower the set point; otherwise, the body will initiate compensatory mechanisms (e.g., shivering) to restore body heat. The same principle applies to the use of cooling blankets; they are most effective in lowering body temperature when the set point has also been lowered. The nursing care of the patient with a fever is presented in Nursing Care Plan 14.1, available on the Evolve website.  RICE.  Rest, ice, compression, and elevation (RICE) constitute a key concept in the treatment of soft tissue injuries and related inflammation. Rest.  Rest helps the body use its nutrients and oxygen for the healing process. The repair process is facilitated when fibrin

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SECTION 2  Pathophysiological Mechanisms of Disease

TABLE 14.10    MEDICATION THERAPY Inflammation and Healing Medication

Mechanisms of Action

Antipyretic Medications Salicylates (Aspirin) Acetaminophen (Tylenol) NSAIDs (e.g., ibuprofen [Motrin, Advil])

Lower temperature by action on heat-­regulating centre in hypothalamus, resulting in peripheral dilation and heat loss; interfere with formation and release of prostaglandins; selectively depress CNS Lowers temperature by action on heat-­regulating centre in hypothalamus Inhibit synthesis of prostaglandins

Anti-­inflammatory Medications Salicylates (Aspirin) Corticosteroids (e.g., prednisone) NSAIDs (e.g., ibuprofen [Motrin], naproxen [Naprosyn], celecoxib [Celebrex])

Inhibit synthesis of prostaglandins, reduce capillary permeability Interfere with tissue granulation, induce immunosuppressive effects (decreased synthesis of lymphocytes), prevent liberation of lysosomes Inhibit synthesis of prostaglandins

Vitamins Vitamin A Vitamin B complex Vitamin C Vitamin D

Accelerates epithelialization Acts as coenzymes Assists in synthesis of collagen and new capillaries Facilitates calcium absorption

CNS, central nervous system; NSAIDs, nonsteroidal anti-­inflammatory drugs.

and collagen are allowed to form across the wound edges with little disruption.  Ice and Heat.  At the time of initial trauma, cold application is usually appropriate to promote vasoconstriction and decreases swelling, pain, and congestion from increased metabolism in the area of inflammation. Cold application should be used with caution in areas where vascular flow is compromised. Heat may be used later (e.g., after 24 to 48 hours) and when swelling has subsided to promote healing by increasing the circulation to the inflamed site and subsequent removal of debris. Heat is also used to localize the inflammatory agents. Warm, moist heat may help debride the wound site if necrotic material is present.  Compression and Immobilization.  Compression counters vasodilation and development of edema after an injury. Compression by direct pressure over a laceration occludes blood vessels to stop bleeding. Compression bandages provide support to injured joints that have tendons and muscles unable to provide support on their own. Distal pulses and capillary refill should be assessed before and after application of compression to assess whether compression has compromised circulation (e.g., as evidenced by pale colour of skin or loss of sensation). Immobilization of the inflamed area promotes healing by decreasing the tissues’ metabolic need. Immobilization with a cast, splint, or bandage supports fractured bones and prevents further tissue injury from sharp bone fragments that could sever nerves or blood vessels (causing hemorrhage).  Elevation.  Elevation of an injured extremity reduces the edema at the inflammatory site by increasing venous and lymphatic return. Elevation helps reduce pain associated with blood engorgement at the injured site. Elevation may be contraindicated in patients with significantly reduced arterial circulation.  Wound Management.  The type of wound management and dressings required depend on the type, extent, and characteristics of the wound and the phase of healing (Nurses Specialized in Wound, Ostomy and Continence Canada [NSWOCC], 2021). The purposes of wound management include (a) cleaning and debriding the wound to remove debris and dead tissue from the wound bed, (b) controlling inflammation and treating infection to prepare the wound for healing, and (c) providing

moisture balance for healable wounds. Tissue debridement and moisture may not always be appropriate for nonhealable and maintenance wounds (Woo, 2017). Treatment of pressure injuries is discussed in more detail later in this chapter.

EVIDENCE-­INFORMED PRACTICE Research Highlight What Is the Effect of Support Surfaces on Pressure Injury Prevention? Clinical Question In patients who are at risk for developing pressure injury (P), what is the effect of therapeutic support surfaces (I) versus standard support surfaces (C) on incidence of pressure injuries (O)? 

Best Available Evidence Randomized controlled trials and quasi-­randomized controlled trials 

Critical Appraisal and Synthesis of Evidence • F  ifty nine trials (n = 12 to 1 171 per trial) involving people who were at risk for pressure injury. Studies included 12 trials that evaluated cushions; 5 evaluating the use of sheepskins; 4 that looked at turning beds/tables; 19 that examined overlays; 28 that looked at mattresses; 3 evaluating use of foam surfaces; 2 examining waffle surfaces; and 1 that examined use of the Heelift suspension boot. • Foam alternatives to the standard hospital foam mattress reduce the incidence of pressure ulcers in people at risk. • Pressure-­relieving overlays on the operating table and in the postoperative period reduce the incidence of postoperative pressure ulcers. 

Conclusion • U  sing tap water to cleanse acute wounds does not increase infection rate and, in some cases, it may reduce infection. 

Implications for Nursing Practice • T  herapeutic surfaces should be considered for the prevention of pressure injuries.

Reference for Evidence McInnes, E., Jammali-­Blasi, A., Bell-­Syer, S. E., et al. (2015). Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews 2015 (Issue 9) Art. No. CD001735. doi:10.1002/14651858.CD001735.pub5. C, comparison of interest or comparison group; I, intervention or area of interest; O, outcomes of interest; P, patient population of interest. (see Chapter 1).

CHAPTER 14  Inflammation and Wound Healing Wound healing management by secondary intention depends on the cause of the wound and the type of tissue in the wound. The red–yellow–black concept of wound care (see Figure 14.5) can be used to describe the wound, and dressing selection depends on the characteristics of the wound. Examples of wound dressing types are presented in Table 14.­11. Red Wound.  A red wound can be superficial or deep and is clean and red or pink in appearance. Examples include skin tears, pressure injuries, partial-­thickness or second-­degree burns, and wounds created surgically that are allowed to heal by secondary intention. The goal of treatment is gentle cleansing and protection of the wound (LeBlanc et al., 2019). Wounds should be cleaned with normal saline, water, or noncytotoxic wound cleansers (NSWOCC, 2021). Clean wounds that are granulating and re-­epithelializing should be kept slightly moist and protected from further trauma (Jones et al., 2018). A dressing that keeps the wound surface clean and slightly moist is optimal in promoting epithelialization. Unnecessary manipulation during

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dressing changes may destroy new granulation tissue and break down fibrin formation.  Yellow Wound.  A yellow wound has nonviable necrotic tissue, which creates an ideal environment for bacterial growth. The goal of treatment is absorption of excessive drainage and removal of nonviable tissue (described in the next section). Topical antimicrobials and antiseptics (e.g., povidone-­iodine, sodium hypochlorite [e.g., Dakin’s solution], hydrogen peroxide, acetic acid, and chlorhexidine) may be used to cleanse wounds containing debris that are highly colonized or infected. They are not recommended to clean granulating wounds (NSWOCC, 2021).  Black Wound.  A black wound is covered with thick, dry, necrotic tissue called eschar that is black, brown, or grey. Examples of black wounds include third-­degree burns and gangrenous ulcers. The risk of wound infection increases in proportion to the amount of necrotic tissue present. The immediate treatment is removal of the nonviable eschar. The debridement

TABLE 14.11    TYPES OF WOUND DRESSINGS Type

Description

Examples

Gauze

Provides minimal absorption of exudate. Supports debridement if applied and kept moist. Can be used as filler dressings in sinus tracts. Woven or nonwoven dressings may be impregnated with petrolatum or antimicrobial medications. Minimally absorbent. Used on minor wounds or skin tears. Semipermeable membrane that permits gaseous exchange between wound bed and environment. Minimally absorbent so that environment is kept moist in presence of exudate. Bacteria do not penetrate membrane. Used for dry, noninfected wounds, wounds with minimal drainage, or stage 1 pressure injuries to help prevent friction and shear. Used for superficial and partial-­thickness wounds with light drainage. Requires less frequent dressing changes. Occlusive dressing does not allow O2 to diffuse from atmosphere to wound bed. Occlusion does not interfere with wound healing and supports debridement. Used for superficial and partial-­thickness wounds with light to moderate drainage. Strong adhesive may not be suitable for fragile skin. Product comes in many shapes and sizes. Absorbs moderate to heavy amount of exudate. Used for partial-­ or full-­thickness wounds or infected wounds. Large volume of exudate can be absorbed. Dressing forms a gel-­like substance that supports autolytic debridement and maintains moistness of wound surface. Fills wound cavities and obliterates dead space. Available in rope or sheet form. For partial-­ or full-­thickness wounds or infected wounds with heavy drainage. Dressing should not be used for lightly draining or dry wounds because it can desiccate the wound bed. A secondary dressing is required. Calcium alginate is a natural hemostatic agent. Sheet, ribbon, or gel impregnated with sodium chloride concentrate. Should not be used on dry wounds (which should be treated with a hydrogel). May be painful on sensitive tissue. Facilitates autolytic debridement of necrotic tissue. Maintains moistness of wound surface. Provides limited absorption of exudate. Available as sheet, gel, and impregnated gauze. A secondary dressing is required. Used for partial-­ or full-­thickness wounds with minimal drainage and for necrotic wounds. Has a cooling effect on the wound and thus is effective in managing pain. Dressing that contains odour-­absorbent charcoal layered within the product. Some products contain silver to enhance antimicrobial capability. Broad spectrum against bacteria. Silver, polyhexamethylene biguinide (PHMB), cadexomer iodine, methylene blue/gentian violet, or honey with vehicle for delivery: sheets, foams, alginates, ribbons, gels, or paste. Products are not to be used on patients with known hypersensitivity to any product components.

Nu Gauze (numerous products available) Adaptic, Jelonet, Bactigras, Inadine

Nonadherent dressing Transparent film

Acrylic clear Hydrocolloid dressing

Foam Alginate, calcium alginate, and hydrofibre dressings

Hypertonic dressing

Hydrogel

Charcoal dressing Antimicrobial dressing

Biological dressing

Living human fibroblasts provided in sheets at ambient or frozen temperatures. Extracellular matrix. Collagen-­containing preparations. Hyaluronic acid. Not to be used on wounds with infections, sinus tracts, or excessive exudate, or on patients with hypersensitivity to any of the product components.

Bioclusive, OpSite, Tegaderm, Mefilm

Tegaderm Absorbent Comfeel, DuoDERM, Restore, Tegasorb

Allevyn, Hydrasorb, Lyofoam, Mepilex, Biatain, Tegaderm Foam Aquacel, Kaltostat, Tegagen, Seasorb, Fibracol, Algisite, Algisite M, Melgisorb

Mesalt, Hypergel

IntraSite Gel, DuoDERM Hydroactive Gel, Normlgel, Nu-­Gel, Tegagel, Tegaderm Hydrogel wound filler

Actisorb, Carbonet, CarboFlex Acticoat, AMD Antimicrobial Foam, Iodosorb, Allevyn Ag, Mepilex Ag, Aquacel Ag, Contreet, Silvercel, SilvaSorb, Tegaderm Ag Mesh, Hydrofera Blue, Medihoney Apligraf, Dermagraft, Oasis Wound Matrix, Promogran, Tegaderm Matrix

Source: Information on antimicrobials and biological dressings from Wounds Canada. (2017). Product picker: Wound dressing formulary. https://www.woundscanada.ca/docman/public /health-­care-­professional/1113-­product-­picker-­2017-­formulary/file

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SECTION 2  Pathophysiological Mechanisms of Disease

method used depends on the amount of debris and the condition of the wound tissue (NSWOCC, 2021). There are several approaches to debridement: 1. Surgical debridement. This fast and cost-­effective method of debridement is indicated when large amounts of tissue are nonviable and the patient has sepsis. Sharp surgical debridement is selective and can be performed in the operating room or at the patient’s bedside, depending on the extent of necrotic material (Woo et  al., 2015). Only wounds that have an adequate blood supply and are considered “healable” should be debrided surgically. Conservative sharp wound debridement involves the removal of devitalized tissue with very minimal bleeding (NSWOCC, 2021). 2. Mechanical debridement. This method is used when debris is minimal. One example is wet-­to-­dry dressings, in which open-­mesh gauze is moistened with normal saline, placed on the wound surface, and allowed to dry. Wound debris adheres to the dressing. When the dressing is removed, the debris trapped in the gauze is mechanically separated from the wound bed. One disadvantage to this method is that it is nonselective and destroys some healthy tissue. Mechanical debridement can be painful, and the patient should receive appropriate pain management before the removal of a wet-­to-­dry dressing. Another method of mechanical debridement is pressurized wound irrigation, in which water is delivered at high or low pressure to remove bacteria, foreign matter, and necrotic tissue from the wound. It is important to ensure that an adequate amount of irrigant is used to ensure thorough cleaning of the wound surface and surrounding areas. Whirlpool is another method of mechanical debridement that is no longer recommended because of the risk of tissue maceration and bacterial cross-­contamination. Ultrasonic debridement devices are costly but they offer a noncontact debridement method. 3. Autolytic debridement. Hydrogels, semi-­occlusive dressings, or occlusive dressings (see Table 14.­11) may be used to promote softening of dry eschar by autolysis. This is a slow but selective and painless process that enables the body’s own endogenous enzymes to selectively rehydrate, soften, and liquefy necrotic tissue. These types of dressings are used in noninfected wounds with necrotic tissue and adequate circulation. The use of a skin protectant around the wound helps prevent maceration. 4. Enzymatic debridement. In this method, a topical ointment containing proteolytic enzymes is applied to the necrotic tissue in the wound and then covered with a moist dressing such as saline-­moistened gauze and changed daily. Santyl collagenase is the only product in this category currently available in Canada. The wound pH must be between 6 and 8 for optimal enzyme activity; therefore, cleansing products containing detergents or heavy metals such as mercury or silver should not be used. 5. Biosurgical debridement. In this debridement method, medical-­grade maggots are applied directly to a wound in a controlled and contained environment. The maggots clean the wound by digesting dead tissue with their proteolytic, digestive enzymes. They also kill bacteria by ingesting them and can destroy biofilm.  Negative-­Pressure Wound Therapy.  This therapy involves the application of negative pressure (suction) to the wound bed. The vacuum creates continuous or intermittent negative pressure at the wound base to remove fluid, exudate, and infectious

material and to promote blood flow. The wound is cleansed, and the periwound area is protected with a skin protectant. For deep open wounds, a filler (foam or gauze dressing depending on the manufacturer) may be used to loosely fill to the surface of the wound. A large semi-­occlusive dressing is applied over the top to create a sealed environment and then attach to a suction pump (Figure 14.9). Wound types suitable for this therapy include chronic, acute, traumatic, and dehisced wounds; partial-­thickness burns; diabetic ulcers; stage 3 and stage 4 pressure injuries; flaps; and grafts. Contraindications include malignancy, untreated osteomyelitis, fistula, eschar, and active bleeding. It is important to count and document the number of pieces of foam or gauze used in the wound. For further information on negative-­pressure wound therapy, refer to the Ontario Ministry of Health and Long-­Term Care document Negative Pressure Wound Therapy (see the Resources at the end of this chapter).  Hyperbaric Oxygen Therapy.  Hyperbaric oxygen therapy is the systemic delivery of oxygen at increased atmospheric pressures. The patient is placed in an enclosed chamber in which 100% oxygen is administered at 1.5 to 3.0 times the normal atmospheric pressure. This form of therapy may accelerate granulation tissue formation and wound closure by increasing blood and tissue oxygen content in hypoxic tissues, which stimulates fibroblast proliferation and collagen synthesis.  Electrical Stimulation.  With this therapy, a generator connected to electrodes is attached to the periwound skin, and an electrical charge is delivered to the wound tissues to produce a physiological response. Electrical stimulation may be used as an adjunct to regular wound care to promote healing and wound closure with stalled but healable stage 2, 3, and 4 pressure injuries that have not responded to other interventions. It should not be used if a patient has osteomyelitis, cancer, an implanted electronic device, or a blood clot in the leg. It should never be applied over a pregnant uterus, dressings with metallic or ionic components, or excitable tissues.  Psychological Implications.  The patient may be distressed at the thought or sight of an incision or wound, because of fear of scarring or disfigurement. Drainage from a wound may also cause alarm. The patient needs to understand the healing process and the normal changes that occur as the wound heals. When a nurse is changing a dressing, their inappropriate facial expressions can alert the patient to problems

A

B

C

FIG. 14.9  Negative-­pressure wound therapy. A, Femoral wound that is not

healing. B, Negative-­pressure wound therapy in place. C, Granulation tissue formation after therapy. Source: Abai, B., Zickler, R. W., Pappas, P. J, et al. (2007). Lymphorrhea responds to negative pressure wound therapy. Journal of Vascular Surgery, 45(3), 610–613. https://doi.org/10.1016/j.jvs.20 06.10.043

CHAPTER 14  Inflammation and Wound Healing with the wound or the nurse’s ability to care for it. Wrinkling of the nose by the nurse may convey disgust to the patient. The nurse should also be careful not to focus on the wound to the extent that the patient is not treated as a total person.  Ambulatory and Home Care.  Because patients are being discharged earlier after surgery and many undergo surgery as outpatients, it is important that the patient, family, or both know how to care for the wound and perform dressing changes. Wound healing may not be complete for 4 to 6 weeks or longer. Adequate rest and good nutrition are essential. Physical and emotional stress should be minimized. The wound should be observed for complications such as infection. The patient should be able to recognize the signs and symptoms of infection and note changes in wound colour and the amount of drainage. The health care provider should be notified of any signs of abnormal wound healing. Medications are often taken for a period after recovery from an acute infection. Medication-­specific adverse effects should be reviewed with the patient, and they should be instructed to contact the health care provider if any of these effects occur. The patient must be taught the necessity to continue the medications for the specified time. For example, a person who is instructed to take an antibiotic for 10 days may stop taking the medication after 5 days because symptoms disappear. However, if a full course of antibiotic is not taken, the infection may not be entirely eliminated and remaining organisms may also become resistant to the antibiotic. 

PRESSURE INJURIES Causes and Pathophysiological Features A pressure injury is a localized injury to the skin or underlying soft tissue, usually over a bony prominence, as a result of excessive or prolonged pressure, shear, and tissue deformation. While most pressure injuries occur from inside out, some of these injuries can be caused by a medical or other device such as catheters. Pressure injuries are generally considered an indicator of the quality of care and most are regarded as avoidable. However, there are instances in which skin breakdown can be considered unavoidable: when patients have limited movement because of hemodynamic instability, when there is inability to provide nutrition and fluids, or at the end of life (Bain et  al., 2020). According to the Canadian Institute for Health Information, pressure injuries are a financial burden to the health care system, in addition to the effect they have on mortality, morbidity, and quality of life. The prevalence of pressure injuries in Canada has been reported to be 0.4% in acute care, 2.4% in home care, 14.1% in complex continuing care, and 6.7% in long-­term care (Canadian Institute for Health Information, 2013). The most common sites for development of pressure injury are the sacrum, ischium, trochanter, coccyx, heels, and malleolus. Factors that influence development of pressure injuries include the amount of pressure (intensity), length of time pressure is exerted on the skin (duration), and ability of the patient’s tissue to tolerate the externally applied stress (Doughty & McNichol, 2016). Besides pressure, shearing force (pressure exerted on the skin when it adheres to the bed and the underlying skin layers slide in the direction of body movement), friction (two surfaces rubbing against each other), and excessive moisture (incontinence or perspiration) contribute to pressure injury formation (EPUAP/NPIAP/PPPIA, 2019). The tolerance

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TABLE 14.12    RISK FACTORS FOR PRESSURE

INJURIES

• Advanced age • Anemia • Contractures • Diabetes mellitus • Elevated body temperature • Immobility • Impaired circulation • Incontinence • Low diastolic blood pressure (90% • Respiratory: Ventolin 2.5 mg via nebulizer every 4 hours PRN for wheezing • Neurovascular checks q1hr × 4 hr • Empty and measure self-­suction drain every shift • Strict intake and output 

Discussion Questions . What are the potential postanaesthesia complications for E. L.? 1 2. Priority decision: What priority nursing interventions would be appropriate to prevent these complications from occurring? 3. What factors may predispose E. L. to the following conditions: atelectasis, infection, pulmonary embolism, and nausea and vomiting? 4. What criteria would determine when E. L. is sufficiently recovered from general anaesthesia to be discharged to the clinical unit? 5. What potential postoperative issues on the clinical unit might be expected? 6. Priority decision: Based on the assessment data presented, what are two priority nursing diagnoses? Are there any interprofessional issues?

Answers are available at http://evolve.elsevier.com/Canada/Lewis/medsurg/.

CHAPTER 22  Nursing Management: Postoperative Care

425

 REVIEW QUESTIONS The number of the question corresponds to the same-­numbered objective at the beginning of the chapter. 1. When a client is admitted to the PACU, what are the priority interventions the nurse performs? a. Assess the surgical site, noting presence and character of drainage. b. Assess the amount of urine output and the presence of bladder distension. c. Assess for airway patency and quality of respirations and obtain vital signs. d. Review results of intraoperative laboratory values and medications received. 2. A client is admitted to the PACU after major abdominal surgery. During the initial assessment, the client states, “I am going to throw up.” What would be the priority nursing intervention? a. Increase the rate of the IV fluids. b. Obtain vital signs, including O2 saturation. c. Position client in lateral recovery position. d. Administer antiemetic medication as ordered. 3. After admission of the postoperative client to the clinical unit, which assessment data require the most immediate attention? a. O2 saturation of 85% b. Respiratory rate of 13/min c. Temperature of 38°C d. Blood pressure of 90/60 mm Hg 4. A 70-­kg postoperative client has an average urine output of 25 mL/ hr during the first 8 hours. Given this assessment, what would the priority nursing intervention(s) be? a. Perform a straight catheterization to measure the amount of urine in the bladder.

b. Notify the physician and anticipate obtaining blood work to evaluate renal function. c. Continue to monitor the client because this is a normal finding during this time period. d. Evaluate the client’s fluid volume status since surgery and obtain a bladder ultrasound. 5. The nurse on the postoperative unit is caring for a client who had a laparoscopic partial colectomy. On postoperative day 2, the client reports abdominal distension and discomfort. Which of the following interventions may be appropriate for this client? (Select all that apply.) a. Increase the dose of opioids for pain relief. b. Insert a nasogastric tube. c. Reassure the client that this complication should subside in a day or two. d. Monitor the client’s abdominal girth by measuring for distension and auscultate the abdomen in all four quadrants. 6. Discharge criteria for the phase II client include which of the following? (Select all that apply.) a. No nausea or vomiting b. Ability to drive themselves home c. No respiratory depression d. Written discharge instructions understood e. Opioid pain medication given 45 minutes ago

REFERENCES

King, C., & Spry, C. (2019). Infection prevention and control. In J. Rothrock & D. McEwen (Eds.), Alexander’s care of the patient in surgery (16th ed., pp. 54–105). Elsevier. Nurses Specialized in Wound, Ostomy and Continence Canada. (2020). The power of 3. https://nswoc.ca/powerof3/ Odom-­Forren, J. (2019). Postoperative pain care and pain management. In J. Rothrock & D. McEwen (Ed.), Alexander’s care of the patient in surgery (16th ed., pp. 261–285). Elsevier. Odom-­Forren, J., & Brady, J. (2018). Postanesthesia recovery. In J. Nagelhout & S. Elisha (Eds.), Nurse anesthesia (6th ed., pp. 1147–1166). Elsevier. Peng, L., & Anker, A. (2020). Outpatient surgery instructions, types of anesthesia, risks and complications. https://www.emedicinehealth.co m/outpatient_surgery/article_em.htm#what_is_outpatient_surgery Peterson, C. (2018). The hepatobiliary and gastrointestinal system. In J. Odom-­Forren (Ed.), Drain’s perianesthesia nursing: A critical care approach (7th ed., pp. 221–226). Elsevier. Registered Nurses’ Association of Ontario. (2016). Delirium, dementia and depression in older adults: Assessment and care (2nd ed.). https://rnao.ca/bpg/guidelines/screening-­delirium-­dementia-­and-­ depression-­older-­adult Smith, C. (2019). Workplace issues and staff safety. In J. Rothrock & D. McEwen (Eds.), Alexander’s care of the patient in surgery (16th ed., pp. 38–53). Elsevier. Wang, L., Xu, D., Wei, X., et al. (2016). Electrolyte disorders and aging: Risk factors for delirium in patients undergoing orthopedic surgeries. BMC Psychiatry, 16, 418. https://doi.org/10.1186/ s12888-­016-­1130-­0

1. c; 2. c; 3. a; 4. d; 5. b, c, d; 6. c, d, e.

Allen, S. (2019). Geriatric surgery. In J. Rothrock & D. McEwen (Eds.), Alexander’s care of the patient in surgery (16th ed., pp. 1069–1090). Elsevier. Bak, J. (2019). Wound healing, dressings, and drains. In J. Rothrock & D. McEwen (Eds.), Alexander’s care of the patient in surgery (16th ed., pp. 244–260). Elsevier. Cagir, B. (2018). Postoperative ileus. https://emedicine.medscape.com/ article/2242141-­treatment Canadian Association of Wound Care and Canadian Association for Enterostomal Therapy. (2011). The Wound CARE Instrument: Collaborative Appraisal and Recommendations for Education. https://www.woundscanada.ca/docman/public/health-careprofessional/551-wound-care-instrument-1/file Canadian Patient Safety Institute. (2020). Surgical site infection (SSI): Getting started kit. https://www.patientsafetyinstitute.ca/en/toolsRe sources/Pages/SSI-­resources-­Getting-­Started-­Kit.aspx Cuming, R. (2019). Concepts basic to perioperative nursing. In J. Rothrock & D. McEwen (Eds.), Alexander’s care of the patient in surgery (16th ed., pp. 1–13). Elsevier. DeVolder, B. (2019). Gastrointestinal surgery. In J. Rothrock & D. McEwen (Eds.), Alexander’s care of the patient in surgery (16th ed., pp. 287–340). Elsevier. Dowsett, C., & von Hallern, B. (2017). The triangle of wound assessment: A holistic framework from wound assessment to management goals and treatments. Wounds International 2017, 8(4), 34–39.

For even more review questions, see the website for this book at http://evolve.elsevier.com/Canada/Lewis/medsurg.

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SECTION 3  Perioperative Care

RESOURCES Canadian Allergy, Asthma, and Immunology Foundation https://www.allergyfoundation.ca Canadian Anesthesiologists’ Society https://www.cas.ca Canadian Pain Society https://www.canadianpainsociety.ca National Association of PeriAnesthesia Nurses of Canada http://www.napanc.org

Operating Room Nurses Association of Canada http://www.ornac.ca Registered Nurses’ Association of Ontario https://rnao.ca Wounds Canada https://www.woundscanada.ca For additional Internet resources, see the website for this book at http://evolve.elsevier.com/Canada/Lewis/medsurg.

S E C T I O N

4

Conditions Related to Altered Sensory Input

Source: © CanStock Photo/Elenathewise

Chapter 23: Nursing Assessment: Visual and Auditory Systems Chapter 24: Nursing Management: Visual and Auditory Conditions Chapter 25: Nursing Assessment: Integumentary System Chapter 26: Nursing Management: Integumentary Conditions Chapter 27: Nursing Management: Burns

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CHAPTER

23

Nursing Assessment

Visual and Auditory Systems Marian Luctkar-­Flude Originating US chapter by Jonel L. Gomez and Mariann M. Harding

WEBSITE http://evolve.elsevier.com/Canada/Lewis/medsurg • • • •

• • •

 eview Questions (Online Only) R Key Points Answer Guidelines for Case Study Conceptual Care Map Creator

 udio Glossary A Supporting Media—Animation • Weber Test Content Updates

LEARNING OBJECTIVES 1. Describe the structures and functions of the visual and auditory systems. 2. Describe the physiological processes involved in normal vision and hearing. 3. Identify the significant subjective and objective assessment data related to the visual and auditory systems that should be obtained from the patient. 4. Describe the appropriate techniques used in the physical assessment of the visual and auditory systems.

5. Differentiate normal from common abnormal findings of a physical assessment of the visual and auditory systems. 6. Explain how age-­related changes in the visual and auditory systems correspond to differences in assessment findings. 7. Describe the purpose, the significance of results, and the nursing responsibilities related to diagnostic studies of the visual and auditory systems.

KEY TERMS accommodation aqueous humor astigmatism conjunctiva hyperopia lens

  

myopia nystagmus PERRLA posterior cavity presbycusis presbyopia

  THE VISUAL SYSTEM STRUCTURES AND FUNCTIONS The visual system consists of the external tissues and structures surrounding the eye, the external and internal structures of the eye, the refractive media, and the visual pathway. The external structures are the eyebrows, eyelids, eyelashes, lacrimal system, conjunctiva, cornea, sclera, and extraocular muscles. The internal structures are the iris, lens, ciliary body, choroid, and retina. The entire visual system is important for visual function. Light reflected from an object in the field of vision passes through the transparent structures of the eye and, in doing so, is refracted

428

retina sclera tinnitus vertigo vitreous humor

(bent) so that a clear image can fall on the retina. From the retina, the visual stimuli travel through the visual pathway to the occipital cortex, where they are perceived as an image.

Structures and Functions of Vision Eyeball.  The eyeball, or globe, is composed of three layers (Figure 23.1). The tough outer layer is composed of the sclera and the transparent cornea. The middle layer consists of the uveal tract (iris, choroid, and ciliary body). The innermost layer is the retina. The anterior chamber lies between the iris and the posterior surface of the cornea, whereas the posterior chamber lies between the anterior surface of the lens and the posterior

CHAPTER 23  Nursing Assessment: Visual and Auditory Systems

429

Sclera Choroid Retina Canal of Schlemm Lens Iris Cornea (transparent)

Fovea centralis Macula

Anterior chamber (contains aqueous humor) Pupil Posterior chamber (contains aqueous humor) Suspensory ligament Ciliary body

Optic nerve Optic disc

Posterior cavity

Vitreous humor FIG. 23.1  The human eye. Source: Adapted from Patton, K. T., & Thibodeau, G. A. (2013). Anatomy and physiology (8th ed., p. 527). Mosby.

surface of the iris. The posterior cavity (vitreous cavity) lies between the posterior lens and the retina.  Refractive Media.  For light to reach the retina, it must pass through several structures: the cornea, the aqueous humor, the lens, and the vitreous humor. All these structures must remain clear for light to reach the retina and stimulate the photoreceptor cells. The cornea, which is normally transparent, is the first structure through which light passes. It is responsible for most of the light refraction necessary for clear vision. Aqueous humor, produced by the ciliary process, is a clear, watery fluid that fills the anterior and posterior chambers of the anterior cavity of the eye. It bathes and nourishes the lens and the endothelium of the cornea. It drains through the trabecular meshwork located in the angle. This circular canal conveys fluid into scleral veins, which enter the circulation of the body. Normal intraocular pressure is between 10 and 21 mm Hg; excess production or decreased outflow of the aqueous humor can cause an elevation in this pressure, a condition termed glaucoma. The lens is a biconvex structure located behind the iris and supported in place by small fibres collectively called the suspensory ligament (also called the zonule) that connect the lens to the ciliary body. The primary function of the lens is to bend light rays, which enables them to fall onto the retina. Anything altering the clarity of the lens affects light transmission. The vitreous humor is located in the posterior (vitreous) cavity (see Figure 23.1). Light passing through the vitreous humor may be blocked by any nontransparent substance within, such as the cellular debris (often called floaters). The effect on vision varies, depending on the amount, type, and location of the substance blocking the light. 

Refractive Errors.  Refraction is the ability of the eye to bend light rays so that they fall on the retina (Figure 23.2). In the normal eye, parallel light rays are focused through the lens into a sharp image on the retina. The state that enables this process is termed emmetropia, which means that light is focused exactly on the retina, not in front of it or behind it. The condition in which the light does not focus properly is called a refractive error. The individual with myopia can see near objects clearly (nearsightedness), but objects in the distance appear blurred. The individual with hyperopia can see distant objects clearly (farsightedness), but near objects appear blurred. Astigmatism is an imperfection in the curvature of the cornea or in the shape of the eye’s lens that causes blurred or distorted vision for both near and far objects. Presbyopia is a normal aging change in which the lens of the eye loses its elasticity and flexibility, resulting in an inability to focus on close objects, usually beginning at approximately age 40.  Visual Pathways.  Once the image travels through the refractive media, it is focused on the retina, inverted, and reversed left to right. For example, if the visualized object is in the upper part of the left temporal visual field, it is focused in the lower part of the nasal retina, upside down, and as a mirror image. From the retina, the impulses travel through the optic nerve to the optic chiasm, where the nasal fibres of each eye cross over to the other side. The optic chiasm is the X-­shaped space just in front of the pituitary gland where the optic nerve fibres partially cross. Fibres from the left field of both eyes form the left optic tract and travel to the left occipital cortex. The fibres from the right field of both eyes form the right optic

430

SECTION 4  Conditions Related to Altered Sensory Input VISION DISORDERS

Lacrimal gland

Lacrimal caruncle Lacrimal canals Normal vision

Lacrimal ducts

Myopia

Lacrimal sac

Hyperopia Astigmatism FIG. 23.2  Vision disorders related to refractive error. Source: © CanStock

Puncta

Nasolacrimal duct

Photo Inc. / Neokryuger.

Left eye

Right eye Frontal lobe

Optic nerve

Optic chiasm

Temporal lobe

Lateral geniculate body

Optic tract

Optic radiation Occipital lobe

Visual cortex of occipital lobe FIG. 23.3  The visual pathway. Fibres from the nasal portion of each retina cross over to the opposite side of the optic chiasm, terminating in the lateral geniculate body of the opposite side. The location of a lesion in the visual pathway determines the resulting visual defect.

tract and travel to the right occipital cortex. Because of this arrangement of the nerve fibres in the visual pathways, it is possible to determine the anatomical location of abnormalities in those nerve fibres from the specific visual field defect (Figure 23.3). 

External Structures and Functions Eyebrows, Eyelids, and Eyelashes.  Eyebrows, eyelids, and eyelashes serve an important role in protecting the eye. They provide a physical barrier to dust and foreign particles. The eye is further protected by the surrounding bony orbit and by fat pads located below and behind the globe, or eyeball. The upper and lower eyelids join at the medial and lateral canthi. The upper eyelid blinks spontaneously approximately 15 times a minute. Blinking distributes tears over the anterior surface of the eyeball and helps control the amount of light entering the visual pathway (Figure 23.4). The eyelids open and close through the action of muscles innervated by cranial nerve (CN) VII, which is the facial nerve. Muscular action also helps hold the eyelids against the eyeball.

FIG. 23.4  External eye and lacrimal apparatus. Tears produced in the lacri-

mal gland pass over the surface of the eye and enter the lacrimal canal. From there, the tears are carried through the nasolacrimal duct to the nasal cavity.

The conjunctiva is a transparent mucous membrane that covers the inner surfaces of the eyelids (the palpebral conjunctiva) and extends over the sclera (the bulbar conjunctiva), forming a “pocket” under each eyelid. Glands in the conjunctiva secrete mucus and tears. The sclera, an opaque structure commonly referred to as the “white” of the eye, is formed by collagen fibres meshed together. The sclera forms a tough shell that helps protect the intraocular structures. The transparent and avascular cornea allows light to enter the eye (see Figure 23.1). The curved cornea refracts (bends) incoming light rays to help focus them on the retina. The cornea consists of six layers: the epithelium, Bowman’s layer, the stroma, Dua’s layer, Descemet’s membrane, and the endothelium (Vargas et al., 2019). The epithelium consists of a layer of cells that helps protect the eye. Epithelial cells regenerate when damaged. The stroma consists of collagen fibrils. The cornea is maintained by the lacrimal system, which consists of the lacrimal gland and ducts, the lacrimal canals and puncta, the lacrimal sac, and the nasolacrimal duct (see Figure 23.4). In addition to the lacrimal gland, other glands provide secretions to make up the mucous, aqueous, and lipid layers of the tear film. The tear film moistens the eye and provides oxygen to the cornea. Each eye is moved by three pairs of extraocular muscles and controlled by three cranial nerves: (a) superior and inferior rectus muscles (CN III), (b) medial (CN III) and lateral rectus muscles (CN VI), and (c) superior (CN IV) and inferior oblique muscles (CN III). Neuromuscular coordination enables simultaneous movement of the eyes in the same direction (conjugate movement). 

Internal Structures and Functions The iris (plural: irides) is the colourful part of the eye. This structure has a small, round opening in its centre, the pupil, which allows light to enter the eye. The pupil constricts through action of the iris sphincter muscle (innervated by CN III [oculomotor nerve]) and dilates through action of the iris dilator muscle (innervated by CN V [trigeminal nerve]) to control the amount of light that enters the eye.

CHAPTER 23  Nursing Assessment: Visual and Auditory Systems The lens is a structure behind the iris whose function is to bend light rays so that they fall onto the retina. The shape of the lens is modified by action of the ciliary body as part of accommodation, the convergence of the eyes and the constriction of the pupils that occurs when the eyes refocus from a far object to a near object. This enables a person to focus on near objects, as in reading a book. The choroid is a highly vascular structure that nourishes the ciliary body, the iris, and the outer portion of the retina. It lies inside and parallel to the sclera and extends from the area where the optic nerve enters the eye to the ciliary body (see Figure 23.1). The ciliary body consists of the ciliary muscles, which surround the lens and lie parallel to the sclera; the ciliary zonules, which attach to the lens capsule; and the ciliary processes, which constitute the terminal portion of the ciliary body. The ciliary processes lie behind the peripheral part of the iris and secrete aqueous humor. The retina is the innermost layer of the eye that extends and gives rise to the optic nerve. Neurons make up the major portion of the retina. Therefore, retinal cells cannot regenerate if destroyed. The retina lines the inside the eyeball, extending from the area of the optic nerve to the ciliary body (see Figure 23.1). It is responsible for converting images into a form that the brain can understand and process as vision. The retina is composed of two types of photoreceptor cells: rods and cones. Rods are stimulated in dim or darkened environments, and cones are receptive to colours in bright environments. The centre of the retina is the fovea centralis, a pinpoint depression composed only of densely packed cones (Patton & Thibodeau, 2020). This area of the retina provides the sharpest visual acuity. Surrounding the fovea is the macula, an area smaller than 1 square millimetre, which has a high concentration of cones and is relatively free of blood vessels. With the exception of the macula, the retina is nourished by retinal arterioles and veins. This blood supply enters the eye through the optic disc, located nasally from the macula. The optic disc is the area where the optic nerve (CN II) exits the eyeball. Within the disc is the physiological cup, a depression that can be visualized through the pupil with the ophthalmoscope. The retinal veins and arteries can also be visualized in this way and can provide information about the condition of the vascular system in general. 

AGE-­RELATED CONSIDERATIONS THE VISUAL SYSTEM Every structure of the visual system is subject to changes as the individual ages. Whereas many of these changes are relatively benign, others may compromise visual acuity severely in the older person. The psychosocial effect of poor vision or blindness can be highly significant. Visual impairment increases with age, ranging from 2.7% in those 45 to 54 years old to 15.6% in those 75 to 84 years old (Aljied et al., 2018). Age-­related changes in the visual system and differences in assessment findings are presented in Table 23.1. Refractive error is the leading cause of visual impairment among Canadians over the age of 45 years (Aljied et al., 2018). 

ASSESSMENT Assessment of the visual system may be as simple as determining a patient’s visual acuity (clarity or sharpness) or as complex as collecting complete subjective and objective data pertinent to the visual system. To perform an appropriate ophthalmic

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evaluation, the nurse must determine which parts of the data collection are important for each patient. Table 23.2 lists suggested questions to ask to obtain subjective data related to the visual system.

Subjective Data Past Health History.  Information about the patient’s health history should include both ocular and nonocular history. The nurse should ask specifically about systemic diseases—such as diabetes mellitus, hypertension, cancer, rheumatoid arthritis, sexually transmitted infections, acquired immune deficiency syndrome (AIDS), muscular dystrophy, myasthenia gravis, multiple sclerosis, inflammatory bowel disease, and hypothyroidism or hyperthyroidism—because many of these diseases have ocular manifestations. It is particularly important to determine whether the patient has any history of cardiac or pulmonary disease because the eye drops often used to treat glaucoma (β-­ adrenergic blockers) may have serious adverse effects, including bronchospasm, hypotension, and heart failure (Skidmore-­Roth & Richardson, 2021).  Medications.  If the patient takes any medications, the nurse should obtain a complete list, including over-­the-­counter medicines, eye drops, herbal therapies, or dietary supplements. Many patients do not think that over-­the-­counter medications, eye drops, or herbal therapies are “real” medications and may not mention their use unless specifically questioned. However, many of them have ocular effects. For example, many preparations for colds contain a form of epinephrine (e.g., pseudoephedrine) that can dilate the pupil. The nurse should also note the use of any antihistamines or decongestants because they can cause ocular dryness. The nurse should specifically ask whether the patient uses any prescription medications such as corticosteroids, thyroid medications, oral hypoglycemic agents, or insulin. Long-­term use of corticosteroids can contribute to development of glaucoma or cataracts. It is especially important to note whether the patient is taking any β-­adrenergic blocker eye drops because they may potentiate the effects of corticosteroids. The nurse should ask female patients whether they are taking birth control pills, are pregnant, or are experiencing perimenopause or menopause, because hormonal changes can affect the wearing of contact lenses. Finally, the nurse should determine whether the patient has allergies to medications or other substances, such as dust, pollens, pets, cosmetics, or scents.  Surgery or Other Treatments.  Surgical procedures related to the head, eye, or brain should be noted. Brain surgery and subsequent swelling can cause pressure on the optic nerve or tract, which results in alterations in vision. Any laser procedures involving the eye should also be documented, as should the effect of any eye surgery or laser treatment on visual acuity. The nurse should ask the patient about previous trauma to the head. Also, inquiring about headaches is important because migraines may create visual disturbances. A history of visual acuity tests should be obtained, including the date of the most recent examination and change in glasses or contact lens prescriptions, as well as testing for glaucoma and the results. The nurse should specifically ask about a history of strabismus, amblyopia, cataracts, retinal detachment, refractive surgery, glaucoma, and any trauma to the eye, its treatment, and sequelae. The patient’s dietary intake of vitamins and trace minerals can be important to ocular health. Antioxidants found in

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SECTION 4  Conditions Related to Altered Sensory Input

TABLE 23.1    AGE-­RELATED DIFFERENCES IN ASSESSMENT Visual System Changes

Differences in Assessment Findings

Eyebrows and Eyelashes Loss of pigment in the hair

Greying of eyebrows, eyelashes

Eyelids Loss of orbital fat, decreased muscle tone Tissue atrophy, prolapse of fat into eyelid tissue Plaques

Entropion (eyelid turned inwards), ectropion (eyelid turned outwards), mild ptosis (eyelid drooping) Blepharodermachalasis (excessive upper eyelid skin) Xanthelasma

Conjunctiva Tissue damage related to chronic exposure to ultraviolet light or to other chronic environmental exposure

Pinguecula (small, yellowish spot seen usually on the medial aspect of the conjunctiva)

Sclera Lipid deposition

Yellowish (as opposed to bluish) scleral colour

Cornea Cholesterol deposits in peripheral cornea Tissue damage related to chronic exposure Decrease in water content, atrophy of nerve fibres Epithelial changes Accumulation of lipid deposits

Arcus senilis (milky or yellow ring encircling periphery of cornea; see Figure 23.1) Pterygium (thickened, triangular bit of pale tissue that extends from the inner canthus of the eye to the nasal border of the cornea) Decreased corneal sensitivity and corneal reflex Loss of corneal lustre Blurring of vision

Lacrimal Apparatus Decreased tear secretion Malposition of the eyelid that results in tears overflowing the eyelid margins instead of draining through the puncta

Dryness Tearing, irritated eyes

Iris Increased rigidity of iris Dilator muscle atrophy or weakness Loss of pigment Shrinking and stiffening of ciliary muscle

Decreased pupil size Slower recovery of pupil size after light stimulation Change of iris colour Decrease in near vision and accommodation

Lens Biochemical changes in lens proteins, oxidative damage, chronic exposure to ultraviolet light Increased rigidity of lens Opacities in the lens (may also be related to opacities in the cornea and the vitreous humor) Accumulation of yellow substances

Cataracts Presbyopia Reports of glare, impairment of night vision Yellow colouring of lens

Retina Retinal vascular changes related to atherosclerosis and hypertension Decrease in cones Loss of photoreceptor cells, retinal pigment, epithelial cells, and melanin Age-­related macular degeneration as a result of vascular changes

Narrowed, pale, straighter arterioles; acute branching Changes in colour perception, especially blue and violet Decreased visual acuity Loss of central vision

Vitreous Humor Liquefaction and detachment of the vitreous humor

fruits and vegetables including anthocyanins, carotenoids, flavonoids, and vitamins have been shown to reduce the risk of eye-­related diseases. Supplementation with vitamins C and E, minerals selenium and zinc, and the phytochemicals lutein and zeaxanthin has been reported in some studies to help delay the progression of eye diseases such as age-­related macular degeneration, whereas other studies reported negative findings (Khoo et al., 2019). (See the Determinants of Health box later in this section.) For a patient who has undergone or will undergo ophthalmological surgical procedures, the nurse should assess the patient’s elimination pattern and determine the potential for constipation, as straining to defecate (the Valsalva manoeuvre) can raise intraocular pressure. Although there is some evidence that elevation of the intraocular pressure during

Increased reports of “floaters” or light flashes

normal activities is not detrimental in relation to the surgical incision made during eye surgery, many surgeons do not want such patients to strain. Social and Occupational Health History.  The patient’s socioeconomic status can impact their vision health. Lower education and income levels are associated with a higher prevalence of visual impairment (Aljied et  al., 2018). The patient’s ability to maintain necessary or desired roles and responsibilities in home, work, and social environments can also be negatively affected by vision problems. For example, macular degeneration may decrease the patient’s visual acuity to a level inadequate for functioning at work. Issues related to Indigenous eye health and care for Indigenous people include high rates of diabetes mellitus and other chronic illnesses, as well as inequity in the social

CHAPTER 23  Nursing Assessment: Visual and Auditory Systems

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TABLE 23.2    HEALTH HISTORY Visual System: Questions for Obtaining Subjective Data Vision Difficulty • Do you have any visual difficulties or change in your visual acuity?* Describe the change in your vision. Describe how this affects your daily life. • Did it come on slowly or progress slowly? Does it affect one or both eyes? Is it constant or intermittent? Do you see spots or floaters move in front of your eyes?* Do you see light flashes?* • Do you have a blind spot?* Do you have any night blindness?* • For older persons: Are you experiencing any visual difficulties when you climb stairs or drive at night? • Do you use any visual aids such as glasses or contact lenses?

Eye Pain • Do you have any eye pain?*

Strabismus or Diplopia • Have you ever had a history of crossed eyes, or do you have double vision?*

Redness or Swelling • Do you have redness or swelling in your eyes?* • Do you have any discharge or watering from your eyes?*

Family History • Do you have a family or personal history of diseases such as atherosclerosis, diabetes mellitus, thyroid disease, hypertension, arthritis, or cancer that might affect your eyes?* • Do you have a family or personal history of ocular conditions such as cataracts, tumours, glaucoma, refractive errors (especially myopia and hyperopia), or retinal degenerative conditions (e.g., macular degeneration, retinal detachment, retinitis pigmentosa)?*

Nutrition and Elimination • Do you take any nutritional supplements?* • Does your visual problem affect your ability to obtain and prepare food?* • Do you have to strain to void or defecate?*

Sleep • Is your vision affected by the amount of sleep you get?* • Is your sleep affected by your eye condition?*

Reproduction–Sexuality • Has your eye condition caused a change in your sex life?* • For women: Are you pregnant? Do you use birth control pills?

Self-­Care History • Do you have regular eye examinations? When was your last test? • Do you wear glasses or contact lenses? When was the last time your eye prescription was checked? Was it changed? • Have you ever been tested for colour vision?* • Do you wear protective eyewear (sunglasses, safety goggles, or hats)?* • Do you wear contact lenses? If so, how do you take care of them? • If you use eye drops, how do you instill them? • Do you spend long periods of time in the sun?* Do you wear sunglasses? • Do you smoke, or are you regularly exposed to second-­hand smoke? • Have you ever been tested for glaucoma?* Results?

Social and Occupational History • Do you have any difficulties at work or home because of your eyes?* • Does your eye condition affect your ability to read?* • Have you made any changes in your social activities because of your eyes?* • Are your activities limited in any way by your eye condition?* • Are there any environmental conditions at home or work that may have an effect on your eyes (e.g., smoke, dust, chemicals, flying sparks)?* If so, do you use goggles for eye protection? • Do you participate in any leisure activities that have the potential for eye injury?* • Do you work for long hours at the computer?*

Coping Abilities • How does your eye condition make you feel about yourself? Has it created stress for you?* • If you have a vision loss, how do you cope?* Are you able to maintain your same living environment?* Do you use large-­print books or Braille?*

Adapted from Jarvis, C., Browne, A. J., MacDonald-­Jenkins, J., et al. (2019). Physical examination & health assessment (3rd Canadian ed., pp. 308–310). Elsevier. *If yes, describe.

CASE STUDY Patient Introduction F. A. (pronouns she/her), 81 years old, comes to the emergency department noting that her vision “looks like everything is covered with spider webs.”

Critical Thinking Throughout this assessment chapter, think about F. A. with the following questions in mind: 1. What are possible causes of F. A.’s visual disturbances? 2. What type of assessment should be most appropriate: comprehensive, focused, or emergency? 3. What questions should the nurse ask F. A.? 4. What should be included in the physical assessment? What would the nurse be looking for? 5. What diagnostic studies might be ordered? See Case Study: Subjective Data and Case Study: Objective Data: Physical Examination for more information on F. A.

Answers available at http://evolve.elsevier.com/Canada/Lewis/medsurg. 

Self-­Care History The nurse should assess the patient’s ocular health care activities, including regular eye examinations and awareness of the importance of eye safety practices, such as wearing protective eyewear during poten-

tially hazardous activities or while playing sports and avoiding noxious fumes and other eye irritants. Information about the use of sunglasses in bright light should be obtained as prolonged exposure to ultraviolet light can affect the retina and may contribute to cataract formation. Nighttime driving habits and any difficulties encountered in nighttime driving should be noted. For a patient who wears contact lenses, the nurse should assess the patient’s use and care habits, which may indicate a need for teaching, as true adherence to proper care has been reported in between 1 and 50% of users (Steele, 2018). Similarly, the nurse should assess the patient’s use of and technique for eye drop instillation. The nurse should also ask about time spent working on computers or handheld devices because eye strain is a common problem. The 20-­20-­20 rule can be promoted: Every 20 minutes, patients should look away from their computer screen for 20 seconds and focus their eyes on something at least 6 metres (20 feet) away (Canadian Association of Optometrists, 2020). Environmental exposures at home or work can cause trauma or irritation to the eyes; eye protection should be discussed. Patients should be asked whether they smoke or are regularly exposed to second-­hand smoke. Smokers are at greater risk for developing age-­related macular degeneration (see the Determinants of Health box). If patients use eye drops, the nurse should ascertain whether they are aware of correct methods for instilling drops to avoid contamination of the container.

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SECTION 4  Conditions Related to Altered Sensory Input

DETERMINANTS OF HEALTH

CASE STUDY

Macular Degeneration

Subjective Data

Gender

A focused subjective assessment of F. A. revealed the following information. Vision Difficulty: Had no vision problems until today. Wears eyeglasses for seeing distances and reading. Now having difficulty reading. Reports seeing periodic light flashes and small white spots “floating” in the air. Denies eye pain, itching, or tearing. Past Health History: Extraocular extraction of cataract on right eye with implantation of intraocular lens 2 months ago. Type 2 diabetes mellitus and hypertension. Medications: Glyburide (DiaBeta), 5 mg/day; metoprolol (Lopressor), 50 mg PO daily. Self-­Care History: States adherence to postoperative regimen of antibiotic and corticosteroid eye drops and with office follow-­up with eye surgeon. Recovery from surgery was uneventful, and eye drops were discontinued 2 weeks ago. Does not have allergies. Walks in the mall at least 1 km three times a week. No resistance or isotonic exercises. Has had difficulty moving bowels with increased straining. Trying prune juice to help. Coping Abilities: Afraid she is having a stroke. See Case Study: Patient Introduction and Case Study: Objective Data: Physical Examination for more information on F. A.

• T  he incidence of macular degeneration is higher among women than among men. Early-­onset menopause can also increase the risk for developing macular degeneration.* 

Biology and Genetic Endowment • T  he risk of developing macular degeneration increases with a family history (first generation).† • White individuals are more likely to develop macular degeneration than any other ethnic group.† • Vision problems are more common among new immigrants and refugees from developing countries than in the general Canadian population.‡ 

Personal Health Practices and Coping Skills • S  moking increases the risk of developing macular degeneration four-­ fold. Smokers also develop the disease approximately 10 years earlier than nonsmokers. Twenty percent of vision loss may be avoided by staying smoke-­free.† • Adequate exercise and a healthy diet (leafy vegetables, omega-­3 fatty acids) reduces the risk of macular degeneration. Antioxidants and zinc can slow the progression of intermediate and advanced macular degeneration and thereby minimize vision loss.† • Ultraviolet radiation damages the retina, which leads to macular degeneration.† References: *Jarvis, C., Browne, A. J., MacDonald-­Jenkins, J., et al. (Eds.). (2019). Physical examination & health assessment (3rd Canadian ed.). Elsevier. †Canadian National Institute for the Blind (CNIB). (2019). Age-­related macular degeneration. https://cnib.ca/en/sight-­loss-­info/your-­eyes/eye-­diseases/age-­related-­macular-­ degeneration?region=on ‡Grenier, D., & Bailon-­Poujol, J. (2018). Caring for kids new to Canada: Vision screening. https://www.kidsnewtocanada.ca/screening/vision

determinants of health such as poverty, poor housing, and inadequate diet. The high incidence of diabetes mellitus among Indigenous people contributes to an increased risk of diabetic retinopathy. Indigenous Canadians also face a number of barriers to accessing eye care (Canadian Association of Optometrists, 2018), such as living on reserve, rurally, or remotely, where there is decreased access to eye health care, lack of continuity of care, and lack of rehabilitation services for severe vision loss. Poverty, difficulties accessing eyeglasses, and transportation difficulties may also affect urban Indigenous people. In many occupations, employees work in conditions in which eye injury may occur. For example, factory workers may be at risk from flying debris; health care workers are at risk from splashes of bodily fluids; and cleaners and laboratory technicians are at risk from chemical burns due to splashes of chemicals or inhalation of noxious vapours. Information should be obtained about eye safety practices, such as use of goggles or safety glasses, and knowledge of prevention and treatment protocols such as eyewash stations. Workers can also be exposed to eyestrain in the office from video display terminals, poor lighting, and glare. An ergonomic consultation may be beneficial. A patient with diabetes mellitus may not be able to see well enough to self-­ administer insulin. This patient may resent dependence on a family member who takes over this function. The patient with exophthalmos (marked protrusion of eyeballs) may be embarrassed by their appearance and avoid usual social

activities. The nurse should sensitively inquire whether the patient’s preferred roles and responsibilities have been affected by the ocular condition. The nurse should also inquire about leisure activities during which the patient may incur an ocular injury. For example, during gardening, woodworking, and other craft activities, foreign bodies can scratch or enter the cornea or conjunctiva or even penetrate the globe. Injuries to the globe or the bony orbit can also occur after blows to the head or eye during sports activities such as racquetball, baseball, and tennis. Other leisure activities such as needlepoint, fly tying, watching television, or playing video games may have high-­level visual demands and produce eye strain.  Coping Abilities.  Patients with temporary or permanent visual difficulties may experience emotional stress. The nurse should assess the patient’s coping strategies and availability of support systems and perform a more comprehensive psychosocial assessment if it is indicated. 

Objective Data Physical Examination.  Physical examination of the visual system includes inspecting ocular structures and determining their functional status. Assessment of ocular structures should include examining the ocular adnexa, the external eye, and internal structures. Some structures, such as the retina and blood vessels, must be visualized with the aid of equipment, such as the ophthalmoscope. Physiological functional assessment includes determining the patient’s visual acuity and ability to judge closeness and distance, assessing extraocular muscle function, evaluating visual fields, observing pupil function, and measuring intraocular pressure. Assessment of the visual system may include all of the components described in the following text, or it may be as brief as measuring the patient’s visual acuity. The nurse assesses what is appropriate and necessary for the specific patient. All of the following assessments are in the nurse’s scope of practice, but some require special training. Normal findings of a physical assessment of the visual system are outlined in Table 23.3. Age-­related

CHAPTER 23  Nursing Assessment: Visual and Auditory Systems TABLE 23.3    NORMAL FINDINGS IN PHYSICAL

ASSESSMENT OF THE VISUAL SYSTEM

• Visual acuity: 20/20* in both eyes; no diplopia • External eye structures: symmetrical and without lesions or deformities • Lacrimal apparatus: nontender and without drainage • Conjunctiva: clear; sclera: white • Pupils: equal, round, and reactive to light and accommodation (PERRLA) • Lens: clear • Extraocular movements: intact • Optic disc margins: sharp • Retinal vessels: normal, with no hemorrhages or spots *20/20 means that the person sees at 20 feet what the majority of people can see at 20 feet.

visual changes and differences in assessment findings are listed in Table 23.1. Assessment techniques related to vision are summarized in Table 23.4. Common abnormalities found during assessment are listed in Table 23.5. The initial observation of the patient can provide information that will help the nurse focus the assessment. A patient with impaired colour vision may dress in clothing with unusual colour combinations. A patient with diplopia may hold their head in a skewed position in an attempt to see a single image. A patient with a corneal abrasion or photophobia may cover their eyes with their hands or wear dark glasses to try to block out room light. The nurse can make a rough estimate of depth perception by extending a hand for the patient to shake. During the initial observation, the nurse should also observe the overall facial and ophthalmic appearance of the patient. The eyes should be symmetrical and normally positioned on the face. The globes should not have a bulging or sunken appearance. Assessing Functional Status Visual Acuity.  Before the patient receives any care, the

nurse should record the patient’s visual acuity. To assess distance visual acuity, the patient sits or stands 6 metres (20 feet) from the Snellen chart with the usual correction (glasses or contact lenses) left in place unless they are used solely for reading. The nurse asks the patient to cover the left eye with an eye spoon and to read through the chart to the smallest line of letters that the patient can possibly discern. The nurse notes the smallest line the patient can read with a maximum of one or two errors. The nurse then asks the patient to cover the right eye, and the process is repeated. At the left of most rows of the Snellen chart is a fraction (e.g., “20/30”) in which the numerator represents the distance the patient is from the chart and the denominator represents the distance at which a normal eye could see the letters in the row. For example, a patient with a visual acuity of 20/30 sees at 20 feet what the patient with no vision problems would see at 30 feet. The larger the denominator, the worse the visual acuity. If vision is poorer than 20/30, the patient should be referred to an ophthalmologist or optometrist (Jarvis et  al., 2019). Legal blindness is defined as the best corrected vision in the better eye of 20/200 or worse. If a patient cannot read letters, the nurse can use an eye chart with pictures, numbers, or symbols, such as the STYCAR graded-­balls test, the Sheridan-­Gardiner letter-­ matching test, or the Snellen E chart.

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To evaluate visual acuity when the patient is unable to see even the largest letters, the nurse holds up a number of fingers in front of the patient at successively closer distances and asks the patient to count them. If the patient cannot count the fingers, the nurse asks the patient to indicate whether they can see hand motion or light from a penlight in front of their face. If the patient reports near vision problems, and for all patients 40 years of age or older, the nurse tests near visual acuity. The patient is instructed to hold a Jaeger chart 35 cm (14 inches) from their eyes. The nurse covers the patient’s left eye with an eye spoon, asks the patient to read successively smaller lines of print from the chart, and records the visual acuity corresponding to the smallest line of print the patient can read comfortably. The procedure is repeated with the right eye covered. A normal result is 14/14. A result of 14/20 means the person can read at 14 inches what someone with normal vision reads at 20 inches. If a screening card is not available, the nurse can assess near vision acuity by asking the patient to read from a newspaper.  Extraocular Muscle Functions.  The nurse observes the corneal light reflex to evaluate for weakness or imbalance of the extraocular muscles. In a darkened room, the nurse asks the patient to look straight ahead while a penlight is shone directly on the cornea. The light reflection should be located in the centre of both corneas as the patient faces the light source. To assess eye movement, the nurse should hold a finger or object 25 to 30 cm from the patient’s nose. The patient is asked to follow the movement of the object or finger with only their eyes through the six cardinal positions of gaze (Figure 23.5). This test can indicate weakness or paralysis in the extraocular muscles or dysfunction in a cranial nerve (oculomotor nerve [CN III], trochlear nerve [CN IV], and abducens nerve [CN VI]).  Pupil Function.  To determine pupil function, the nurse inspects the pupils and their reactions to light. Pupil size is noted before reaction to light is checked. Normal pupil size is 3 to 5 mm. Pupils should be equal in size and round and should react briskly to light. With age, pupil size decreases (Jarvis et al., 2019). In a small percentage of the population, pupils are unequal in size (anisocoria). Pupils should react to light directly (pupil constricts when a light shines into the eye) and consensually (pupil of one eye constricts when a light shines into the opposite eye). Accommodation should also be present: When the patient looks at a distant object 60 to 90 cm away and then is asked to focus on an object 7 to 8 cm from the nose, the nurse should observe convergence, simultaneous inward movement of both eyes toward each other, and constriction of the pupils. Normal pupil function may be documented as PERRLA (pupils equal, round, reactive to light and accommodation). 

CASE STUDY Objective Data: Physical Examination Physical examination findings of F. A. are as follows: PERRLA. No abnormalities noted on visual examination of external eye structures. EOM (extraocular movement) intact and symmetrical.

Diagnostic Studies Ophthalmoscopic examination identifies a partial retinal detachment, which is confirmed via ultrasonography. See Case Study: Patient Introduction and Case Study: Subjective Data for more information on F. A.

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SECTION 4  Conditions Related to Altered Sensory Input

TABLE 23.4    NURSING ASSESSMENT Visual System Technique

Description

Purpose

Patient reads from Snellen chart at a distance of 6 m (distance vision test) and from Jaeger test type at a distance of 35 cm (near vision test); examiner notes smallest print that patient can read on each chart. Patient faces examiner, covers one eye, fixates on examiner’s face, and counts number of fingers that the examiner brings into patient’s field of vision.

To determine patient’s distance and near visual acuity

Basic Techniques Visual acuity testing

Confrontation visual field test Pupil function testing

Extraocular muscle functioning Colour vision testing

Examiner shines light into patient’s pupil and observes pupillary response; each pupil is examined independently; examiner also checks for consensual and accommodative response. Patient faces examiner, holds head still, and follows (with eyes only) object that examiner moves through six cardinal positions of gaze. Examiner also tests corneal light reflex. Patient identifies numbers or paths formed by pattern of dots in a series of colour plates.

To determine whether patient has a full field of vision, without obvious scotomas To determine whether patient has normal pupillary response To determine whether muscles and cranial nerves III, IV, and VI are functioning normally To determine patient’s ability to distinguish colours

Advanced Techniques* Tono-­Pen tonometry

Ophthalmoscopy

Keratometry

Covered end of probe gently touches the anaesthetized corneal surface several times; examiner records several readings to obtain a mean intraocular pressure (see Figure 23.7). Examiner holds ophthalmoscope close to patient’s eye, shining light into back of eye and looking through aperture on ophthalmoscope; examiner adjusts dial to select one of the lenses in ophthalmoscope that produces the desired amount of magnification to inspect ocular fundus. Examiner aligns the projection and notes the readings of corneal curvature.

To measure intraocular pressure (normal pressure is 10–22 mm Hg) To observe retina and optic nerve head

To measure the corneal curvature; often performed before fitting of contact lenses, before refractive surgery, or after corneal transplantation

*Performed by qualified health care provider.

TABLE 23.5    ASSESSMENT ABNORMALITIES Visual System Finding

Description

Possible Etiology and Significance

Foreign body sensation

Superficial corneal erosion or abrasion; can result from contact lens wear or trauma or from foreign body in the conjunctiva or cornea Anterior uveitis, acute glaucoma, infection; acute glaucoma also associated with nausea, vomiting Inflammation or infection of cornea or anterior uveal tract (iris and ciliary body), conjunctivitis Refractive errors, corneal opacities, cataracts, migraine aura, retinal changes (detachment, macular degeneration) Most common: liquefaction of the vitreous humor (benign phenomenon); other possible causes include hemorrhage into the vitreous humor, retinal holes, or retinal tears Light flashes may occur as the retina is being tugged, torn, or detached. Decreased tear formation or changes in tear composition because of aging or various systemic diseases Abnormalities of extraocular muscle action related to muscle or cranial nerve abnormality Related to corneal inflammation or to opacities in cornea, lens, or vitreous humor that scatter the incoming light; can also result from light scatter around edges of an intraocular lens; worse at night, when pupil is dilated

Subjective Data Pain

Severe, deep, throbbing Photophobia

Persistent abnormal intolerance to light

Blurred vision

Gradual or sudden inability to see clearly

Appearance of spots, floaters, or light flashes (photopsias)

Seeing spots, “spider webs,” “a curtain,” or floaters within the field of vision, or flashes or flickers of light

Dryness

Discomfort, sandy or gritty sensation, irritation, or burning Double vision

Diplopia Glare

Headache, ocular discomfort, reduced visual acuity

Objective Data Eyelids Allergic reactions Hordeolum (stye) Blepharitis

Redness, excessive tearing, and itching of eyelid margins Small, superficial white nodule along eyelid margin Redness, swelling, and crusting along eyelid margins

Many possible allergens; associated eye trauma can occur from rubbing itchy eyelids Infection of a sebaceous gland of eyelid; causative organism is usually bacterial (most commonly Staphylococcus aureus) Bacterial invasion of eyelid margins; often chronic

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TABLE 23.5    ASSESSMENT ABNORMALITIES Visual System—cont’d Finding

Description

Possible Etiology and Significance

Ptosis

Drooping of upper eyelid margin; unilateral or bilateral Inward turning of upper or lower eyelid margin, unilateral or bilateral Outward turning of lower eyelid margin

Mechanical causes as a result of eyelid tumours or excess skin; myogenic causes such as myasthenia gravis or neurogenic causes Congenital causes resulting in development abnormalities

Conjunctivitis

Redness, swelling of conjunctiva; possibly itching

Subconjunctival hemorrhage

Appearance of blood spot on sclera; may be small or can affect entire sclera

Bacterial or viral infection; may be allergic response or inflammatory response to chemical exposure; may be the first or only symptom of SARS-­CoV-­2 infection* Conjunctival blood vessels rupture, leaking blood into the subconjunctival space

Entropion Ectropion

Mechanical causes as a result of eyelid tumours, herniated orbital fat, or extravasation of fluid

Conjunctiva

Cornea and Sclera Corneal abrasion

Localized painful disruption of the epithelial layer of cornea; visualized with fluorescein dye Yellow discoloration† of the entire sclera

Trauma; overwear or improper fit of contact lenses

Protrusion of globe beyond its normal position within bony orbit; sclera often visible above iris when eyelids are open

Intraocular or periorbital tumours; hyperthyroidism; Crouzon’s syndrome

Anisocoria

Pupils are unequal (constricted)

Abnormal response to light or accommodation

Pupils respond asymmetrically or abnormally to light stimulus or accommodation

Central nervous system disorders; in a small percentage of the population, slight difference in pupil size is normal Central nervous system disorders, general anaesthesia

Jaundice

Related to liver dysfunction or hemolytic disease

Globe Exophthalmos

Pupil

Iris Irides are different colours‡

Congenital causes (Horner’s syndrome); acquired causes (chronic iritis, metastatic carcinoma, diffuse iris nevus or melanoma)

Deviation of eye position in one or more directions

Overaction or underaction of one or more extraocular muscles

Opacification of lens; pupil can appear cloudy or white when opacity is visible behind pupil opening

Aging, trauma, diabetes mellitus, long-­term systemic corticosteroid therapy

Peripheral

Partial or complete loss of peripheral vision

Central

Loss of central vision

Glaucoma; interruption of visual pathway (e.g., tumour); migraine headache Macular disease

Heterochromia

Extraocular Muscles Strabismus

Lens Cataract

Visual Field Defect

*Source: Ozturker, Z. (2021). Conjunctivitis as sole symptom of COVID-­19: A case report and review of the literature. European Journal of Ophthalmology, 31(2), NP161–NP166. https: //doi.org/10.1177/1120672120946287 †Yellow colour is normal after a diagnostic study necessitating intravenous fluorescein injection. ‡Most cases of heterochromia occur by chance and are not associated with any other symptoms or conditions.

Assessing Structures.  The visual system is unique because the nurse can directly inspect not only the external structures but also many of the internal structures by using special equipment such as the ophthalmoscope and the slit-­lamp microscope, which enables examination of conjunctiva, sclera, cornea, anterior chamber, iris, lens, vitreous humor, and retina under magnification. The ophthalmoscope, a hand-­held instrument with a light source and magnifying lenses, is held close to the patient’s eye to visualize the posterior part of the eye. Little pain or discomfort is associated with these examinations. Eyebrows, Eyelashes, and Eyelids.  All structures should be present, symmetrical, and without deformities, redness, or swelling. Eyelashes extend outward from the eyelid margins. In

normal closing, the upper and lower eyelid margins just touch. The lacrimal puncta should be open and positioned properly against the globe. If the sac is inflamed, pressure over the lacrimal sac may cause purulent material to ooze from the puncta.  Conjunctiva and Sclera.  The nurse can examine the conjunctiva and sclera at the same time, evaluating colour, smoothness, and presence of any lesions or foreign bodies. The conjunctiva covering the sclera is normally clear, with fine blood vessels visible, more commonly in the periphery. The sclera is normally white, but its colour may become yellowish in older individuals because of lipid deposition in the sclera. A pale blue cast caused by scleral thinning can also be normal in older persons and in infants (who have naturally

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SECTION 4  Conditions Related to Altered Sensory Input Optic disc

Right and up

Left and up

Right

Left

Right and down

Left and down

Fovea centralis

FIG. 23.5  Six cardinal positions of gaze. Source: Adapted from Bowling, B.

(2015). Kanski’s clinical ophthalmology: A systematic approach (8th ed, p. 731). Saunders.

thinner sclerae). A slightly yellow cast may also be normal finding in some dark-­skinned people.  Cornea.  The cornea should be clear, transparent, and shiny. The iris should appear flat and not bulge toward the cornea. The area between the cornea and iris should be clear, with no blood or purulent material visible in the anterior chamber.  Iris.  Both irides should be of similar colour and shape. However, a colour difference between the irides is normal in a small proportion of individuals. Round or notched areas of missing iris tissue are often the result of cataract or glaucoma surgery. The nurse should determine the cause of these round, notched, or triangular areas and document the findings.  Retina and Optic Nerve.  To assess these structures, the nurse uses an ophthalmoscope to magnify the ocular structures and bring them into crisp focus (Figure 23.6). This enables the examiner to directly view arteries, veins, and the optic nerve. The nurse directs the beam of light from the ophthalmoscope obliquely into the patient’s pupils and should note the appearance of a red reflex. This reflex is a result of light’s reflecting off the retina. Any dense area in the lens or nontransparent material in the vitreous humor decreases the red reflex. The optic nerve or disc is examined for size, colour, and abnormalities. The optic disc is creamy yellow with distinct margins. A slight blurring of the nasal margin is common. A central depression in the disc, called the physiological cup, is the exit site for the optic nerve. The cup should be less than half the diameter of the disc. Normally, no hemorrhages or exudates are present in the fundus (retinal background). Careful inspection of the fundus can reveal the presence of retinal holes, tears, detachments, or lesions. Small hemorrhages can be associated with diabetes mellitus or hypertension and can appear in various shapes, such as dots or flames. Finally, the nurse examines the macula for shape and appearance. This area of high reflectivity is devoid of any blood vessels. The nurse can obtain important information about the vascular system and the central nervous system through direct visualization with an ophthalmoscope. Skilled use of this instrument requires practice.  Focused Assessment.  A focused assessment (see the Focused Assessment box) may be performed by the nurse when a patient is admitted to hospital or an outpatient clinic. Inspection of the eyes may be performed routinely as part of the assessment of a hospitalized patient. In addition, the nurse should assess for and document use of glasses or contact lenses. Assessment for PERRLA may be performed routinely

Retinal blood vessels Macula FIG. 23.6 Illustration of magnified view of retina through the ophthalmo-

scope. Source: Adapted from Patton, K. T., & Thibodeau, G. (2020). Structure and function of the body (16th ed., p. 215). Mosby.

FOCUSED ASSESSMENT Visual System Use this checklist to make sure the key assessment steps have been performed.

Subjective Ask the patient about any of the following and note responses. Changes in vision (e.g., acuity, blurred) Eye redness, itching, discomfort Drainage from eyes

Y Y Y

N N N

Objective: Physical Examination Inspect Eyes for any discoloration or drainage Conjunctiva and sclera for colour and vascularity Lens for clarity Eyelid for ptosis

✓ ✓ ✓ ✓

Assess Vision based on patient’s looking at nurse or Snellen chart Extraocular movements Peripheral vision Pupil function: PERRLA

✓ ✓ ✓ ✓

PERRLA, pupils equal, round, reactive to light, and accommodation.

as part of neurological assessment of a hospitalized patient (see Chapter 58).  Special Assessment Techniques Colour Vision.  Testing the patient’s ability to distinguish colours can be an important part of the overall assessment because some occupations may require accurate colour discrimination. The Ishihara test for colour blindness determines the patient’s ability to distinguish a pattern of colour in a series of colour plates. Each plate has a pattern of dots of a specific colour which form a number or shape printed against a background of dots of other colours. A patient with normal colour

CHAPTER 23  Nursing Assessment: Visual and Auditory Systems

439

structures of the ear itself: external, middle, and inner ear (Figure 23.8). This system is concerned with the reception and perception of sound. The external and middle portions of the ear function to conduct and amplify sound waves from the environment. The inner ear serves functions of hearing and balance. The central auditory system (the brain and its pathways) integrates and assigns meaning to what is heard.

FIG. 23.7  Tono-­Pen tonometry. Source: Courtesy the Eye Institute, Department of Ophthalmology and Visual Services, University of Iowa Health Care, Iowa City, Iowa.

vision can see each pattern (Jarvis et al., 2019). Older persons have a loss of colour discrimination at the blue end of the colour spectrum and loss of sensitivity throughout the entire spectrum, especially when cataracts are present.  Stereopsis.  Stereoscopic vision enables a patient to see objects in three dimensions. Any event causing a patient to have monocular vision (e.g., enucleation, patching) results in loss of stereoscopic vision, which impairs the individual’s depth perception. This condition can have serious consequences—for example, if the patient trips over a step when walking or follows too closely behind another vehicle when driving.  Intraocular Pressure.  Testing intraocular pressure is important because high intraocular pressure is a major risk factor for glaucoma. Intraocular pressure can be measured by a variety of methods, including the Tono-­Pen (Figure 23.7). Use of the Tono-­Pen is common because it is simple, and results are very accurate. The surface of the anaesthetized cornea is touched lightly several times with the covered end of the probe. The instrument records several readings and provides a mean measurement on a digital light-­emitting diode (LED) screen located on the front surface. Normal intraocular pressure ranges from 10 to 22 mm Hg. 

DIAGNOSTIC STUDIES Diagnostic studies provide important objective data to the nurse monitoring the patient’s condition and planning appropriate interventions. Table 23.6 presents the most common basic diagnostic studies of the visual system. SAFETY ALERT Nurses should avoid using the abbreviations OS for left eye, OD for right eye, and OU for both eyes when documenting in patients’ charts or transcribing medication orders because they can be easily confused with each other and with the abbreviations AD, AS, and AU for the ear. Use of these abbreviations can contribute to communication errors and potentially serious medication errors (Institute for Safe Medication Practices Canada, 2016). 

  THE AUDITORY SYSTEM STRUCTURES AND FUNCTIONS The auditory system is composed of the peripheral and central auditory systems. The peripheral auditory system includes the

External Ear The external ear consists of the auricle (pinna) and the external auditory canal. The auricle is composed of cartilage and connective tissue covered with epithelium, which also lines the external auditory canal (see Figure 23.8). The external auditory canal is a slightly S-­shaped tube about 2.5 cm in length in the adult. The skin that lines the canal contains fine hairs (outer half of the canal only) and sebaceous (oil) glands and ceruminous (wax) glands. The cerumen (wax) helps prevent infection and serves as a physical barrier to the external environment (Swain et al., 2018). The inner half of the external auditory canal is highly sensitive. The function of the external ear and canal is to collect and transmit sound waves to the tympanic membrane (eardrum). This shiny, translucent, pearl-­ grey membrane is composed of epithelial cells, connective tissue, and mucous membrane. It serves as a partition and instrument of sound transmission between the external auditory canal and middle ear.  Middle Ear The middle ear cavity is an air space located in the temporal bone. Mucosa lines the middle ear and is continuous from the nasal pharynx via the Eustachian (auditory) tube. The Eustachian tube functions to equalize atmospheric air pressure between the middle ear and throat and allows the tympanic membrane to move freely. It opens during yawning and swallowing. Blockage of this tube can occur with allergies, nasopharyngeal infections, or enlarged adenoids. The middle ear contains three tiny bones, or ossicles: malleus, incus, and stapes. Vibrations of the tympanic membrane cause the ossicles to move and transmit sound waves to the oval window. The resulting vibration in the oval window causes fluid in the inner ear to move and stimulate hearing receptors. The round window sits below the oval window and is covered with a thin membrane called the fenestra cochlea; it also opens into the inner ear and acts as a pressure valve that moves outward as fluid pressure builds in the inner ear. The superior part of the middle ear is called the epitympanum (attic). It also communicates with air cells within the mastoid bone. The facial nerve (CN VII) passes above the oval window of the middle ear. The thin, bony covering of the facial nerve can become damaged by chronic ear infection, skull fracture, or trauma during ear surgery. Such damage can cause problems with voluntary facial movements, eyelid closure, and taste discrimination. Permanent damage to the facial nerve can also result.  Inner Ear The inner ear is composed of a bony labyrinth (maze) surrounding a membrane. This complex contains the functional organs for hearing and balance. The receptor organ for hearing is the cochlea, a coiled structure. It contains the organ of Corti, whose tiny hair cells respond to stimulation of selected portions of the basilar membrane according to pitch. This stimulus is converted into an electrochemical impulse and then transmitted by the cochlear branch of the vestibulocochlear nerve (CN VIII;

440

SECTION 4  Conditions Related to Altered Sensory Input

TABLE 23.6    DIAGNOSTIC STUDIES Visual System Study

Description and Purpose

Patient Education*

Refractometry

Subjective measure of refractive error; multiple lenses are mounted on rotating wheels. While patient sits looking through apertures at Snellen acuity chart, lenses are changed; patient chooses lenses that make acuity sharpest. Cycloplegic medications are used to paralyze accommodation during refraction process. A-­scan probe is placed on patient’s anaesthetized cornea; used primarily for axial length measurement for calculating power of intraocular lens implanted after cataract extraction. B-­scan probe is applied to patient’s closed eyelid; used more often than A-­scan for diagnosis of ocular disorders such as intraocular foreign bodies or tumours, opacities in the vitreous humor, and retinal detachments. Fluorescein (a nonradioactive, non-­iodine dye) is intravenously injected into antecubital or other peripheral vein, followed by serial photographs (over 10-­min period) of the retina through dilated pupils. Provides diagnostic information about flow of blood through pigment epithelial and retinal vessels; often used in patients with diabetes mellitus to accurately locate areas of diabetic retinopathy before laser destruction of neovascularized area.

Procedure is painless; patient may need help holding the head still. Pupil dilation makes it difficult for the patient to focus on near objects; dilation may last 3–4 hr. Procedure is painless (cornea is anaesthetized).

Ultrasonography

Fluorescein angiography

Amsler grid test

Test is self-­administered with a hand-­held card printed with a grid of lines (similar to graph paper); patient fixates on centre dot and records any perceived abnormalities of the grid lines, such as wavy, missing, or distorted areas. Test is used to monitor macular concerns.

Fluorescein is toxic to tissue if extravasation occurs; systemic allergic reactions are rare, but the nurse should be familiar with emergency equipment and procedures. The patient should be informed that dye can sometimes cause transient nausea or vomiting and transient yellow discoloration of urine and skin. Regular testing is necessary to identify any changes in macular function.

*Patient education regarding the purpose and method of testing is a nursing responsibility for all diagnostic procedures.

External ear (not to scale) Auricle (pinna)

Middle ear

External acoustic Temporal bone meatus

Inner ear

Tympanic membrane Semicircular canals Oval window Facial nerve Vestibular nerve Cochlear nerve

Vestibulo-cochlear nerve (CN VIII)

Cochlea

Malleus Incus Stapes Auditory ossicles

Vestibule Round window Auditory tube

FIG. 23.8  External, middle, and inner ear. CN, cranial nerve. Source: Adapted from Patton, K. T., & Thibodeau, G. A. (2020). Structure and function of the body (16th ed., p. 217). Mosby.

formerly called the acoustic nerve) to the temporal lobe of the brain to process and interpret the sound. Three semicircular canals and the vestibule make up the membranous labyrinth, which is housed in the bony labyrinth and enables the sense of balance. The membranous labyrinth is filled with endolymphatic fluid, and the bony labyrinth is filled with perilymphatic fluid. This extracellular fluid cushions these two sensitive organs and communicates with the brain and the subarachnoid spaces of the brain. The nervous stimuli are communicated by the vestibular portion of CN VIII. Debris or

excessive pressure within the lymphatic fluid can cause disorders such as vertigo. 

Transmission of Sound and Implications for Hearing Loss Sound waves are conducted by air (air conduction) and picked up by the auricles and the auditory canal. The sound waves strike the tympanic membrane, causing it to vibrate. The central area of the tympanic membrane is connected to the malleus, which also starts to vibrate, transmitting the vibration to the incus and then the stapes. As the stapes moves back and forth,

CHAPTER 23  Nursing Assessment: Visual and Auditory Systems it pushes the membrane of the oval window in and out. Movement of the oval window produces waves in the perilymphatic fluid. Pathological disturbances in the external ear canal or the middle ear may cause a conductive hearing loss, resulting in an alteration in the patient’s perception of or sensitivity to sounds. Once sound has been transmitted to the liquid medium of the inner ear, the vibration is picked up by the tiny sensory hair cells of the cochlea, which initiate nerve impulses. These impulses are carried by nerve fibres to the main branch of the acoustic portion of CN VIII and then to the brain. Disruptions of the inner ear or along the nerve pathway from the inner ear to the brain can result in sensorineural hearing loss. This may result in an alteration of the patient’s perception of or sensitivity to specific tones. Impairment within the central auditory system causes central hearing loss. This type of hearing loss causes difficulty in understanding the meaning of words that are heard. (Types of hearing loss are discussed further in Chapter 24.) The bones of the skull can also transmit sound directly to the inner ear (bone conduction). This can be demonstrated by placing the stem of a vibrating tuning fork on the patient’s head, against the skull. 

AGE-­RELATED CONSIDERATIONS THE AUDITORY SYSTEM Age-­related changes in the auditory system can result in hearing impairment. Presbycusis, or hearing loss caused by aging, can also result from insults from a variety of sources. Noise exposure, vascular or systemic diseases, poor or inadequate nutrition, ototoxic medications, and pollution during the lifespan can damage delicate hair cells of the organ of Corti or cause atrophy of lymph-­producing cells. Sound transmission is diminished by calcification of the ossicles. Dry cerumen in the external canal can also interfere with transmission of sound. Tinnitus, or the perception of ringing in the ears, may accompany hearing loss that results from the aging process. Hearing impairment, especially in an older person, can lead to social and health consequences, including embarrassment, fatigue, anxiety, depression, distress, social isolation, participation restrictions, falls and other injuries, lower quality of life, and mortality (Ramage-­Morin et al., 2019). As the average lifespan increases, the number of people with hearing impairment will also increase. As many as 77% of adults aged 40 to 79 years have unperceived hearing impairment (Ramage-­Morin et al., 2019). Regular screening and early identification of hearing problems will ensure patients are more active and healthier as they age. Age-­related changes in the auditory system and differences in assessment findings are presented in Table 23.7. 

ASSESSMENT Assessment of the auditory system includes assessment of the vestibular (balance) system because the auditory and vestibular systems are so closely related. Initially, the nurse should try to categorize symptoms related to balance and distinguish them from symptoms related to hearing loss or tinnitus. Problems with balance may manifest as nystagmus or vertigo. Nystagmus is abnormal eye movements that may be observed by other people as twitching of the patient’s eyeball or may be described by the patient as a blurring of vision with head or eye movement. Vertigo is a sense that the person or objects around the person are moving or spinning and is usually

441

TABLE 23.7    AGE-­RELATED DIFFERENCES IN

ASSESSMENT

Auditory System Changes

Differences in Assessment Findings

External Ear Increased production of and drier cerumen Increased hair growth Loss of elasticity in cartilage

Impacted cerumen; potential hearing loss Visible hair, especially in men Collapsed ear canal

Middle Ear Atrophic changes of tympanic membrane

Conductive hearing loss

Inner Ear Hair cell degeneration, neuron degeneration in auditory nerve and central pathways, reduced blood supply to cochlea, calcification of ossicles Less effective vestibular apparatus in semicircular canals

Presbycusis, diminished sensitivity to high-­pitched sounds, impairment in speech reception, tinnitus

Alterations in balance and body orientation

Brain Decline in ability to filter out unwanted and unnecessary sound

Difficulty hearing in a noisy environment, heightened sensitivity to loud sounds

stimulated by movement of the head. Dizziness is a sensation of being off-­balance that occurs when the person is standing or walking. It does not occur when the person is lying down. Health history questions to ask a patient with an auditory condition are listed in Table 23.8.

Subjective Data Important Health History

Current Health of Auditory System.  The nurse should inquire about earache or pain in the ear. Such pain may be caused by ear conditions such as middle ear infection or may be referred pain originating in the teeth or temporomandibular joint. If pain is present, the patient should be asked to describe the pain and the treatments used for relief. If the patient has experienced any ear infections or has a history of chronic ear infections, this may contribute to increased hearing loss. Pus or bloody discharge may indicate an ear infection, whereas clear discharge may consist of cerebrospinal fluid, particularly if the patient has experienced any head trauma. Cerebrospinal fluid will feel oily and test positive for glucose (Jarvis et al., 2019). The nurse should note the time of onset of the hearing loss, whether it was sudden or gradual, and the person who noted the onset. Gradual hearing losses are most often noted by people who communicate regularly with the patient. Sudden losses and those exacerbated by some other condition are most often reported by the patient. If a hearing loss is identified in an older patient, the nurse can use the questions from the Hearing Handicap Inventory for Older Persons (Table 23.9). Referral is recommended for individuals scoring 10 or higher on the inventory. If the patient has experienced any ringing, crackling, or buzzing sensation, the nurse should note time of onset and whether the patient is taking any medications that might cause tinnitus. Symptoms such as dizziness, tinnitus, and hearing loss are recorded in detail in the patient’s own words. This careful description could help differentiate the cause. 

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SECTION 4  Conditions Related to Altered Sensory Input

TABLE 23.8    HEALTH HISTORY Auditory System: Questions for Obtaining Subjective Data Earache • Do you have earache or another kind of pain in your ear?* • Where is it located? Can you describe the pain? • Do you have any symptoms of a cold or a sore throat?* • What measures have you used to relieve the pain?* Were they effective?

Discharge • Have you experienced discharge from your ears? How much and what colour? • Have you had ear infections? How frequent? How were they treated?

Hearing Loss • Was the hearing loss sudden or gradual?* • Is it all your hearing or just hearing of certain sounds that has decreased? • Where do you notice the hearing loss (e.g., conversations in a crowd, telephone conversations, watching television)? • Have you travelled by airplane recently? • Do you have any allergies that result in ear problems?* • How does your hearing loss affect your daily life at home and at work?

Nutrition and Elimination • Do you have any food allergies that affect your ears?* • Do you notice any differences in symptoms with changes in your diet?* • Does your ear condition cause nausea that interferes with your food intake?* • Does chewing or swallowing cause you any ear discomfort? • Does straining during a bowel movement cause you ear pain?*

Activities of Daily Living and Exercise • Does your ear condition cause you to change your usual activity or exercise?* • Do you need help with certain activities (e.g., lifting, bending, climbing stairs, driving, speaking) because of symptoms?* • Do you have any limitations in activities of daily living because of your symptoms?* • Is your sleep disturbed by symptoms of pain, tinnitus, or dizziness?*

Self-­Care History

• When did you last have your ears checked? • How do you clean your ears? • Do you use any devices to improve your hearing (e.g., hearing aid, special Environmental Noise volume control, headphones for television or audio devices)?* • Do you have loud noise in your home or work environment?* • Do you work near loud noises such as heavy machinery or drums in a band? • How long have you used a hearing aid? Do you have any problems using or maintaining your hearing aid?* Tinnitus • Do you use any means to protect your ears, such as headphones or • Have you ever experienced ringing, crackling, or buzzing in earplugs?* When? your ears?* • Do you use personal sound systems such as iPhones or MP3 players?* • Does the noise seem louder at certain times?* Coping Abilities • When does it bother you the most? • Is your ability to communicate and understand affected by your • What things have you tried that help? symptoms?* Vertigo • What effect has your ear condition had on your work, family, or • Have you felt vertigo—a spinning sensation?* social life? • Have you felt dizzy, as if you were falling or losing your balance?* • How does your ear condition make you feel about yourself? • Do you ever experience lightheadedness or giddiness?* • Do you consider your ear condition a stressor?* • Have you ever fallen because of the dizziness?* • How do you cope with your ear condition? • How does the dizziness affect your daily life?* Source: Adapted from Jarvis, C., Browne, A. J., MacDonald-­Jenkins, J., et al. (Eds.). (2019). Physical examination and health assessment (3rd Canadian ed., pp. 355–358). Elsevier. *If yes, describe.

Past Health History.  Many conditions related to the ear are sequelae of childhood illnesses or result from conditions of adjacent organs. Consequently, a careful assessment of past health conditions is important. The patient should be questioned about previous conditions regarding the ears, especially those experienced during childhood. The frequency of acute middle ear infections (otitis media), perforations of the eardrum, drainage, and history of mumps, measles, or scarlet fever should be recorded. Congenital hearing loss can result from infectious diseases (e.g., rubella, influenza, or syphilis), teratogenic medications, or hypoxia in the first trimester of pregnancy. Information regarding family members with hearing loss and type of hearing loss is important. Some congenital hearing loss is hereditary. The age at onset of presbycusis also follows a familial pattern. Head injury should be documented because it can result in hearing loss. Information about food and environmental allergies is important because they can cause the Eustachian tube to become edematous and prevent aeration of the middle ear. 

Medications.  The nurse should obtain information about current or past medications that are ototoxic (cause damage to CN VIII) and can produce hearing loss, tinnitus, and vertigo. The amount and frequency of acetylsalicylic acid (ASA; Aspirin) use is important because tinnitus can result from high ASA (Aspirin) intake. Salicylates and nonsteroidal anti-­inflammatory medications, aminoglycoside and macrolide antibiotics, antimalarial agents, platinum-­based chemotherapeutics, and loop diuretics are groups of mediations that are potentially ototoxic (Ganesan et al., 2018). Careful monitoring for hearing and balance issues is essential. Many medications produce hearing loss that may be reversible if treatment is stopped. The nurse should also inquire about the use of herbal or alternative therapies, including ear candling. Health Canada does not recommend ear candling because patients have experienced burns and hearing loss as a result (Government of Canada, 2013).  Surgery or Other Treatments.  The nurse should obtain information about previous hospitalizations for ear surgery (e.g., myringotomy, tympanoplasty), tonsillectomy, and adenoidectomy. Use of and satisfaction with a hearing aid should

CHAPTER 23  Nursing Assessment: Visual and Auditory Systems TABLE 23.9    THE HEARING HANDICAP

INVENTORY FOR OLDER PERSONS*

Does a hearing problem cause you 1. (E) To feel embarrassed when meeting new people? 2. (E) To feel frustrated when talking to members of your family? 3. (S) To have difficulty understanding when someone speaks in a whisper? 4. (E) To feel handicapped? 5. (S) To have difficulty when visiting friends, relatives, or neighbours? 6. (S) To attend religious services less often than you would like? 7. (E) To have arguments with family members? 8. (S) To have difficulty when listening to television or radio? 9. (E) To feel that your hearing limits or hampers your personal or social life? 10. (S) To have difficulty when in a restaurant with relatives and friends? Source: Adapted from Ventry, I. M., & Weinstein, B. E. (1982). The Hearing Handicap Inventory for the Elderly: a new tool. Ear and Hearing, 3, 128–134. *Overall scoring: yes = 4 points; sometimes = 2 points; no = 0 points. (E), question referring to emotional handicap; (S), question referring to social handicap.

be documented. Problems with impacted cerumen should also be noted.  Nutrition and Elimination.  Both alcohol and sodium affect the amount of endolymph in the inner ear system. Patients with Ménière’s disease generally notice some improvement in their symptoms with alcohol restriction and a low-­sodium diet. Improvements and exacerbations associated with food intake should be noted. The patient should also be questioned about any ear pain or discomfort that occurs with chewing or swallowing, which might decrease nutritional intake. This situation is often associated with a problem in the middle ear. Assessment of clenching or grinding of the teeth helps differentiate conditions of the ear from referred pain of the temporomandibular joint. The nurse should ask about dental issues and dentures. Elimination patterns and their association with ear conditions are of interest mainly in patients with perilymph fistula or in patients immediately after surgery. Frequent constipation or straining with bowel or bladder elimination may interfere with healing of a perilymph fistula or its repair. A patient who has just undergone stapedectomy especially needs to prevent the increase in intracranial (and consequent inner ear) pressure associated with straining during bowel movements. Stool softeners may be ordered postoperatively for a patient who reports chronic problems with constipation.  Activities of Daily Living and Exercise.  Activity and exercise review is most important in assessing a patient with vestibular issues. If vertigo is a problem, the patient should be questioned about the onset, duration, and frequency of this symptom. Patients who have Ménière’s disease demonstrate increasing inability to compensate for environmental input as the day progresses. Symptoms are experienced most often in the evening. In contrast, patients with chronic vertigo syndrome (benign paroxysmal positional vertigo) note that the symptoms improve throughout the day as adjustment to the visual and positional input from the environment occurs. The nurse and the patient should identify a list of activities and exercises that aggravate and relieve dizziness and vertigo or cause nausea or vomiting. Frequent repetition of an activity that causes symptoms (habituation) may help the body adjust so that the activity is no longer a problem. A patient with chronic tinnitus should be questioned about sleep problems. Tinnitus can disturb sleep and activities

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conducted in a quiet environment. Affected patients should be asked whether they have used or tried any masking devices or techniques to drown out the tinnitus. The nurse should also assess for snoring because it can be caused by swelling or hypertrophy of tissue in the nasopharynx. This excessive tissue can impair the functioning of the Eustachian tube and cause the sensation of ear fullness or pain.  Self-­Care History.  Patients should be questioned about personal practices such as the most recent ear examination, use of cotton ear swabs, use of earphones for personal listening devices, and measures used to preserve hearing. Patients should be questioned about contact with environments that have excessive noise levels, such as work with jet engines and machinery, firing of firearms, and electronically amplified music. The use of protective ear covers or earplugs is good practice for people in high-­noise environments and is important to document. If the patient is a swimmer, the frequency and duration of swimming and use of ear protection should be documented. It is also important to note the type of water (pool, lake, or ocean) in which the swimming takes place to help identify contact with contaminated water. Placement of any item in the ear, including hearing aids, that can cause trauma to the skin increases risk of infection.  Coping Abilities.  Patients should be questioned about the effect the ear condition has had on family life, work responsibilities, and social relationships. Hearing loss can strain family relations and create misunderstandings. Failure to acknowledge hearing loss and failure to seek treatment can further hinder family relationships. Many jobs rely on the ability to hear accurately and respond appropriately. If hearing loss is present, the nurse should gather detailed information of its effect on the patient’s job. The patient should be assisted to realistically evaluate the job situation. The unpredictability of vertigo attacks can have devastating effects on all aspects of a patient’s life. Ordinary activities such as driving, childcare, housework, climbing stairs, and cooking all acquire an element of danger. The patient should be asked to describe the effect of the vertigo on the many roles and responsibilities of life. Compensatory practices to avoid the development of dangerous situations should also be noted. Hearing loss often leaves the patient feeling isolated from valued social relationships. The nurse should historically document social activities such as playing cards, going to movies, and attending religious functions from before and since the hearing loss occurred. Comparison of the frequency and enjoyment of the events can indicate whether a problem is present. The nurse should determine whether hearing loss or deafness has interfered with the patient’s establishment of a satisfactory sex life. Although intimacy does not depend on the ability to hear, it could interfere with establishing or maintaining a relationship. 

Objective Data Physical Examination.  During the health history interview, the nurse can collect valuable objective data regarding the patient’s ability to hear. Clues such as posturing of the head and appropriateness of responses should be noted. Does the patient ask to have certain words repeated? Does the patient intently watch the examiner but miss comments when not looking at the examiner? Such observations are significant and should be recorded. This is also important because many patients are unaware of hearing loss or do not admit to changes in hearing until moderate losses have occurred. A normal assessment of the ear is described in Table 23.10.

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SECTION 4  Conditions Related to Altered Sensory Input

TABLE 23.10    NORMAL FINDINGS IN PHYSICAL

Posterior fold

ASSESSMENT OF THE AUDITORY SYSTEM

• Ears: symmetrical in location and shape • Auricles and tragus: nontender, without lesions • Canal: clear; tympanic membrane: intact; landmarks and light reflex: intact • Ability to hear low whisper at 30 cm; Rinne’s test results: air conduction is better than bone conduction; Weber’s test results: no lateralization

Pars flaccida Anterior fold Short process of malleus

Incus

Umbo Manubrium of malleus Annulus Pars tensa

Cone of light

TYMPANIC MEMBRANE FIG. 23.10 Illustration of normal landmarks of the right tympanic mem-

brane, as seen through an otoscope. Source: Jarvis, C., Browne, A. J., MacDonald-­Jenkins, J., et al. (2019). Physical examination & health assessment (3rd Canadian ed.). Elsevier.

FIG. 23.9  Otoscopic examination of the adult ear. The auricle is pulled up and back. The examiner’s hand holding the otoscope is braced against the patient’s face for stabilization. Source: Courtesy Maureen Barry.

Age-­related changes of the auditory system and differences in assessment findings are listed in Table 23.7. External Ear.  The external ear is inspected and palpated before examination of the external canal and tympanum. The auricle, preauricular area, and mastoid area are observed for symmetry of the ears, colour of skin, temperature, nodules, swelling, redness, and lesions. The auricle and mastoid areas are then palpated for tenderness and nodules. Grasping the auricle may elicit a pain response, especially if inflammation of the external ear or canal is present.  External Auditory Canal and Tympanum.  Before inserting an otoscope, the nurse should inspect the canal opening for patency, palpate the tragus, and gently move the auricle to check for discomfort. A speculum only slightly smaller than the size of the ear canal is selected. The patient’s head is tipped to the opposite shoulder. The top of the auricle is grasped and gently pulled up and backward in adults and slightly down and backward in children to straighten the canal. The otoscope, held in one of the examiner’s hands and stabilized on the patient’s head by the fingers of the other hand, is inserted slowly (Figure 23.9). A tight seal of the speculum is essential during this step of the examination. The canal is observed for size and shape and for the colour, amount, and type of cerumen. The tympanic membrane separates the external ear from the middle ear. If a large amount of cerumen is present, the tympanic membrane may not be visible. The tympanic membrane is observed for colour, landmarks, contour, and intactness (Figure 23.10). It is pearl-­ grey, white, or pink; shiny; and translucent. The handle (manubrium) of the malleus and the end (umbo) are formed from the short process of the malleus and should be visible through the membrane. The somewhat anterior position

and concave shape of the tympanic membrane causes the light from the otoscope to reflect back as a cone of light with crisp edges. If the tympanic membrane is bulging or retracted, the edges of the light reflex do not have the cone shape; instead, the reflected light spreads out or moves and has irregular edges (diffuse). The circumference of the tympanum is thickened into a dense, whitish, fibrous ring, or annulus, except in the superior area. The tympanum within the annulus (pars tensa) is taut. Above the short process of the malleus is the pars flaccida, the flaccid part of the tympanum. The malleolar folds are anterior and posterior to the short process of the malleus. The middle and inner ear cannot be examined with the otoscope because of the tympanic membrane. Table 23.11 summarizes common abnormalities of the auditory system that are found in the assessment.  Focused Assessment.  A focused assessment (see the Focused Assessment box) may be performed by a nurse when a patient is admitted to a hospital or an outpatient clinic. The ears may be inspected routinely as part of the assessment of a hospitalized patient. In addition, the nurse should assess for the presence of a hearing aid and document whether the patient has been using it. 

FOCUSED ASSESSMENT Auditory System Use this checklist to make sure the key assessment steps have been performed.

Subjective Ask the patient about any of the following and note responses. Changes in hearing Ear pain Ear drainage

Y Y Y

N N N

Objective: Physical Examination Inspect Alignment and position of ears on head Size, shape, symmetry, colour, and skin intactness External auditory meatus for discharge or lesions

✓ ✓ ✓

Assess Hearing, according to ability to respond to conversation, respond ✓ to a whisper, or hear a ticking watch

CHAPTER 23  Nursing Assessment: Visual and Auditory Systems

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TABLE 23.11    ASSESSMENT ABNORMALITIES Auditory System Finding

Description

Possible Cause and Significance

Usually within skin, possible presence of black dot (opening to sebaceous gland) Hard nodules in the helix or antihelix, consisting of uric acid crystals Wax that has not been excreted from the ear normally; no visualization of eardrum

Removal or incision and drainage if painful

External Ear and Canal Sebaceous cyst behind ear Tophi Impacted cerumen

Discharge in canal

Infection of external ear, usually painful

Swelling of auricle, pain

Infection of glands of skin, hematoma caused by trauma Change in usual appearance of skin

Scaling or lesions Exostosis

Bony growth extending into canal, causing narrowing of canal

Associated with gout, metabolic disorder; further diagnosis needed Decreased hearing possible, sensation of fullness in auditory canal; removal necessary before otoscopic examination can be conducted Swimmer’s ear, infection of external ear; possibly caused by ruptured eardrum and otitis media Aspiration (for hematoma) Seborrheic dermatitis, squamous cell carcinoma, atrophic dermatitis Possible interference with visualization of tympanum; usually asymptomatic

Tympanum Retracted eardrum Hairline fluid level, yellow-­amber bubbles above fluid level Bulging red or blue eardrum, lack of landmarks Perforation of eardrum (central or marginal)

Recruitment

Appearance of shorter, more horizontal malleus; cone of light is absent or bent Caused by transudate of blood and serum; meniscus of fluid produces hairline appearance Middle ear filled with fluid (pus, blood) Previous perforations of the eardrum that have failed to heal; thin, transparent layer of epithelium surrounding eardrum Disproportionate loudness of sound; difficulty in using hearing aid

DIAGNOSTIC STUDIES Table 23.12 describes diagnostic studies commonly used to assess the auditory system.

Tests for Hearing Acuity Tests involving the whispered and the spoken voice can provide gross screening information about the patient’s ability to hear. Audiometric testing provides more detailed information that can be used for diagnosis and treatment. In the whispered voice test, the examiner stands 30 to 60 cm behind the patient and, after exhaling, speaks in a low whisper. A louder whisper is used if the patient does not respond correctly. Spoken voice, increasing in loudness, is similarly used. The patient is asked to repeat numbers or words or answer questions. One ear at a time is tested while hearing in the other ear is masked to prevent sound transmission around the head. During testing, the nontest ear is masked by the patient, who occludes the ear, or by the examiner, who gently occludes the auditory canal with a finger and rubs the tragus in a circular motion. Tuning-­Fork Tests.  Tuning-­fork tests aid in differentiating between conductive and sensorineural hearing loss. For this examination, 512-­Hz tuning forks are generally used. Both skill and experience are necessary to ensure accurate results. If a hearing difficulty is suspected, further evaluation by pure-­tone audiometry is essential. The most common tuning-­fork tests are the Rinne test and Weber test (see Table 23.12). Results of tuning-­fork tests are subjective. A patient with inconsistent test results or questionable results should be referred for more objective audiometric evaluation. 

Vacuum in middle ear, blockage of Eustachian tube, negative pressure in middle ear Serous otitis media Acute otitis media; perforation possible Chronic otitis media, mastoiditis

Malfunction of inner ear

Audiometry.  Audiometry is beneficial as a screening test for hearing acuity and as a diagnostic test for determining the degree and type of hearing loss. The audiometer produces pure tones at varying intensities to which the patient can respond. Sound is characterized by the number of vibrations or cycles that occur each second. Hertz (Hz) is the unit of measurement used to classify the frequency of a tone; the higher the frequency, the higher the pitch. Hearing loss can affect certain sound frequencies. The specific pattern produced on the audiogram by these losses can assist in the diagnosis of the type of hearing loss. The intensity or strength of a sound wave is expressed in terms of decibels (dB), ranging from 0 to 110 dB. The intensity of a sound required to make any frequency barely audible to the average normal ear is 0 dB. Threshold refers to the signal level at which pure tones are detected (pure tone thresholds) or the signal level at which the patient correctly hears 50% of the signals (speech detection thresholds). Normal speech is approximately 40 to 65 dB; a soft whisper is 20 dB. Normally, a child and a young adult can hear frequencies from about 16 to 20 000 Hz, but hearing is most sensitive between 500 and 4 000 Hz. This range is similar to the frequencies contained in speech. A 40-­to 45-­dB loss in these frequencies causes moderate difficulty in hearing normal speech. A hearing aid may be helpful because it makes sound information louder, although not clearer. A hearing aid may not be helpful to a patient who has problems with discrimination of sounds or sound information, because the consonants are still not heard well enough to make speech understandable. Screening Audiometry.  Screening audiometry is the testing of large numbers of people with a fast, simple test to

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TABLE 23.12    DIAGNOSTIC STUDIES Auditory System Study

Description and Purpose

Nursing Responsibility

Sounds are presented through earphones in a soundproof room. Patient responds nonverbally when sound is heard. Response is recorded on an audiogram. Purpose is to determine patient’s hearing range in terms of decibels (dB) and hertz (Hz) for diagnosing conductive and sensorineural hearing loss. Tinnitus can cause inconsistent results. Includes speech-­awareness threshold (SAT) (measure of intensity at which speech is recognized) and speech recognition threshold (SRT) (ability to discriminate among various speech sounds).

Nurse does not usually participate in examination.

Compares hearing by bone conduction (BC) and air conduction (AC). Stem of vibrating tuning fork is held against mastoid bone and time noted. When the sound is no longer perceived behind the ear (BC of sound), time is noted once again and the still-­ vibrating fork is moved close to the pinna. Have patient report when sound next to the ear canal (AC) is no longer heard and note time. Normally, sound is heard twice as long in front of the ear as it is on the bone. With conductive hearing loss, the relationship is reversed; BC is longer than AC. With sensorineural hearing loss, both AC and BC are reduced, but AC remains longer. Stem of vibrating tuning fork is placed on midline of skull or forehead. Patient is asked to indicate where the sound is heard best. In normal auditory function, the patient perceives a midline tone and the sound is heard equally in both ears. If a patient has conductive hearing loss in one ear, the sound will be heard louder (lateralizes) in that ear. If sensorineural loss is present, the sound is louder (lateralizes) in the normal (unaffected) ear. Procedure is similar to electroencephalography (see Chapter 58, Table 58.8). Electrodes are attached to patient in a darkened room. Electrodes are placed typically at vertex, mastoid process, or earlobes and forehead. A computer is used to record auditory activity in isolation from other electrical activity of the brain. Electrical peaks along auditory pathway of inner ear to brain are measured, and diagnostic information is related to acoustical neuromas, brainstem problems, and stroke. Test is useful for uncooperative patient or for patient who cannot volunteer useful information. Test records electrical activity in the cochlea and auditory nerve.

Nurse may perform test.

Auditory Tests Pure tone audiometry

Speech audiometry

Nurse does not usually participate in examination.

Tuning-­Fork Tests Rinne test

Weber test

Auditory evoked potential (AEP)

Auditory brainstem response (ABR) Electrocochleography

Nurse may perform test.

Nurse should explain procedure to patient. Nurse should not leave patient alone in the darkened room.

Nurse does not usually participate in examination.

Nurse does not usually participate in examination.

Tympanometric Tests Tympanometry (impedance audiometry)

Useful in diagnosis of middle ear effusions. A probe is placed snugly in the external ear canal, and positive and negative pressures are then applied. Compliance of the middle ear is then noted in response to the pressures.

Nurse does not usually participate in examination.

Endolymph of the semicircular canals is stimulated by irrigation of cold (20°C) or warm (36°C) solution into the ear. Patient is seated or in supine position. Observation of type of nystagmus, nausea and vomiting, falling, or vertigo is helpful in diagnosing disease of labyrinth. Decreased response indicates decreased function and thus disease of vestibular system. The other ear is tested similarly, and results from both are compared. Electrodes are placed near patient’s eyes, and movement of eyes (nystagmus) is recorded on a graph during specific eye movements and when ear is irrigated. Study aids in diagnosing diseases of vestibular system. A balance test in which one semicircular canal can be isolated from others to determine site of lesion

Nurse instructs patient to eat no more than a light meal before test, to prevent nausea. Nurse observes patient for vomiting and assists patient if necessary. Nurse ensures patient safety.

Vestibular Tests Caloric test stimulus

Electronystagmography

Posturography

Rotary chair testing

The patient is seated in a chair driven by a motor under computer control. Test is an evaluation of peripheral vestibular system.

Nurse instructs patient to eat no more than a light meal before test, to prevent nausea. Nurse observes patient for vomiting and assists patient if necessary. Nurse ensures patient safety. Nurse informs patient that test is time consuming and uncomfortable but that the test can be discontinued any time at patient’s request. Nurse instructs patient to eat no more than a light meal before test, to prevent nausea. Nurse observes patient for vomiting and assists patient if necessary. Nurse ensures patient safety.

CHAPTER 23  Nursing Assessment: Visual and Auditory Systems detect possible hearing problems. A pass–fail criterion is used to identify people who will need additional diagnostic testing. People who fail the screening should be referred to an audiologist for pure-­tone (threshold) audiometry (see Table 23.12). 

Specialized Tests Specialized tests of the auditory system are most often performed in an outpatient setting by an audiologist using audiometers and computers that record electrical activity from the middle ear, the inner ear, and the brain. The test most commonly performed by audiologists is pure-­tone audiometry. More sophisticated

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tests are available to determine the origin of certain hearing losses. These include the auditory evoked potential (AEP), auditory brainstem response (ABR), and electrocochleography (see Table 23.12). Computed tomography (CT) and magnetic resonance imaging (MRI) are used to diagnose the site of a lesion, such as a tumour of the auditory nerve. 

Test for Vestibular Function Table 23.12 describes diagnostic studies commonly used to assess vestibular function. Results of these tests can be altered by use of caffeine, other stimulants, sedatives, and antivertigo agents.

 REVIEW QUESTIONS The number of the question corresponds to the same-­numbered objective at the beginning of the chapter. 1. In a client with a hemorrhage in the vitreous cavity of the eye, where is the blood accumulating? a. In the aqueous humor b. Between the lens and the retina c. Between the cornea and the lens d. In the space between the iris and the lens 2. Why might intraocular pressure increase? a. Edema of the corneal stroma b. Dilation of the retinal arterioles c. Blockage of the lacrimal canals and ducts d. Increased production of aqueous humor by the ciliary process 3. Which of the following should the nurse question clients about if they are using eye drops to treat glaucoma? a. Use of corrective lenses b. Their usual sleep pattern c. A history of heart or lung disease d. Sensitivity to opioids or depressants 4. For a client with an ophthalmic condition, the nurse should always assess for which of the following? a. Visual acuity b. Pupillary reactions c. Intraocular pressure d. Confrontation visual fields

5. W  hich of the following normal findings would the nurse expect during assessment of the auditory system? a. Absence of the cone of light b. Pearl-­grey tympanic membrane c. Lateralization with Weber’s test d. Bone conduction greater than air conduction 6. Which of the following are common age-­related changes in the auditory system? (Select all that apply.) a. Drier cerumen b. Tinnitus in both ears c. Auditory nerve degeneration d. Atrophy of the tympanic membrane e. Greater ability to hear high-­pitched sounds 7. Before fluorescein is injected for angiography, what should the nurse do? (Select all that apply.) a. Obtain an emesis basin. b. Ask whether the client is fatigued. c. Administer a topical anaesthetic. d. Inform the client that skin may turn yellow. e. Assess for allergies to iodine-­based contrast media.

REFERENCES

Institute for Safe Medication Practices Canada. (2016). Do not use: List of dangerous abbreviations, symbols, and dose designations. https://www.ismp-­canada.org/dangerousabbreviations.htm Jarvis, C., Browne, A. J., MacDonald-­Jenkins, J., et al. (2019). Physical examination & health assessment (3rd Canadian ed.). Elsevier. Khoo, H. E., Ng, H. S., Yap, W.-­S., et al. (2019). Nutrients for prevention of macular degeneration and eye-­related diseases. Antioxidants, 8, 85. https://doi.org/10.3390/antiox8040085 Patton, K., & Thibodeau, G. (2020). Structure and function of the body (16th ed.). Mosby. Ramage-­Morin, P. L., Banks, R., Pineault, D., et al. (2019). Unperceived hearing loss among Canadians aged 40-­79. Statistics Canada: Health Reports, 30(8), 11–20. https://doi.org/10.25318/82.003-­ x201900800002-­eng Skidmore-­Roth, L., & Richardson, F. (2021). Mosby’s Canadian nursing drug reference (1st Canadian ed.). Mosby. Steele, K. (2018). Contact lens compliance: A review. Contact lens update. Clinical insights based on current research (Vol. 44). https://contactlens update.com/2018/10/26/contact-­lens-­compliance-­a-­review/

1. b; 2. d; 3. c; 4. a; 5. b; 6. a, c, d; 7. a, d.

Aljied, R., Aubin, M.-­J., Buhrmann, R., et al. (2018). Prevalence and determinants of visual impairment in Canada: Cross-­sectional data from the Canadian Longitudinal study on aging. Canadian Journal of Ophthalmology, 53(3), 291–297. https://doi. org/10.1016/j.jcjo.2018.01.027 Canadian Association of Optometrists. (2018). Indigenous access to eye health and vision care in Canada. https://opto.ca/docume nt/indigenous-­access-­to-­eye-­health-­and-­vision-­care-­in­canada Canadian Association of Optometrists. (2020). The 20-­20-­20 rule. https://opto.ca/health-­library/the-­20-­20-­20-­rule Ganesan, P., Schmiedge, J., Manchaiah, V., et al. (2018). Ototoxicity: A challenge in diagnosis and treatment. Journal of Audiology & Otology, 22(2), 59–68. https://doi.org/10.7874/jao.2017.00360 Government of Canada. (2013). Ear candling. https://www.canada.ca/en/health-­canada/services/medical-­ procedures/ear-­candling.html

For even more review questions, visit http://evolve.elsevier.com/Cana da/Lewis/medsurg.

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Swain, S. K., Sahu, M. C., Debta, P., et al. (2018). Antimicrobial properties of human cerumen. Apollo Medicine, 15, 197–200. https:// doi.org/10.4103/am.am_69_18 Vargas, V., Arnalich-­Montiel, F., & Alió del Barrio, J. L. (2019). Corneal healing. In J. Alió, J. Alió del Barrio, & F. Arnalich-­ Montiel (Eds.), Corneal regeneration. Essentials in ophthalmology. Springer.

RESOURCES Resources for this chapter are listed after Chapter 24. For additional Internet resources, see the website for this book at http: //evolve.elsevier.com/Canada/Lewis/medsurg.

CHAPTER

24

Nursing Management

Visual and Auditory Conditions Anita Robertson Originating US chapter by Jonel L. Gomez and Mariann M. Harding

WEBSITE http://evolve.elsevier.com/Canada/Lewis/medsurg • R  eview Questions (Online Only) • Key Points • Answer Guidelines for Case Study

• •

 tudent Case Study S • Patient Undergoing Cataract Surgery Customizable Nursing Care Plan • Patient After Eye Surgery

• C  onceptual Care Map Creator • Audio Glossary • Content Updates

LEARNING OBJECTIVES 1. Compare and contrast the types of refractive errors and appropriate corrections. 2. Describe the etiology of and interprofessional care for extraocular disorders. 3. Review the pathophysiological features and clinical manifestations of selected intraocular disorders and the nursing management and interprofessional care of affected patients. 4. Discuss the nursing measures that promote health of the eyes and ears. 5. Explain the general preoperative and postoperative care of the patient undergoing ophthalmological or otological surgery. 6. Summarize the action and uses of medication therapy for treating conditions of the eyes and ears.

7. Explain the pathophysiological features and clinical manifestations of common ear conditions and the nursing management and interprofessional care of affected patients. 8. Compare the causes, management, and rehabilitative potential of conductive and sensorineural hearing loss. 9. Explain the use of, care of, and patient teaching regarding assistive devices for eye and ear problems. 10. Describe the common causes and assistive measures for uncorrectable visual impairment and deafness. 11. Describe the measures used to assist the patient in adapting psychologically to decreased vision and hearing.

KEY TERMS acoustic neuroma age-­related macular degeneration (AMD) amblyopia astigmatism benign paroxysmal positional vertigo (BPPV) cataract conjunctivitis enucleation

  

external otitis glaucoma hordeolum hyperopia keratitis lacrimal puncta Ménière’s disease myopia

This chapter describes visual and auditory conditions, with an emphasis on their pathophysiological features and clinical manifestations and on the interprofessional care and nursing management of affected patients. Assistive devices for visual and hearing impairment are also discussed.

  VISUAL CONDITIONS The eye contains numerous structures, all of which are critical for proper functioning of the visual system. These components

otosclerosis presbycusis presbyopia refractive error retinal detachment retinopathy strabismus

include, most anteriorly, the tear film and cornea; the anterior segment structures, including the iris and lens; and posterior structures, including the vitreous, retina, and optic nerve. The optic nerves of both eyes meet and cross at the optic chiasm. At this point, the information from both eyes is combined and then splits according to the visual field. Information from the visual fields travels via the right or left optic tract, which terminates in the posterior part of the brain in the occipital cortex. Loss of some or all vision has a significant impact on the lives of those who experience it, as well as their families. Vision loss

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affect’s quality of life, independence, and mobility and has been linked to falls, injury, and worsened status in mental health, cognition, social function, employment, and educational attainment (Welp et al., 2016). 

CORRECTABLE REFRACTIVE ERRORS The most common visual condition is refractive error. In this defect, light rays focus either in front of or behind the retina. The cornea is responsible for two thirds of the refractive power of the eye, and the lens is responsible for one third of refractive power. In addition to their combined refractive power, the length of the eye is an important determinant of potential refractive error. When light rays are out of focus, the patient may experience blurry vision, eye strain (asthenopia), headaches, or generalized eye discomfort. The principal refractive errors of the eye can be corrected by the use of lenses in the form of eyeglasses or contact lenses, by refractive surgery, or by surgical implantation of an artificial lens. Refractive errors in young children should be corrected because such children may develop amblyopia (reduced or no vision in affected eye), also known as “lazy eye,” which may result in permanent vision loss if not treated in early childhood (National Eye Institute, 2019a). Undetected and untreated refractive errors and cataracts in persons older than 65 can lead to falls and unintentional injuries. Falls and fractures are of particular concern because of the effect on the individual’s independence and long-­term health (Welp et al., 2016). SAFETY ALERT Upon admission to hospital, older patients should undergo vision screening and, when it is warranted, be referred to an appropriate eye care specialist.

Myopia (nearsightedness) is an inability to accommodate for objects at a distance. It causes light rays to be focused in front of the retina. Myopia may occur because of excessive light refraction by the cornea or lens or because of an abnormally long eye. Hyperopia (farsightedness) is an inability to accommodate for near objects. The light rays focus behind the retina, and so the patient must use accommodation to focus the light rays on the retina for near objects. This type of refractive error occurs when the cornea or lens does not have adequate focusing power or when the eyeball is too short. Presbyopia is the loss of accommodation associated with age. This condition generally appears at approximately age 40. As the eye ages, the lens becomes larger, firmer, and less elastic. These changes, which progress with aging, result in an inability to focus on near objects. The first sign of presbyopia is often the need to hold reading material farther away. Astigmatism is caused by an irregular corneal curvature. This irregularity causes the incoming light rays to be bent unequally. Consequently, the light rays do not converge in a single point of focus on the retina. Astigmatism can occur in conjunction with any of the other refractive errors. Aphakia is the absence of the lens, which results in significant refractive error. Without the focusing ability of the lens, images are projected behind the retina. In rare cases, the lens may be absent congenitally, or it may be removed during cataract surgery. A lens that is traumatically injured is removed and replaced with an intraocular lens (IOL) implant. The lens accounts for approximately 30% of ocular refractive power.

Nonsurgical Corrections Corrective Glasses.  Myopia, hyperopia, presbyopia, and astigmatism can be modified by the appropriate corrective lenses. Myopia necessitates a “minus” (concave) corrective lens, whereas hyperopia and presbyopia necessitate a “plus” (convex) corrective lens. Glasses for presbyopia are often called reading glasses because they are usually worn only for close work. The presbyopic correction may also be combined with a correction for another refractive error, such as myopia or astigmatism. In these combined glasses, the presbyopic correction is in the lower portion of the spectacle lens. A traditional bifocal or trifocal has visible lines. A newer type of corrective glasses for presbyopia, the progressive lens, is actually a multifocal lens in which the transition from near to far correction is graduated seamlessly over a range in the middle area of the lens. This eliminates the visible lines between the different corrective lenses. The lower lens in multifocal glasses may predispose older people to falls because viewing the environment through their lower lenses impairs important visual capabilities (contrast sensitivity and depth perception) for detecting environmental hazards, particularly in unfamiliar environments (Gagnon-­Roy et al., 2018).  Contact Lenses.  Use of contact lenses is another way to correct refractive errors; they are available in rigid and soft types. The rigid types are available in standard and gas-­permeable forms. Their care requires separate solutions for cleaning, storing, and wetting. The soft types are available in many forms. The most commonly used soft contact lenses are the standard and disposable forms, which are less durable and more expensive than rigid forms. Contact lenses generally provide better vision than glasses because the patient has more normal peripheral vision without the distortion and obstruction of glasses and their frames. This is especially true with high refractive errors. Contact lenses are made from various plastic and silicone substances, which are very permeable by oxygen, have a high water content, and thus enable longer wearing time with greater comfort. If the oxygen supply to the cornea is decreased, the cornea becomes swollen, visual acuity decreases, and the patient experiences severe discomfort. Altered or decreased tear formation can make wearing contact lenses difficult. Tear production can be decreased by medications such as antihistamines, decongestants, diuretics, hormone medications such as oral contraceptives, and the hormones produced during pregnancy. Environmental factors such as wind, fans, and dust may also decrease the tear film. Allergic conjunctivitis with itching, tearing, and redness can also affect contact lens wear. In general, the nurse must know whether the patient wears contact lenses, the pattern of wear (daily versus extended), and care practices. Shining a light obliquely on the eyeball can help the nurse visualize a contact lens. The patient should know the signs and symptoms of contact lens problems that must be managed by the eye care professional. These symptoms are remembered better with the mnemonic device RSVP: redness, sensitivity, vision problems, and pain. SAFETY ALERT The nurse should stress the importance of removing contact lenses immediately when the patient experiences RSVP symptoms. 

Surgical Therapy Surgical procedures are designed to eliminate or reduce the need for eyeglasses or contact lenses and correct refractive errors by

CHAPTER 24  Nursing Management: Visual and Auditory Conditions changing the focus of the eye. Surgical management for refractive errors includes laser surgery and IOL implantation. Laser Surgery.  Laser-­assisted in situ keratomileusis (LASIK) may be considered for patients with low to moderately high degrees of myopia, hyperopia, and astigmatism. It has revolutionized refractive surgery, and millions of LASIK procedures have been performed worldwide. The procedure first involves using a laser or surgical blade to create a thin flap in the cornea. Through new “wave-­front” technology, the laser is then programmed to use a map of the patient’s cornea to sculpt the cornea and correct the refractive error. The flap is then repositioned and adheres on its own without sutures in a few minutes (Artini et  al., 2018). Perceptions of glare, halos, double images, and starbursts are negative consequences for some patients despite uncomplicated and successful surgery (Eydelman et al., 2017). Photorefractive keratectomy is indicated for low to moderate degrees of myopia, hyperopia, and astigmatism and is a good option for a patient with insufficient corneal thickness for a LASIK flap. In this procedure, only the epithelium is removed, and the laser is used to sculpt the cornea to correct the refractive error. Laser-­assisted epithelial keratomileusis (LASEK) is similar to photorefractive keratectomy except that the epithelium is replaced after surgery.  Implantation.  Intracorneal ring segments are two semicircular pieces of plastic that are implanted between the layers of the cornea to treat mild forms of myopia. They are designed to change the shape of the cornea by adjusting the focusing power. Intracorneal ring segments can be removed, and the cornea usually returns to its original shape within a few weeks. Refractive IOL implantation is an option for patients with severe myopia or hyperopia. Like cataract surgery, it involves the removal of the patient’s natural lens and implantation of an IOL, which is a small plastic lens to correct a patient’s refractive error. Because this requires entering the eye, the risk of complications is higher. New accommodating IOLs correct both myopia and presbyopia. Phakic IOLs are sometimes referred to as implantable contact lenses. They are implanted into the eye without removal of the eye’s natural lens. They are used for patients with severe myopia and hyperopia. Unlike the refractive IOL, the phakic IOL is placed in front of the eye’s natural lens. Leaving the natural lens in the eye preserves the ability of the eye to focus for reading vision. The Artisan IOL is one type of phakic IOL used for moderate to severe myopia. 

UNCORRECTABLE VISUAL IMPAIRMENT Approximately 5% of Canadians have a seeing disability, defined as either difficulty seeing ordinary newsprint with corrective lenses if those are usually worn or difficulty seeing the face of someone 4 m across a room with corrective lenses if those are usually worn (Statistics Canada, 2018). The partially sighted individual may actually have significant vision. It is important in working with a visually impaired patient to understand that a person classified as blind may have useful vision. Appropriate responses and interventions depend on the nurse’s understanding of an individual patient’s visual abilities.

Levels of Visual Impairment Total blindness is defined as no light perception and no usable vision. With functional blindness the patient has some light perception but no usable vision. A patient with either total or

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TABLE 24.1    DEFINITION OF BLINDNESS IN

CANADA

Legal blindness is defined as follows: • Central visual acuity for distance: 20/200 or worse in the better eye (with correction) • Visual field: no more than 20 degrees in its widest diameter or in the better eye

functional blindness may use vision substitutes such as guide dogs and canes for ambulation. Vision enhancement techniques are not helpful. Legal blindness is defined as visual acuity 20/200 (6/60) or less in both eyes after correction and/or a visual field of 20 degrees or narrower (Canadian National Institute for the Blind [CNIB], 2019). The more common unit for expressing visual acuity is feet (i.e., 20/20), but some sources use the metric conversion (i.e., 6/6). More than 5.5 million Canadians have a major eye disease that could cause vision loss (Canadian Association of Optometrists [CAO], 2019). Most cases of vision impairment and blindness are caused by conditions such as age-­related macular degeneration, glaucoma, diabetic retinopathy, or cataracts. These conditions are preventable, treatable, or both. The prevalence of vision loss in Canada is expected to increase nearly 30% by 2025 (CAO, 2019). A legally blind individual meets the criteria developed by the federal government to determine eligibility for government programs and income tax benefits (Table 24.1). A legally blind individual may have some usable vision. The partially sighted individual who is not legally blind has a corrected visual acuity greater than 20/200 in the better eye and more than 20 degrees of visual field, but the visual acuity is 20/50 or worse in the better eye. The patient who is partially sighted but also legally blind can benefit greatly from vision enhancement techniques. 

NURSING MANAGEMENT VISUAL IMPAIRMENT NURSING ASSESSMENT It is important to determine how long a patient has had a visual impairment because recent loss of vision has particular implications for nursing care. To determine how the patient’s visual impairment affects normal functioning, the nurse should question the patient about the level of difficulty encountered when they perform certain tasks. For example, the nurse may ask how much difficulty the patient has when reading a newspaper, writing a cheque, moving from one room to the next, or watching television. Other questions can help the nurse determine the personal meaning that the patient attaches to the visual impairment. The nurse can ask how the vision loss has affected specific aspects of the patient’s life, whether the patient has lost a job, or in what activities the patient no longer engages because of the visual impairment. Techniques such as describing where personal items are located, advising the patient when the nurse will be providing direct care, and informing the patient where food items are located on the tray are helpful strategies (Touhy et al., 2019). In older patients in all health care settings, vision should be assessed using a reliable tool. Patients may attach many negative meanings to the impairment because of societal opinions about blindness. For example, patients may view the impairment as punishment or view

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SECTION 4  Conditions Related to Altered Sensory Input

themselves as useless and burdensome. It is also important to determine a patient’s primary coping strategies, the patient’s emotional reactions, and the availability and strength of the patient’s support systems.  NURSING DIAGNOSES Nursing diagnoses depend on the degree of visual impairment and how long it has been present. Nursing diagnoses for a visually impaired patient include but are not limited to the following: • Potential for injury resulting from alteration in sensation (visual impairment) • Reduced self-­care resulting from perceptual disorders (visual impairment) • Preparedness for intensified self-­care as demonstrated by willingness to learn self-­care alterations as a result of visual impairment • Potential for grieving resulting from loss of vision  PLANNING For a patient with recently impaired vision or a patient with impaired adjustment to long-­ standing visual impairment, the overall goals are that the patient will (a) make a successful adjustment to the impairment, (b) verbalize feelings related to the loss, (c) identify personal strengths and external support systems, and (d) use appropriate coping strategies. If the patient has been functioning at an appropriate or acceptable level, the goal is to maintain the current level of function.  NURSING IMPLEMENTATION HEALTH PROMOTION.  When a partially sighted patient is at risk for preventable further visual impairment, the nurse should encourage the patient to seek appropriate health care. For example, the patient with vision loss from glaucoma may prevent further visual impairment by adhering to prescribed therapies and suggested ophthalmological evaluations.  ACUTE INTERVENTION.  The nurse needs to provide emotional support and direct care to patients with visual impairment of recent onset. Active listening and facilitating are important components of nursing care for these patients. The nurse should allow the patient to express anger and grief and help the patient identify fears and successful coping strategies. The patient’s family is intimately involved in the experiences that follow vision loss. With the patient’s knowledge and permission, the nurse should include family members in discussions and encourage members to express their concerns. Many people are uncomfortable around a blind or partially sighted individual because they are not sure what behaviours are appropriate. Sensitivity to the person’s feelings without being overly concerned or stifling the person’s independence is vital in creating a therapeutic nursing presence. The nurse should always communicate in a normal conversational tone and manner with the patient and address the patient directly, not the caregiver or friend who may accompany the patient. Common courtesy dictates introducing oneself and any other persons who approach a blind or partially sighted patient and saying goodbye on leaving. Making eye contact with the partially sighted patient accomplishes several objectives. It ensures that the nurse speaks while facing the patient so that the patient has no difficulty hearing the nurse. The nurse’s head position confirms that the nurse is attentive to the patient. Also, establishing eye contact ensures that the nurse can observe the patient’s facial expressions and reactions.

Orientation to the environment lessens patients’ anxiety or discomfort and facilitates independence. In orienting a partially sighted or blind patient to a new area, the nurse should identify one object as the focal point and describe the location of other objects in relation to it. For example, the nurse may say, “The bed is straight ahead, approximately 10 steps. The chair is to the left of the bed, and the nightstand is to the right, near the head of the bed. The bathroom is to the left of the foot of the bed.” The nurse should explain any activities or noises occurring in the patient’s immediate surroundings. The nurse should assist the patient in ambulating to each major object in the area, using the sighted-­guide technique. When using this technique, the nurse stands slightly in front and to one side of the patient and offers an elbow for the patient to hold. The nurse serves as the sighted guide, walking slightly ahead of the patient with the patient holding the back of the nurse’s arm. When using this technique, in any situation, the nurse describes the environment to help orient the patient. For example, the nurse may say, “We’re going through an open doorway and approaching two steps down. There is an obstacle on the left.” To assist the patient to sit, the nurse can place one of the patient’s hands on the back of the chair. The nurse should be familiar with common vision deficits such as cataracts, refractive errors, macular degeneration, glaucoma, and diabetic retinopathy and their associated nursing strategies for care. For example, age-­related macular degeneration entails loss of central vision, and the patient is best cared for by being approached from the side. This condition affects a person’s ability to see detail required for reading, writing, preparing meals, and recognizing faces. When caring for the patient with glaucoma, which entails loss of peripheral vision, the nurse should directly face the patient. Vision loss from glaucoma primarily affects a person’s mobility, especially in a dynamic moving environment (Touhy et al., 2019).  AMBULATORY AND HOME CARE.  Rehabilitation after partial or total loss of vision can foster independence, self-­esteem, and productivity. The nurse should know what services and devices are available for a partially sighted or blind patient and be prepared to make appropriate referrals for those services and devices. For patients who are legally blind and those with low-­degree vision, the primary resource for services is the Canadian National Institute for the Blind (CNIB). A list of agencies that serve the partially sighted or blind patient is available from this institute (see the Resources at the end of this chapter). Braille or audio books for reading and a cane or guide dog for ambulation are examples of vision substitution techniques. These are usually most appropriate for patients with no functional vision. For most patients who have some remaining vision, vision enhancement techniques can provide enough help for them to learn to ambulate, read printed material, and accomplish activities of daily living. Optical Devices for Vision Enhancement.  A wide range of technological advances have become available to assist people with low-­degree vision. These devices include desktop video magnification/closed-­circuit units, electronic hand-­held magnifiers, text-­to-­speech scanners, e-­readers, and computer tablets (material read aloud, magnification, image zooming, brighter screen, voice recognition). Many of these devices require some training and practice for successful use. The nurse should encourage patients to practise with the device so that they can use it successfully. 

CHAPTER 24  Nursing Management: Visual and Auditory Conditions Nonoptical Methods for Vision Enhancement.  Approach magnification is a simple but sometimes overlooked technique for enhancing the patient’s residual vision. The nurse can recommend that the patient sit closer to the television or hold books closer to their eyes, which the patient may be reluctant to do unless encouraged. Contrast enhancement techniques include watching television in black and white, placing dark objects against a light background (e.g., a white plate on a black placemat), using a black felt-­tip marker to write, and using contrasting colours (e.g., a red stripe at the edge of steps or curbs). Increased lighting can be provided by halogen lamps, direct sunlight, or gooseneck lamps that can be aimed directly at the reading material or other near objects. Large type is often helpful, especially in conjunction with other optical or nonoptical vision enhancements. 

EVALUATION The overall expected outcomes are that the patient with severe visual impairment will • Have no further loss of vision • Be able to use adaptive coping strategies • Not experience a decrease in self-­esteem or social interactions • Function safely within their own environment 

AGE-­RELATED CONSIDERATIONS VISUAL IMPAIRMENT Older persons are at an increased risk for vision loss caused by eye disease (Touhy et al., 2019). Older people may have other deficits, such as cognitive impairment or limited mobility, that further affect the ability to function in usual ways. Financial resources may meet normal needs but can be inadequate in meeting increased demands of vision services or devices. Older patients may become confused or disoriented when visually compromised. The combination of decreased vision and confusion increases the risk of falls, which have potentially serious consequences for older persons. Decreased vision may compromise an older person’s ability to function, which raises concerns about maintaining independence and damaging the patient’s self-­image. Because of decreased manual dexterity, some older people may have difficulty instilling prescribed eye drops. It is important to provide proper instruction and demonstration. Having the patient demonstrate the technique is an important aspect of nursing education and reassurance for patients. Eye drop assistive devices are available for purchase at pharmacies in Canada, and their use can be suggested. 

EYE TRAUMA Although the eyes are well protected by the bony orbit and by fat pads, everyday activities can result in ocular trauma. Ocular injuries can involve the ocular adnexa, the superficial structures, or the deeper ocular structures. Eye trauma is one of the leading causes of vision impairment in Canada; an estimated 700 workers experience an eye injury every day (Lian, 2018). Of all Canadian workers, 40% do not get needed visual aids, and approximately 200 per day suffer eye injuries. Furthermore, many of these injuries are serious enough to cause workers to lose work time, and some can lead to permanent eye damage or blindness. A Canadian online eye injury registry has been developed to gather data about the pattern and types of eye

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injuries that occur. Table 24.2 outlines emergency management of an eye injury. Types of ocular trauma include blunt injuries, penetrating injuries, and chemical exposure injuries. Causes of ocular injuries include automobile accidents, falls, injuries from sports and leisure activity, assaults, and work-­related situations. Trauma is often a preventable cause of visual impairment. Almost 90% of all eye injuries could be prevented by the wearing of protective eyewear during potentially hazardous work, hobbies, or sports activities. The nurse’s role in individual and community education is extremely important in reducing the incidence of ocular trauma. 

EXTRAOCULAR DISORDERS Inflammation and Infection One of the most common conditions encountered by ophthalmologists is inflammation or infection of the external eye. Many external irritants or microorganisms can affect the eyelids and conjunctiva and can involve the avascular cornea. The nurse is responsible for teaching the patient appropriate interventions related to the specific disorder. Hordeolum.  An external hordeolum (commonly called a stye) is an infection of the sebaceous glands in the eyelid margin (Figure 24.1). The most common bacterial infective pathogen is Staphylococcus aureus. The affected area rapidly becomes red, swollen, circumscribed, and acutely tender. The nurse should instruct the patient to apply warm, moist compresses at least four times a day until it improves. This may be the only treatment necessary. If it tends to recur, the patient should be taught to perform eyelid scrubs daily. In addition, use of appropriate antibiotic ointments or drops may be indicated.  Chalazion.  A chalazion is a chronic inflammatory granuloma of the meibomian (sebaceous) glands in the eyelid. A hordeolum may evolve into a chalazion. A chalazion may also occur as a response to the material released into the eyelid when a blocked gland ruptures. The chalazion usually appears on the upper eyelid as a swollen, tender, reddened area that may be painful. Initial treatment is similar to that for a hordeolum. If warm, moist compresses are ineffective in causing spontaneous drainage, the ophthalmologist may surgically remove the lesion (this is normally an office procedure), or the ophthalmologist may inject the lesion with corticosteroids.  Blepharitis.  Blepharitis is a chronic inflammatory process of the eyelid margin. It is a common eye disorder throughout the world and can affect any age group. The cause is unknown and probably multifactorial. Bacteria have been implicated in playing a significant role. It may be associated with several systemic diseases such as rosacea or seborrheic dermatitis. It is related to other ocular conditions such as dry eye, chalazion, conjunctivitis, and keratitis. Symptoms include a burning sensation, irritation, tearing, photophobia, blurred vision, and redness of the conjunctiva. These symptoms are usually worse in the morning because the inflamed eyelids are in close contact with the ocular surface and tear production is decreased overnight as a result of less blinking. Basic treatment includes a long-­term commitment to eyelid hygiene. Warm compresses and washing the eyelid margins with baby shampoo diluted in water and applied gently with a cotton-­tipped swab are recommended. An antibiotic-­ corticosteroid ointment can be used for short periods only.  Conjunctivitis.  Conjunctivitis is an infection or inflammation of the conjunctiva, the mucous membrane that lines the eyelids and covers the conjunctiva. These infections may be

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SECTION 4  Conditions Related to Altered Sensory Input

TABLE 24.2    EMERGENCY MANAGEMENT Eye Injury Cause Trauma • B  lunt: Fist; other blunt objects • P  enetrating: Fragments such as glass, metal, wood; knife, stick, or other large object

Chemical Burn • Alkaline • Acid

Thermal Burn • Direct burn from curling iron or other hot surface • Indirect burn from ultraviolet light (e.g., welding torch, sun lamp)

Foreign Bodies • Glass • Metal • Wood • Plastic • Ceramic

Possible Assessment Findings Depending on Cause • Pain • Photophobia • Redness: diffuse or localized • Swelling • Ecchymosis • Tearing • Blood in the anterior chamber • Absence of eye movements • Fluid drainage from eye (e.g., blood, CSF, aqueous humor) • Abnormal or decreased vision • Visible foreign body • Prolapsed globe • Abnormal intraocular pressure • Visual field defect

Interventions Initial • Determine mechanism of injury. • Ensure airway, breathing, and circulation. • Assess for other injuries. • Assess for chemical exposure. • In case of chemical exposure, begin ocular irrigation immediately; do not stop until emergency personnel arrive to continue irrigation. Use sterile saline or water if saline is unavailable. • Do not attempt to treat the injury (except as noted above for chemical exposure). • Assess visual acuity. • Do not put pressure on the eye. • Instruct patient not to blow nose. • Stabilize foreign objects. • Cover injured eye or eyes with dry, sterile patches, and a protective shield. • Do not give the patient food or fluids. • Elevate head of bed to 45 degrees. • Do not put medication or solutions in the eye unless ordered by physician. • Administer analgesic medications as appropriate.

Ongoing Monitoring • Reassure the patient. • Monitor pain. • Anticipate surgical repair for penetrating injury, globe rupture, or globe avulsion.

CSF, cerebrospinal fluid.

FIG. 24.1  External hordeolum (stye) on the upper eyelid caused by staphy-

lococcal infection. Source: Courtesy Cory J. Bosanko, OD, FAAO, Eye Centers of Tennessee, Crossville, Tennessee.

caused by bacteria or viruses (Varu et al., 2019). Conjunctival inflammation may result from exposure to allergens or chemical irritants. Symptoms include ocular redness, discharge, burning, and sometimes itching and light sensitivity. It can occur in one or both eyes and is contagious, requiring meticulous care not to cross-­contaminate the unaffected eye. Careful hand hygiene and the use of individual or disposable towels and preventing close contact with others can help prevent the spread of the condition (Varu et al., 2019). Bacterial Infections.  Acute bacterial conjunctivitis (pinkeye) is a common infection. Although it occurs in every age group,

epidemics commonly occur among children because of their limited personal hygiene habits. In adults and children, the most common causative microorganism is S. aureus. Streptococcus pneumoniae and Haemophilus influenzae are other common causative pathogens, but they are seen more often in children than in adults. A patient with bacterial conjunctivitis may have discomfort, pruritus, tearing, redness, and a mucopurulent drainage. Although this initially occurs in one eye, it generally spreads within 48 hours to the unaffected eye. The infection is usually self-­limiting, but treatment with antibiotic drops shortens the course of the disorder.  Viral Infections.  Conjunctival infections may be caused by many different viruses. A patient with viral conjunctivitis may experience tearing, foreign-­body sensation, redness, and mild photophobia. This condition is usually mild and self-­limiting. However, it can be severe, with considerable discomfort and subconjunctival hemorrhaging. Adenovirus conjunctivitis may be contracted in contaminated swimming pools and through direct contact with an infected patient. Treatment is usually palliative. If the patient’s symptoms are severe, topical corticosteroids provide temporary relief but do not cure the infection. Antiviral drops are ineffective and therefore not indicated.  Chlamydial Infections.  Trachoma is a chronic conjunctivitis caused by Chlamydia trachomatis (serotypes A through C). It is a major cause of blindness worldwide. It is responsible for visual impairment in approximately 1.9 million people and is responsible for about 1.4% of all blindness worldwide (World

CHAPTER 24  Nursing Management: Visual and Auditory Conditions Health Organization, 2021). This preventable eye disease is transmitted mainly via contact with the hands and by flies. Adult inclusion conjunctivitis (AIC) is caused by C. trachomatis (serotypes D through K). Manifestations of both trachoma and AIC are mucopurulent ocular discharge, irritation, redness, and eyelid swelling. For unknown reasons, AIC does not carry the long-­term consequences of trachoma. AIC also differs from trachoma in that it is common in economically developed countries, whereas trachoma is most common in underdeveloped countries. Antibiotic therapy is usually effective for trachoma and AIC. Although antibiotic treatment may be successful in adults with AIC, these patients have a high risk of concurrent chlamydial genital infection, as well as other sexually transmitted infections. The nurse’s teaching plan for this patient should include the implications of AIC for sexual activity and reproductive health.  Allergic Conjunctivitis.  Conjunctivitis caused by exposure to an allergen can be mild and transitory, or it can be severe enough to cause significant swelling, sometimes causing the conjunctiva to balloon beyond the eyelids. The defining symptom of allergic conjunctivitis is itching. The patient may also experience burning, redness, and tearing. In the acute stage, the patient may have white or clear exudate. If the condition is chronic, the exudate is thicker and becomes mucopurulent. The patient may develop allergic conjunctivitis in response to pollens, in addition to animal dander, ocular solutions and medications, or even contact lenses. The nurse should instruct the patient to avoid the allergen if it is known. Artificial tears can be effective in diluting the allergen and washing it from the eye. Effective topical medications include antihistamines and corticosteroids.  Keratitis.  Keratitis is an inflammation or infection of the cornea that can be caused by a variety of microorganisms or by other factors. The condition may involve the conjunctiva, the cornea, or both. When it involves both, the disorder is termed keratoconjunctivitis. Bacterial Infections.  When the epithelial layer is disrupted, the cornea can become infected by a variety of bacteria. Topical antibiotics are generally effective but eradicating the infection may require subconjunctival antibiotic injection or, in severe cases, intravenous antibiotics. Risk factors include mechanical or chemical corneal epithelial damage, contact lens wear, debilitation, nutritional deficiencies, immunosuppressed states, and use of contaminated products (e.g., lens care solutions and cases, topical medications, cosmetics).  Viral Infections.  Herpes simplex virus (HSV) keratitis is the most frequently occurring infectious cause of corneal blindness in the Western hemisphere. It is a growing problem, especially among immunosuppressed patients. It may be caused by HSV-­1 or HSV-­2 (genital herpes), although HSV-­2 ocular infection is much less common. The resulting corneal ulcer has a characteristic dendritic (tree-­branching) appearance (Tognarelli et al., 2019). Pain and photophobia are common. In up to 40% of patients, herpetic keratitis heals spontaneously. The spontaneous healing rate increases to 70% if the cornea is debrided to remove infected cells. Interprofessional management includes corneal debridement, followed by topical therapy with trifluridine for 2 to 3 weeks. Topical corticosteroids are usually contraindicated because they contribute to a longer course and possible deeper ulceration of the cornea. Medication therapy may also include oral acyclovir (Zovirax).

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The varicella-­zoster virus causes both chicken pox and herpes zoster ophthalmicus (HZO). HZO occurs in approximately 10 to 20% of all cases of herpes zoster (Freund & Chen, 2018). HZO causes a painful vesicular rash and may occur by reactivation of an endogenous infection that has persisted in latent form after an earlier attack of varicella or by contact with a patient with chicken pox or herpes zoster. It occurs most frequently in older persons and in immunosuppressed patients. Interprofessional care of a patient with acute HZO may include analgesics for the pain, topical corticosteroids to reduce inflammation, antiviral medications such as acyclovir (Zovirax) to reduce viral replication, mydriatic medications to dilate the pupil and relieve pain, and topical antibiotics to combat secondary infection. Ideally, antiviral agents should be initiated within 72 hours of onset of the rash to minimize complications. However, given the risk of blindness and other complications with HZO, antiviral agents may be started beyond this time frame (Freund & Chen, 2018). The patient may apply warm compresses and povidone-­iodine gel to the affected skin (gel should not be applied too near the eye). Epidemic keratoconjunctivitis is the most serious ocular adenoviral disease. This condition is spread by direct contact, including sexual activity. In the medical setting, contaminated hands and instruments can be the source of spread. The patient may experience tearing, redness, photophobia, and sensation of a foreign body in the eye. In most patients, the disease involves only one eye. Treatment is primarily palliative and includes ice packs and dark glasses. In severe cases, therapy can include mild topical corticosteroids to temporarily relieve symptoms and topical antibiotic ointment. The nurse’s most important role is to teach the patient and caregivers the importance of good hygienic practices to avoid spreading the disease.  Other Causes of Keratitis.  Keratitis may also be caused by fungi (most commonly Aspergillus, Candida, and Fusarium species), especially in the case of ocular trauma in an outdoor setting in which fungi are prevalent in the soil and moist organic matter. Acanthamoeba keratitis is caused by a parasite that is associated with contact lens wear, probably as a result of using contaminated lens care solutions or cases. Homemade saline solution is particularly susceptible to Acanthamoeba contamination. The nurse should instruct all patients who wear contact lenses in good lens care practices. Medical treatment of fungal and Acanthamoeba keratitis is difficult. The Acanthamoeba organism is resistant to most medications. If antimicrobial therapy fails, the patient may require corneal transplantation. Exposure keratitis occurs when the patient cannot adequately close the eyelids. The patient with exophthalmos (protruding eyeball) caused by thyroid eye disease or masses posterior to the globe is susceptible to exposure keratitis.  Corneal Ulcer.  Tissue loss caused by infection of the cornea produces a corneal ulcer (infectious keratitis) (Figure 24.2). The infection can be caused by bacteria, viruses, or fungi. Corneal ulcers are often very painful, and patients may feel as if a foreign body is in the eye. Other symptoms can include tearing, purulent or watery discharge, redness, and photophobia. Treatment is generally aggressive to prevent permanent loss of vision. Antibiotic, antiviral, or antifungal eye drops may be prescribed as frequently as every hour, night and day, for the first 24 hours. An untreated corneal ulcer can result in corneal scarring and perforation (hole in the cornea). Corneal transplantation may be indicated. 

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SECTION 4  Conditions Related to Altered Sensory Input

FIG. 24.2  Corneal ulcer. Infection associated with poor contact lens care. Source: Courtesy Cory J. Bosanko, OD, FAAO, Eye Centers of Tennessee, Crossville, Tennessee.

NURSING MANAGEMENT INFLAMMATION AND INFECTION NURSING ASSESSMENT The nurse should assess ocular changes—such as edema, redness, decreasing visual acuity, the sensation that a foreign body is present, or discomfort—and document the findings in the patient’s record. In the assessment, the nurse should also consider the psychosocial aspects of the patient’s condition, especially when the patient’s vision is also impaired.  NURSING DIAGNOSES Nursing diagnoses for the patient with inflammation or infection of the external eye include but are not limited to the following: • Acute pain resulting from biological injury agent (infection) • Anxiety resulting from threat to current status (major change in health status)  PLANNING The overall goals are that the patient with inflammation or infection of the external eye will (a) avoid spread of infection, (b) maintain an acceptable level of comfort and functioning during the course of the specific ocular problem, (c) maintain or improve visual acuity, (d) adhere to the prescribed therapy, and (e) engage in appropriate health-­seeking behaviours.  NURSING IMPLEMENTATION HEALTH PROMOTION.  Careful asepsis and frequent, thorough hand hygiene are essential to prevent spread of organisms from one eye to the other, to other patients, to family members, and to the nurse. The patient and family require information about avoiding sources of ocular irritation or infection and responding appropriately if an ocular condition occurs. Patients with infective disorders that may be transmitted sexually or who have an associated sexually transmitted infection need specific information about those disorders. The nurse should inform the patient about the appropriate use and care of lenses and lens care products.  ACUTE INTERVENTION.  The nurse can apply warm or cool compresses if indicated for the patient’s condition. Darkening the room and providing an appropriate analgesic are other comfort measures. If the patient’s visual acuity is decreased, the nurse may need to modify the patient’s environment or activities for safety. The patient may require eye drops as frequently as every hour. If the patient receives two or more different types of

drops, the nurse should stagger the eye drop dosing to promote maximum absorption. For example, if two different eye drops are ordered hourly, the nurse should administer one kind of drop on the hour and the other kind of drop on the half-­hour unless otherwise prescribed. This staggered schedule promotes maximum absorption. The patient who needs frequent eye drop administration may experience sleep deprivation.  AMBULATORY AND HOME CARE.  The patient’s primary need in the home environment is for information about required care and how to accomplish that care. The patient and family also need information about proper techniques for medication administration. If the patient’s vision is compromised, the nurse should provide suggestions for alternative ways to accomplish necessary daily activities and self-­care. A patient who wears contact lenses and develops infections should discard all opened or used lens care products and cosmetics to decrease the risk of reinfection from contaminated products (a common problem and a probable source of infection for many patients).  EVALUATION The overall expected outcomes are that the patient with inflammation or infection of the external eye will • Adhere to the treatment plan • Experience relief from ocular discomfort • Effectively cope with functional changes if visual acuity is decreased • Obtain specific information to prevent recurrent disease 

DRY EYE DISORDERS Keratoconjunctivitis sicca (dry eyes) is a common condition, particularly among older persons and individuals with certain systemic diseases such as scleroderma and systemic lupus erythematosus. Patients with dry eyes can experience irritation or the sensation of sand in the eye, and the sensation typically worsens throughout the day. This condition is caused by a decrease in the quality or quantity of the tear film, and treatment is directed at the underlying cause. If it is caused by lacrimal duct dysfunction, the condition may respond to hot compresses and eyelid massage. With decreased tear secretion, the patient may use artificial tears or ointments. They should be used sparingly because preservatives in the drops or overuse can cause further ocular irritation. In severe cases, closure of the lacrimal puncta may be necessary. Patients with dry eyes in association with dry mouth may have Sjögren syndrome (see Chapter 67). 

STRABISMUS Strabismus is a condition in which the patient cannot consistently focus both eyes simultaneously on the same object (Figure 24.3). One eye may deviate inward (esotropia), outward (exotropia), upward (hypertropia), or downward (hypotropia). Strabismus in adults may be caused by thyroid disease, neuromuscular disorders of the eye muscles, retinal detachment repair, or cerebral lesions. The primary symptom with strabismus is double vision. 

CORNEAL DISORDERS Corneal Scars and Opacities The cornea is a transparent tissue that allows light rays to enter the eye and focus on the retina, thus producing a visual image. Any wound causes the cornea to become abnormally hydrated

CHAPTER 24  Nursing Management: Visual and Auditory Conditions

FIG. 24.3  Strabismus with right exotropia and fixation of the left eye.

Source: Courtesy Cory J. Bosanko, OD, FAAO, Eye Centers of Tennessee, Crossville, Tennessee.

and decreases the normal transparency. A rigid contact lens can be effective in correcting the irregular astigmatism that results from corneal scars. In other situations, the treatment for corneal scars or opacities is penetrating keratoplasty (corneal transplantation). In this surgical procedure, the ophthalmological surgeon removes the full thickness of the patient’s cornea and replaces it with a donor cornea that is sutured into place (Figure 24.4). Vision may not be restored for up to 12 months. Corneal problems leading to blindness are uncommon, but if they occur, corneal transplantation can preserve vision that otherwise would be lost. Corneal transplantation surgery is one of the fastest and safest of all tissue or organ transplantation procedures (Del Buey et al., 2019). The time between the donor’s death and the removal of the tissue should be as short as possible. Most surgeons prefer this interval to be 4 hours or less. The eye banks test donors for human immunodeficiency virus (HIV) and hepatitis B and C viruses. The tissue is preserved in a special nutritive solution, and it can be kept for up to 5 days in the storage medium, if used for transplantation. Improved methods of tissue procurement and preservation, refined surgical techniques, postoperative topical corticosteroids, and careful follow-­up have decreased the incidence of graft rejection. Matching the blood type of the donor and the recipient may also improve the success rate (National Eye Institute, 2019b). 

Keratoconus Keratoconus is a noninflammatory, usually bilateral disease that has a familial tendency. It can be associated with Down syndrome, atopic dermatitis, Marfan syndrome, aniridia (congenital absence of the iris), and retinitis pigmentosa (hereditary disease characterized by bilateral primary degeneration of the retina beginning in childhood and progression to blindness by middle age). The anterior cornea thins and protrudes forward, taking on a cone shape. Keratoconus usually appears during adolescence and slowly progresses between the ages of 20 and 60 years. The only symptom is blurred vision. The astigmatism may be corrected with glasses or rigid contact lenses. Intacs inserts, for example, are two clear plastic lenses surgically inserted on the cornea’s perimeter to reduce astigmatism and myopia. Intacs inserts are generally used to delay the need for corneal transplantation when contact lenses or glasses no longer help a patient achieve adequate vision. The cornea can perforate as central corneal thinning progresses. In advanced cases, a penetrating keratoplasty is indicated before perforation. 

457

FIG. 24.4  Sutures on a donated cornea after penetrating keratoplasty (corneal transplantation). Source: Courtesy Cory J. Bosanko, OD, FAAO, Eye Centers of Tennessee, Crossville, Tennessee.

INTRAOCULAR DISORDERS Cataract A cataract is an area of opacity within the lens. The patient may have a cataract in one or both eyes. If cataracts are present in both eyes, one cataract may affect the patient’s vision more than the other. Cataracts are one of the leading causes of reversible vision loss worldwide, affecting 95 million people, including nearly 2.5 million Canadians (Jin et al., 2019). Causes and Pathophysiological Processes.  Although most cataracts are age related (senile cataracts), they can be associated with other factors. These include blunt or penetrating trauma, congenital factors such as maternal rubella, exposure to radiation or ultraviolet light, certain medications such as systemic corticosteroids or long-­term topical corticosteroids, and ocular inflammation. Patients with diabetes mellitus tend to develop cataracts at a younger age than average. Cataract development is mediated by a number of factors. In senile cataract formation, it appears that altered metabolic processes within the lens cause an accumulation of water and alterations in the lens fibre structure. These changes affect lens transparency, causing vision changes.  Clinical Manifestations.  Patients with cataracts may experience a decrease in vision, abnormal colour perception, and glare. Glare results from light scatter caused by the lens opacities, and it may be significantly worse at night when the pupil dilates. The visual decline is gradual, but the rate of cataract development varies from patient to patient. Secondary glaucoma can also occur if the enlarging lens causes an increase in intraocular pressure (IOP).  Diagnostic Studies.  Diagnosis is based on decreased visual acuity or other reports of visual dysfunction. The opacity is directly observable by ophthalmoscopic or slit-­lamp microscopic examination. A totally opaque lens creates the appearance of a white pupil. Table 24.3 outlines other diagnostic studies that may be helpful in evaluating the visual effect of a cataract.  Interprofessional Care.  The presence of a cataract does not necessarily indicate a need for surgery. For many patients, the diagnosis is made long before they actually decide to have surgery. Nonsurgical therapy may postpone the need for surgery. Interprofessional care for cataracts is described in Table 24.3. Nonsurgical Therapy.  Currently, the only way to “cure” cataracts is through surgical removal. If the cataract is not removed, the patient’s vision will continue to deteriorate. However, specific strategies may help the patient. In many cases, changing the patient’s eyewear prescription can improve the level of visual acuity, at least temporarily. Other visual aids, such as strong

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SECTION 4  Conditions Related to Altered Sensory Input

TABLE 24.3    INTERPROFESSIONAL CARE Cataract Diagnostic Studies • History and physical examination • Visual acuity measurement • Ophthalmoscopy (direct and indirect) • Slit-­lamp microscopy • Glare testing, potential acuity testing in selected patients • Keratometry and A-­scan ultrasonography (if surgery is planned) • Other tests (e.g., visual field perimetry) may be indicated to determine cause of visual loss

Interprofessional Therapy Nonsurgical • Prescription change for glasses • Strong reading glasses or magnifiers • Increased lighting • Lifestyle adjustment

Acute Care: Surgical Therapy Preoperative • Mydriatic, cycloplegic medications (see Table 24.4) • Nonsteroidal anti-­inflammatory drugs • Topical antibiotics • Antianxiety medications

During Surgery • Removal of lens: • Phacoemulsification (see Figure 24.5) • Extracapsular extraction • Correction of surgical aphakia • Intraocular lens implantation (most frequent type of correction) • Contact lens

Postoperative • Topical antibiotic • Topical corticosteroid or other anti-­inflammatory medication • Mild analgesic medication if necessary • Eye shield and activity as preferred by patient’s surgeon

reading glasses or magnifiers of some type, may help the patient with close vision. Increasing the amount of light to read or accomplish other near-­vision tasks is another useful measure. The patient may be willing to adjust their lifestyle to accommodate for visual decline. For example, if glare makes it difficult to drive at night, a patient may elect to drive only during daylight hours and to have a family member drive at night. Sometimes, informing and reassuring the patient about the disease process can make the patient comfortable about choosing nonsurgical measures, at least temporarily.  Surgical Therapy.  When palliative measures no longer provide an acceptable level of visual function, the patient is an appropriate candidate for surgery. The patient’s occupational needs and lifestyle changes are also factors affecting the decision to undergo surgery. In some instances, factors other than the patient’s visual needs may influence the need for surgery. Lens-­induced conditions such as increased IOP may necessitate lens removal. Opacities may prevent the ophthalmologist from obtaining a clear view of the retina in a patient with diabetic retinopathy or other sight-­threatening pathological conditions. In those cases, the cataract may be removed to allow the surgeon to visualize the retina and adequately manage the problem. Preoperative Phase.  The patient’s preoperative preparation should include an appropriate documentation of the history and a physical examination. Because almost all patients undergo the procedure under local anaesthesia, many physicians and

surgical facilities do not require an extensive preoperative physical assessment. However, most patients with cataracts are older persons and may have several medical conditions that should be evaluated and controlled before surgery. The surgeon may order preoperative antibiotic eye drops. The patient should not have food or fluids for approximately 6 to 8 hours before surgery. Almost all patients with cataracts are admitted to a surgical facility on an outpatient basis. The patient is normally admitted several hours before surgery to allow adequate time for necessary preoperative procedures.

EVIDENCE-­INFORMED PRACTICE Research Highlight Does the Administration of Perioperative Antibiotic Prophylaxis Prevent Endophthalmitis After Cataract Surgery? Clinical Question In adults undergoing cataract surgery (P), does perioperative antibiotic prophylaxis (I) as compared to different antibiotics or no antibiotics perioperatively (C) result in the prevention of endophthalmitis and better visual acuity postoperatively (O)? 

Best Available Evidence Systematic review of randomized controlled trials 

Critical Appraisal and Synthesis of Evidence • M  eta-­analysis of five randomized controlled trials (n = 101 005) • The review included a narrative synthesis. • Primary outcomes were endophthalmitis (presence or absence) and visual acuity within 6 weeks of cataract surgery. • Intraocular and periocular administration demonstrated that ocular injections had the lowest rates of endophthalmitis. Irrigation solution was compared with one group receiving vancomycin and gentamycin in a balanced salt solution (BSS) and the other group receiving the BSS only. The group that had the antibiotics in the BSS reported no incidence of endophthalmitis. • Comparing topical levofloxacin to no antibiotic perioperatively showed no differences in the incidence of endophthalmitis. • No studies reported any differences in visual acuity postoperatively. 

Conclusions • Intracameral antibiotics are recommended for reducing endophthalmitis post–cataract surgery. 

Implications for Nursing Practice • P  rovide information that antibiotics given perioperatively can reduce the incidence of a serious postoperative infection, endophthalmitis. • Inform the patient that there is no evidence to support a decline in visual acuity postoperatively with the use of antibiotics in the perioperative period.

Reference for Evidence Fong, E. (2019). Acute endophthalmitis post-­cataract surgery: Perioperative antibiotics. JBI Evidence Summary AN: JBI 17117. P, patient population of interest; I, intervention or area of interest; C, comparison of interest or comparison group; O, outcome or outcomes of interest (see Chapter 1).

The instillation of dilating and nonsteroidal anti-­ inflammatory eye drops helps maintain pupil dilation and reduce inflammation, respectively. One type of medication used for dilation is a mydriatic, an α-­adrenergic agonist that produces pupillary dilation by causing contraction of the iris dilator muscle. Another type of medication is a cycloplegic, an anticholinergic medication that produces paralysis of accommodation (cycloplegia) and thus pupillary dilation (mydriasis) by blocking the effect of acetylcholine on the ciliary body

CHAPTER 24  Nursing Management: Visual and Auditory Conditions

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TABLE 24.4    MEDICATION THERAPY Topical Medications for Pupil Dilation Examples

Onset

Duration

Comments

45–60 min

4–6 hr

May cause tachycardia and elevation in blood pressure, especially in older patients; can cause a reflexive decrease in heart rate when blood pressure rises Punctal occlusion should be used to limit systemic absorption

Tropicamide (Mydriacyl)

20–40 min

4–6 hr

Cyclopentolate HCl acid (Cyclogyl)

30–75 min

6–24 hr

Homatropine hydrobromide (Isopto Homatropine) Atropine sulphate (Isopto Atropine)

30–60 min

1–3 days

30–180 min

6–12 days

1% Solution used in cycloplegic refraction; 0.5% solution used in fundus examination Has been associated with psychotic reactions and behavioural disturbances Used in cycloplegic refraction, fundus examination, and uveitis Used in cycloplegic refraction, uveitis; may be used for pupil dilation to allow patient to see around a central lens opacity Used in cycloplegic refraction, uveitis

Mydriatic Medications Phenylephrine hydrochloric acid (Mydfrin)

Cycloplegic Medications

muscles. Examples of mydriatic and cycloplegic medications are listed in Table 24.4, and nursing considerations are discussed in the Nursing Management: Cataracts section. Many patients receive preoperative antianxiety medication before the injection of local anaesthetic. MEDICATION ALERT—Cycloplegics and Mydriatics

• Instruct patient to wear dark glasses to minimize photophobia. • Monitor for signs of systemic toxicity (e.g., tachycardia, central nervous system effects). 

Intraoperative Phase.  Cataract extraction is an intraocular procedure. The anterior capsule is opened and the lens nucleus and cortex are removed, leaving the remaining capsular bag intact. In extracapsular extraction, the surgeon can remove the lens nucleus by “scooping” it out with a lens loop or by phacoemulsification, in which the nucleus is fragmented by ultrasonic vibration and aspirated from inside the capsular bag (Mayo Clinic, 2019). In either case, the remaining cortex is aspirated with an irrigation and aspiration instrument. The choice of placement and type of incision varies among surgeons. Corneoscleral incisions necessitate closure with sutures, whereas scleral tunnel incisions are self-­sealing and require no closing suture. The incision required for phacoemulsification is considerably smaller than that required with intracapsular or standard extracapsular surgery. In almost all cases today, an IOL is implanted at the time of cataract extraction surgery (Figure 24.5). Because most patients undergo an extracapsular procedure, the lens of choice is usually a posterior chamber lens that is implanted in the capsular bag behind the iris. However, other patient needs (e.g., financial resources) may dictate an additional type of lens. At the end of the procedure, additional medications such as antibiotics and corticosteroids may be administered. Depending on the type of anaesthetic, the patient’s eye is covered with a patch or protective shield. If used, a patch or protective shield is usually worn overnight and removed during the first postoperative visit, which is usually the day after surgery. Patients should be instructed not to drive a vehicle while the eye shield is in place.  Postoperative Phase.  Unless complications occur, most patients are ready to go home as soon as the effects of sedative medications have worn off. Postoperative medications usually include antibiotic drops to prevent infection and corticosteroid drops to decrease the postoperative inflammatory response. There is some evidence that postoperative activity restrictions

FIG. 24.5  Intraocular lens implant after cataract surgery. Source: Courtesy

Cory J. Bosanko, OD, FAAO, Eye Centers of Tennessee, Crossville, Tennessee.

and nighttime eye shielding are unnecessary. However, many ophthalmologists still prefer that the patient avoid activities that increase the IOP, such as bending or stooping, coughing, or lifting. During each postoperative examination, the ophthalmologist measures the patient’s visual acuity, checks anterior chamber depth, assesses corneal clarity, and measures IOP. A flat anterior chamber may cause adhesions of the iris and cornea. The cornea may become hazy or cloudy from intraoperative trauma to the endothelium. Even on the day of surgery, the patient’s uncorrected visual acuity in the operative eye may be good. However, it is not unusual or indicative of any problem if the patient’s visual acuity is reduced immediately after surgery. The postoperative eye drops are gradually reduced in frequency and finally discontinued when the eye has healed. When the eye is fully recovered, the patient receives a final prescription for glasses if still required after surgery. The newest innovation is a multifocal IOL that corrects for both near and distance vision. Regardless of the type of IOL used, patients may still need glasses to achieve their best visual acuity. 

NURSING MANAGEMENT CATARACTS NURSING ASSESSMENT The nurse should assess the patient’s distance and near visual acuity. If the patient is to undergo surgery, the nurse should especially note the visual acuity in the patient’s nonoperative

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SECTION 4  Conditions Related to Altered Sensory Input

eye. With this information, the nurse can determine how visually compromised the patient may be while the operative eye is healing. In addition, the nurse should assess the psychosocial effect of the patient’s visual disability and the patient’s level of knowledge regarding the disease process and therapeutic options. Postoperatively, it is important to assess the patient’s level of comfort and ability to follow the postoperative regimen.  NURSING DIAGNOSES Nursing diagnoses for the patient with a cataract include but are not limited to the following: • Reduced self-­care resulting from perceptual disorders (visual impairment) • Anxiety resulting from unmet needs (knowledge about surgical and postoperative experience)  PLANNING Preoperatively, the overall goals are that the patient with a cataract will (a) make informed decisions regarding therapeutic options and (b) experience minimal anxiety. Postoperatively, the overall goals are that the patient with a cataract will (a) understand and adhere to postoperative therapy, (b) maintain an acceptable level of physical and emotional comfort, and (c) remain free of infection and other complications.  NURSING IMPLEMENTATION HEALTH PROMOTION.  There are no proven measures to prevent cataract development. However, it is wise (and certainly does no harm) to suggest that the patient wear sunglasses, avoid extraneous or unnecessary radiation, and maintain good nutrition and appropriate intake of antioxidant vitamins (e.g., vitamins C and E). Also, information about vision enhancement techniques should be provided to the patient who chooses not to undergo surgery.  ACUTE INTERVENTION.  Preoperatively, patients with cataracts need accurate information about the disease process and the treatment options, especially because cataract surgery is considered an elective procedure. Although cataracts are not a life-­threatening condition, patients need to know that without surgery, some degree of visual disability will develop. The nurse should be available to give each patient and the family or caregivers information to help them make an informed decision about appropriate treatment. For a patient who elects to have surgery, the nurse is able to provide information, support, and reassurance about the surgical and postoperative experience that can reduce or alleviate the patient’s anxiety. When administering topical medications for pupil dilation before surgery (see Table 24.4 for examples), the nurse should note that patients with dark irides may need a larger dose. Photophobia is common; therefore, decreasing the room lighting is helpful. These medications produce transient stinging and burning and are contraindicated for use in patients with narrow-­angle glaucoma because angle-­closure glaucoma may be produced. Mydriatic medications can produce significant cardiovascular effects. Table 24.5 outlines patient and caregiver teaching after eye surgery. Patients with a patch should be informed that they will not have depth perception until the patch is removed (usually within 24 hours). This necessitates special considerations to avoid possible falls or other injuries. The patient with significant

TABLE 24.5    PATIENT & CAREGIVER TEACHING

GUIDE

After Eye Surgery Include the following information when teaching the patient and the caregiver after eye surgery. 1. Proper hygiene and eye care techniques to ensure that medications, dressings, and surgical wound are not contaminated during eye care 2. Signs and symptoms of infection and when and how to report those to allow early recognition and treatment of possible infection 3. Importance of adhering to postoperative restrictions on head positioning, bending, coughing, and the Valsalva manoeuvre to optimize visual outcomes and prevent increased intraocular pressure 4. How to instill eye medications with the use of aseptic techniques and to adhere to prescribed eye medication regimen to prevent infection 5. How to monitor pain, take pain medication, and report pain not relieved by medication 6. Importance of continued follow-­up as recommended to maximize potential visual outcomes Source: Adapted from Lamb, P., & Simms-­Eaton, S. (2008). Core curriculum for ophthalmic nursing (3rd ed.). Kendall-­Hunt.

visual impairment in the nonoperative eye requires more assistance while the operated eye is patched. Once the patch is removed (usually within 24 hours), most patients with visual impairment in the nonoperative eye have adequate vision for necessary activities because the implanted IOL provides immediate visual rehabilitation in the operated eye. On occasion, a patient may require 1 or 2 weeks for the visual acuity in the operated eye to reach an adequate level for most visual needs. Such a patient also needs some special assistance until the vision improves. After cataract surgery, most patients experience little or no pain. There may be some scratchy sensation in the operative eye. Mild analgesics are usually sufficient to relieve any pain. If the pain is intense, the patient should notify the surgeon because this may indicate hemorrhage, infection, or increased IOP. The nurse should also instruct the patient to notify the surgeon of increased or purulent drainage, increased redness, or any decrease in visual acuity. (A nursing care plan for the patient after eye surgery is available on the Evolve website.)  AMBULATORY AND HOME CARE.  For a patient with cataracts who has not undergone surgery, the nurse can suggest ways in which the patient may modify activities or lifestyle to accommodate the visual deficit caused by the cataract. The nurse should also provide the patient with accurate information about appropriate long-­term eye care. Patients with cataracts who undergo surgery remain in the surgical facility for only a few hours. The patient and the family are responsible for almost all postoperative care. The nurse must give them written and verbal instructions before discharge. These instructions should include information about postoperative eye care, activity restrictions, medications, follow-­up visit scheduling, and signs and symptoms of possible complications. The patient’s family should be included in the instruction because some patients may have difficulty with self-­care activities, especially if the vision in the nonoperative eye is poor. The nurse should provide an opportunity for the patient and family to demonstrate any necessary self-­care activities. Most patients experience little visual impairment after surgery. IOL implants provide immediate visual rehabilitation, and many patients achieve a usable level of visual acuity within a few

CHAPTER 24  Nursing Management: Visual and Auditory Conditions days after surgery. Also, the patient’s eye may remain patched for only 24 hours, and many patients have good vision in the nonoperative eye. A few patients may experience significant visual impairment postoperatively: those who do not have an IOL implanted at the time of surgery, those who require several weeks to achieve a usable level of visual acuity after surgery, or those with poor vision in the nonoperative eye. For these patients, the time between surgery and receiving glasses or contacts can be a period of significant visual disability. The nurse can suggest ways in which the patient and the family can modify activities and the environment to maintain an adequate level of safe functioning. Suggestions may include getting assistance with going up stairs, removing area rugs and other potential obstacles, preparing meals for freezing before surgery, and obtaining audio books for diversion until visual acuity improves.  EVALUATION The overall expected outcomes are that after cataract surgery, the patient will • Have improved vision • Be better able to take care of self • Have minimal to no pain • Be optimistic about expected outcomes 

AGE-­RELATED CONSIDERATIONS Most patients with cataracts are older persons. When an older patient is visually impaired, even temporarily, they may experience a loss of independence, lack of control over their life, and a significant change in self-­perception. Many older patients need emotional support and encouragement, as well as specific suggestions to allow a maximum level of independent function. The nurse should assure older patients that cataract surgery can be accomplished safely and comfortably with minimal sedation. A retrospective case-­series study found that very old patients (over 85 years of age) undergoing cataract surgery may be more prone to complications (Sella et al., 2020). 

RETINOPATHY Retinopathy is a process of microvascular damage to the retina. It can develop slowly or rapidly and lead to blurred vision and progressive vision loss. In adults, retinopathy is most often associated with diabetes mellitus or hypertension. Diabetic retinopathy is a common complication of diabetes mellitus, especially in patients with long-­standing uncontrolled diabetes (Chaudhary et  al., 2018). It is the leading cause of visual disability and blindness in Canadians with long-­standing uncontrolled diabetes (diabetes is discussed in Chapter 52). Because diabetes has been diagnosed in increasing numbers of Canadians, the incidence of diabetic retinopathy will continue to increase. In a Canadian study of diabetic retinopathy in Indigenous and non-­Indigenous Canadians, the data indicated that ethnicity plays a significant role in the development and severity of diabetic retinopathy, even though potential risk factors are not significantly different (Altomare et al., 2018). Nonproliferative retinopathy is the most common form of diabetic retinopathy and is characterized by capillary microaneurysms, retinal swelling, and hard exudates. Macular edema represents a worsening of the retinopathy, inasmuch as plasma leaks from macular blood vessels. As capillary walls weaken they can rupture, which leads to intraretinal “dot and blot”

461

FIG. 24.6  Diabetic retinopathy. Intraretinal “dot and blot” hemorrhages. Source: Courtesy Cory J. Bosanko, OD, FAAO, Eye Centers of Tennessee, Crossville, Tennessee.

hemorrhaging (Figure 24.6). This can lead to a severe loss of central vision. As the disease advances, proliferative retinopathy may occur, where new blood vessels grow. However, these blood vessels are abnormal, fragile, and predisposed to leak and thus predispose the patient to severe vision loss. Fluorescein angiography is used to detect diabetic macular edema, which may be treated with laser photocoagulation (National Eye Institute, 2019c). Hypertensive retinopathy is caused by blockages in retinal blood vessels that result from hypertension. (Hypertension is discussed in Chapter 35.) These changes may not initially affect a person’s vision. On a routine eye examination, retinal hemorrhages and macular swelling can be noted. Sustained, severe hypertension can cause swelling of the optic disc and nerve (papilledema) and lead to sudden visual loss. Treatment, which may be required on an emergency basis, focuses on lowering the blood pressure. Normal vision is restored in patients with treatment of the underlying cause of the hypertension. 

RETINAL DETACHMENT A retinal detachment is a separation of the retina and the underlying pigment epithelium, with fluid accumulation between the two layers. The incidence of nontraumatic retinal detachment is approximately 1 per 15 000 individuals each year. This number is higher when aphakic individuals are included because retinal detachment is more likely to occur in aphakic patients. Almost all patients with an untreated, symptomatic retinal detachment become blind in the involved eye, hence the importance of immediate treatment. On average, 9 out of 10 patients have positive outcomes from retinal detachment treatment and surgery (National Eye Institute, 2020).

Etiology and Pathophysiology Retinal detachment has many causes, the most common of which is a retinal break. A retinal break is an interruption in the full thickness of the retinal tissue, and such breaks can be classified as tears or holes. Retinal holes are atrophic retinal breaks that occur spontaneously. Retinal tears can occur as the vitreous humor shrinks during aging and pulls on the retina. The retina tears when the traction force exceeds the strength of the retina. Once the retina has a break, liquid vitreous can enter the subretinal space between the sensory layer and the retinal pigment epithelium layer, causing a rhegmatogenous retinal detachment. Retinal detachment can also occur when abnormal membranes

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SECTION 4  Conditions Related to Altered Sensory Input

TABLE 24.6    RISK FACTORS FOR RETINAL

DETACHMENT

• Increasing age • Severe myopia • Infection or eye trauma • Retinopathy (diabetic) • Eye diseases or tumours • Cataract or glaucoma surgery • Family or personal history of retinal detachment Source: Adapted from National Eye Institute. (2020). Retinal detachment. https://www.nei.nih.gov/learn-­about-­eye-­health/eye-­conditions-­and-­diseases/retinal-­ detachment

mechanically pull on the retina. Such detachments are called tractional detachments and are less common. A third type of retinal detachment is the secondary or exudative detachment, which occurs in conditions that allow fluid to accumulate in the subretinal space (e.g., choroidal tumours, intraocular inflammation). Risk factors for retinal detachment are listed in Table 24.6. 

Clinical Manifestations Patients with a detaching retina describe symptoms that include photopsia (light flashes), floaters, and a “cobweb,” “hairnet,” or ring in the field of vision. Once the retina has detached, the patient describes a painless loss of peripheral or central vision, “like a curtain” coming across the field of vision. The area of visual loss corresponds to the area of detachment. If the detachment is in the superior nasal retina, the visual field loss is in the inferior temporal area. If the detachment is small or develops slowly in the periphery, the patient may not be aware of a visual problem. The effects of a retinal detachment can be viewed online at VisionSimulations.com (see the Resources at the end of this chapter).  Diagnostic Studies Visual acuity measurements should be the first diagnostic procedure with any report of vision loss (Table 24.7). The retinal detachment can be directly visualized through direct and indirect ophthalmoscopy or slit-­lamp microscopy in conjunction with a special lens to view the far periphery of the retina. Ultrasonography may be useful for identifying a retinal detachment if the retina cannot be directly visualized (e.g., when the cornea, the lens, or the vitreous humor is hazy or opaque). Interprofessional Care.  Some retinal breaks are not likely to progress to detachment. The ophthalmologist monitors the patient, giving precise information about the warning signs and symptoms of impending detachment and instructing the patient to seek immediate evaluation if any of those signs or symptoms occurs. The ophthalmologist usually refers the patient with a detachment to a retinal specialist. Treatment objectives are to seal any retinal breaks and to relieve inward traction on the retina. Several techniques are used to accomplish these objectives (National Eye Institute, 2020).  Surgical Therapy Laser Photocoagulation and Cryopexy.  These techniques

seal retinal breaks by creating an inflammatory reaction that causes a chorioretinal adhesion or scar. In laser photocoagulation, an intense, precisely focused light beam is used to create an inflammatory reaction. The light is directed at the area of the retinal break. For retinal breaks accompanied by significant detachment, the retinal specialist may use photocoagulation

TABLE 24.7    INTERPROFESSIONAL CARE Retinal Detachment Diagnostic Studies

Surgery

• History and physical examination • Visual acuity measurement • Ophthalmoscopy (direct and indirect) • Slit-­lamp microscopy • Ultrasonography if cornea, lens, or vitreous humor is hazy or opaque

• Laser photocoagulation • Cryotherapy (cryopexy) • Scleral buckling procedure • Draining of subretinal fluid • Vitrectomy • Intravitreal bubble

Interprofessional Therapy Preoperative • Mydriatic, cycloplegic eye drops (see Table 24.4) • Photocoagulation of retinal break that has not progressed to detachment

Postoperative • Topical antibiotic • Topical corticosteroid • Analgesia • Mydriatics • Positioning and activity as preferred by patient’s surgeon

intraoperatively in conjunction with scleral buckling. Tears or holes without accompanying retinal detachment may be treated prophylactically with laser photocoagulation if there is a high risk of progression to retinal detachment. When used alone, laser therapy is an outpatient procedure for which most patients require only topical anaesthesia. Patients may experience minimal adverse symptoms during or after the procedure. Another method used to seal retinal breaks is cryopexy. This procedure involves the use of extreme cold to create the inflammatory reaction that produces the sealing scar. The ophthalmologist applies the cryoprobe instrument to the external globe in the area over the tear. This is usually done on an outpatient basis and with the use of a local anaesthetic. As with photocoagulation, cryotherapy may be used alone or during scleral buckling surgery. The patient may experience significant discomfort and eye pain after cryopexy. The nurse should encourage the patient to take the prescribed pain medication after the procedure.  Scleral Buckling.  Scleral buckling is an extraocular surgical procedure that involves compressing the globe so that the pigment epithelium, the choroid, and the sclera move toward the detached retina. The retinal surgeon sutures a silicone implant against the sclera, causing the sclera to buckle inward. The surgeon may place an encircling band over the implant if there are multiple retinal breaks, if suspected breaks cannot be located, or if there is widespread inward traction on the retina (Figure 24.7). To drain any subretinal fluid, a small-­gauge needle is inserted to facilitate contact between the retina and the buckled sclera. Scleral buckling is usually done as an outpatient procedure with the patient under local anaesthesia.  Intraocular Procedures.  In addition to the extraocular procedures described, retinal surgeons may use one or more intraocular procedures in treating some retinal detachments. Pneumatic retinopexy is the intravitreal injection of a gas to form a temporary bubble in the vitreous that closes retinal breaks and provides apposition of the separated retinal layers. Because the intravitreal bubble is temporary, this technique is combined with laser photocoagulation or cryotherapy (cryopexy). A patient with an intravitreal bubble must position their head so that the bubble is in contact with the retinal break. It may be necessary for the patient to maintain this position as much as possible for up to several weeks.

CHAPTER 24  Nursing Management: Visual and Auditory Conditions Retinal break with detachment

Silicone implant

Sclera Choroid

Encircling band

Retinal tear Silicone implant

Encircling band

FIG. 24.7  Retinal break with detachment (top); surgical repair by scleral buckling technique (middle and bottom).

Vitrectomy (surgical removal of the vitreous) may be used to relieve traction on the retina, especially when the traction results from proliferative diabetic retinopathy. Vitrectomy may be combined with scleral buckling to provide a dual effect in relieving traction.  Postoperative Considerations in Scleral Buckling and Intraocular Procedures.  Reattachment procedures are successful in

90% of retinal detachments (National Eye Institute, 2020). Visual prognosis varies, depending on the extent, length, and area of detachment. Postoperatively, the patient may be on bed rest and may require special positioning to maintain proper position of an intravitreal bubble. The patient may need multiple topical medications, including antibiotics, anti-­inflammatory medications, or dilating medications. The level of activity restriction after retinal detachment surgery varies greatly. The nurse should verify the prescribed level of activity with the patient’s surgeon and help the patient plan for any necessary assistance in relation to activity restrictions. In most cases, retinal detachment is an urgent situation, and the patient is confronted suddenly with the need for surgery. The patient needs emotional support, especially during the immediate preoperative period when preparations for surgery can lead to additional anxiety. When the patient experiences postoperative pain, the nurse should administer prescribed pain medications and teach the patient to take the medication as necessary after discharge. The patient may go home within a few hours of surgery or may remain in the hospital for several days, depending on the surgeon and the type of repair.

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Discharge planning and teaching are important, and the nurse should begin these processes as early as possible because the patient does not remain hospitalized long. Patient and caregiver teaching after eye surgery is discussed in Table 24.5. The patient is at risk for retinal detachment in the other eye. Therefore, the nurse should teach the patient the signs and symptoms of retinal detachment. The nurse can also promote use of proper protective eyewear to help avoid retinal detachments related to trauma. 

AGE-­R ELATED MACULAR DEGENERATION Age-­related macular degeneration (AMD) is an eye disease that progressively destroys the macula (the central portion of the retina), causing irreversible central vision loss. It is the leading cause of blindness and vision loss in Canada (Canadian National Institute for the Blind [CNIB], 2021). AMD is a common eye condition, affecting 2 million people in Canada, with the majority aged 50 years or older (Devenyi et al., 2016). Canadians who have AMD outnumber those who have breast cancer, prostate cancer, Parkinson’s disease, or Alzheimer’s disease combined (CNIB, 2021). AMD is divided into two forms: dry (nonexudative) and wet (exudative). People with dry AMD, which is the more common form (90% of all cases), often notice that close-­vision tasks become more difficult. In this form, the macular cells start to atrophy, leading to a slowly progressive and painless vision loss. Wet AMD is the more severe form. Wet AMD accounts for 90% of the cases of AMD-­related blindness. Wet AMD has a more rapid onset and is characterized by the development of abnormal blood vessels in or near the macula.

Etiology and Pathophysiology AMD is related to retinal aging. The prevalence increases drastically with age and occurs more often in women than in men. Genetic factors also appear to play a major role, and family history is a major risk factor for AMD (Touhy et al., 2019). People who smoke cigarettes are twice as likely to develop late AMD as are nonsmokers (National Eye Institute, 2021). Other risk factors include long-­term exposure to ultraviolet light, hyperopia, and light-­coloured irides. Nutritional factors may play a role in the progression of AMD. A dietary supplement of vitamin C, vitamin E, beta-­carotene, and zinc decreases the progression of advanced AMD but has no effect on people with minimal AMD or those with no evidence of AMD (Chew, 2017). Mechanisms of protection are also being discovered among non-­antioxidant nutrients such as omega-­3 fatty acids and the B vitamins. A nutritious diet is thought to be more protective than nutritional supplements. Zinc was found to increase the subretinal fluid and the thickness of the macula, which decrease the risk of acquiring AMD in older patients (Detaram et al., 2019). The dry form of AMD starts with the abnormal accumulation of yellowish extracellular deposits called drusen in the retinal pigment epithelium. The macular cells then undergo atrophy and degeneration. Wet AMD is characterized by the growth of new, fragile blood vessels from their normal location in the choroid to an abnormal location in the retinal epithelium. As the new blood vessels leak, scar tissue gradually forms. Acute vision loss may occur in some cases, with bleeding from subretinal neovascular membranes.  Clinical Manifestations The patient may experience blurred and darkened vision, the presence of scotomas (blind spots in the visual field), and

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SECTION 4  Conditions Related to Altered Sensory Input

metamorphopsia (distortion of vision). Many people may not notice unilateral early changes in their vision if the other eye is not affected. 

Diagnostic Studies In addition to visual acuity measurement, the primary diagnostic procedure is ophthalmoscopy. The examiner looks for drusen and other fundus changes associated with AMD. The Amsler grid test may help define the involved area, and the result provides a baseline for future comparison. Fundus photography and intravenous angiography with fluorescein or indocyanine green dyes, or both, may help to further define the extent and type of AMD.  Interprofessional Care Vision often does not improve for most people with AMD. Limited treatment options for patients with wet AMD include several medications that are injected directly into the vitreous cavity. Ranibizumab (Lucentis) and bevacizumab (Avastin) are selective inhibitors of endothelial growth factor that help to slow vision loss in wet AMD. Adverse effects can include blurred vision, eye irritation, eye pain, and photosensitivity. The injections are given at 4-­to 6-­week intervals, depending on which medication is used. Retinal stability is determined by ocular coherence tomography, which enables the physician to identify fluid in the central retina to determine the need for continued intravitreal injections. Photodynamic therapy entails the use of verteporfin (Visudyne) intravenously and a “cold” laser to excite the dye. This procedure is used for cases of wet AMD and destroys the abnormal blood vessels without permanent damage to the retinal pigment epithelium and photoreceptor cells. Verteporfin is a photosensitizing drug that becomes active when exposed to the low-­level laser light wave. Until the drug is completely excreted by the body, it can be activated by exposure to sunlight or other high-­ intensity light such as halogen; therefore, patients are cautioned to avoid direct exposure to sunlight and other intense forms of light for 5 days after treatment. After receiving therapy, patients must be completely covered because any exposure to skin by sunlight could activate the drug in that area, which would result in a thermal burn. People at risk for developing advanced AMD should consider supplements of vitamins and minerals (in consultation with their health care provider). The cessation of smoking may also help in halting the progression of dry AMD to a more advanced stage. Many patients with assistive devices for low-­degree vision can continue reading and retain a licence to drive during the daytime and at lowered speeds. The permanent loss of central vision has significant psychosocial implications for nursing care. Nursing management of patients with uncorrectable visual impairment is discussed earlier in the chapter and is appropriate for patients with AMD. The nurse should avoid giving the impression that “nothing can be done” about the condition when caring for a patient with AMD. Although therapy will not recover lost vision, much can be done to augment the remaining vision. 

loss in Canadians. It affects more than 400 000 Canadians and 80 million people worldwide (Glaucoma Research Society of Canada, 2021). Risk factors for glaucoma include family history, age, nearsightedness, diabetes, and ethnicity (e.g., individuals of African descent are more likely to develop the disease). The incidence of glaucoma increases with age. Blindness from glaucoma is largely preventable with early detection and appropriate treatment.

Etiology and Pathophysiology A proper balance between the rate of aqueous production (referred to as inflow) and the rate of aqueous reabsorption (referred to as outflow) is essential to maintain the IOP within normal limits. The place where the outflow occurs is the angle where the iris meets the cornea. When the rate of inflow is greater than the rate of outflow, IOP can rise above the normal limits. If IOP remains elevated, vision loss may be permanent. Primary open-­angle glaucoma (POAG) is the most common type of glaucoma. In POAG, the outflow of aqueous humor is decreased in the trabecular meshwork. The drainage channels become clogged, and damage to the optic nerve can then result. Primary angle-­closure glaucoma (PACG) is due to a reduction in the outflow of aqueous humor that results from angle closure. Usually this is caused by the lens’s bulging forward as a result of the aging process. Angle closure may also occur as a result of pupil dilation in the patient with anatomically narrow angles. An acute attack may be precipitated by situations in which the pupil remains in a partially dilated state long enough to cause an acute and significant rise in the IOP. This may occur because of medication-­induced mydriasis, emotional excitement, or darkness. Medication-­induced mydriasis may occur not only from topical ophthalmic preparations but also from many systemic medications (both prescription and over-­the-­counter medications). The nurse should check medication records and documentation before administering medications to the patient with angle-­closure glaucoma and instruct the patient not to take any mydriatic medications. 

GLAUCOMA

Clinical Manifestations POAG develops slowly and without symptoms of pain or pressure. The patient usually does not notice the gradual visual field loss until peripheral vision has been severely compromised. Eventually, patients with untreated glaucoma have “tunnel vision,” in which only a small centre field can be seen and all peripheral vision is absent. Acute angle-­ closure glaucoma causes definite symptoms, including sudden, excruciating pain in or around the eye. This is often accompanied by nausea and vomiting. Visual symptoms include blurred vision, ocular redness, and seeing coloured halos around lights. The acute rise in IOP may also cause corneal edema, which gives the cornea a frosted appearance. Manifestations of subacute or chronic angle-­closure glaucoma appear more gradually. The patient who has had a previous, unrecognized episode of subacute angle-­closure glaucoma may report a history of blurred vision, ocular redness, eye or brow pain, or seeing coloured halos around lights. The effects of glaucoma can be viewed online at VisionSimulations.com (see the Resources at the end of this chapter). 

Glaucoma is a group of disorders characterized by elevated IOP and its consequences: optic nerve atrophy and peripheral visual field loss. Glaucoma is the second most common reason for vision

Diagnostic Studies IOP is usually elevated in glaucoma (normal IOP is 10–21 mm Hg). In cases of elevated pressures, the ophthalmologist usually

CHAPTER 24  Nursing Management: Visual and Auditory Conditions

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TABLE 24.8    INTERPROFESSIONAL CARE Glaucoma Diagnostic Studies

A

• History and physical examination • Visual acuity measurement • Tonometry • Ophthalmoscopy (direct and indirect) • Slit-­lamp microscopy • Gonioscopy • Visual field perimetry

Interprofessional Therapy Chronic Open-­Angle Glaucoma Medication Therapy*

B FIG. 24.8  The optic disc. A, In the normal eye, the optic disc is pink with little cupping. B, In glaucoma, the optic disc is pale, and optic cupping is present. (Note the appearance of the retinal vessels, which travel over the edge of the optic cup and appear to dip into it.)

repeats the measurements over time to verify the elevation. In open-­angle glaucoma, IOP is usually between 22 and 32 mm Hg. In acute angle-­closure glaucoma, IOP may exceed 50 mm Hg. In open-­angle glaucoma, slit-­lamp microscopy reveals a normal angle. In angle-­closure glaucoma, the examiner may note a markedly narrow or flat anterior chamber angle, an edematous cornea, a fixed and moderately dilated pupil, and ciliary injection (hyperemia of the ciliary blood vessels produces redness). Measures of peripheral and central vision provide other diagnostic information. Whereas central acuity may remain 20/20 even in the presence of severe peripheral visual field loss, visual field perimetry may reveal subtle changes in the peripheral area of the retina early in the disease process, long before actual scotomas develop. In acute angle-­closure glaucoma, central visual acuity is reduced if corneal edema is present, and the visual fields may be markedly decreased. As glaucoma progresses, optic disc cupping may be one of the first signs of chronic open-­angle glaucoma. The optic disc becomes wider, deeper, and paler (light grey or white); these characteristics are visible with direct or indirect ophthalmoscopy (Figure 24.8). 

Interprofessional Care The primary focus of glaucoma therapy is to keep the IOP low enough to prevent optic nerve damage. Therapy varies with the type of glaucoma. The diagnostic studies and interprofessional care of glaucoma are summarized in Table 24.8. Chronic Open-­Angle Glaucoma.  Initial treatment in chronic open-­angle glaucoma is with medications (Table 24.9). The patient must understand that continued treatment and supervision are necessary because the medications control, but do not cure, glaucoma. Argon laser trabeculoplasty (ALT) is a noninvasive option to lower IOP when medications are not successful or when the patient either cannot or will not use the medication therapy as recommended. ALT is an outpatient procedure that necessitates

Surgical Therapy • Argon laser trabeculoplasty (ALT) • Trabeculectomy with or without filtering implant

Acute Angle-­Closure Glaucoma • Topical cholinergic medication • Hyperosmotic medication • Laser peripheral iridotomy • Surgical iridectomy

• β  -­Adrenergic blockers • α  -­Adrenergic agonists • Cholinergic medications (miotics) • Carbonic anhydrase inhibitors

*See Table 24.9.

only topical anaesthesia. The laser stimulates scarring and contraction of the trabecular meshwork, which opens the outflow channels. ALT reduces IOP approximately 75% of the time. The patient uses topical corticosteroids for approximately 3 to 5 days after the procedure. The most common postoperative complication is an acute rise in IOP. The ophthalmologist examines the patient 1 week and again 4 to 6 weeks after surgery. Filtration surgery, also called a trabeculectomy, may be indicated if medical management and laser therapy are not successful. The success rate of this surgery is 75 to 85%.  Acute Angle-­ Closure Glaucoma.  Acute angle-­closure glaucoma is an ocular emergency that necessitates immediate intervention. Miotics and oral or intravenous hyperosmotic medications are usually successful in immediately lowering the IOP (see Table 24.8). A laser peripheral iridotomy or surgical iridectomy is necessary for long-­term treatment and prevention of subsequent episodes. These procedures allow the aqueous humor to flow through a newly created opening in the iris and into normal outflow channels. One of these procedures may also be performed on the other eye as a precaution because many patients often experience an acute attack in the other eye. SAFETY ALERT Patients who take miotic medications must be warned that they may experience decreased visual acuity, especially in dim light. 

NURSING MANAGEMENT GLAUCOMA NURSING ASSESSMENT Because glaucoma is a chronic condition that necessitates long-­ term management, the nurse must assess the patient’s ability to understand and adhere to the rationale and regimen of the prescribed therapy. In addition, the nurse should assess the patient’s psychological reaction to the diagnosis of a potentially sight-­ threatening chronic disorder. The nurse must include the patient’s caregiver in the assessment process because the chronic nature of this disorder can affect the family in many ways. Some families

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SECTION 4  Conditions Related to Altered Sensory Input

TABLE 24.9    MEDICATION THERAPY Acute and Chronic Glaucoma Medication

Action

Adverse Effects

Nursing Considerations

Betaxolol (Betoptic)

Cardioselective β1-­adrenergic blocker; probably decreases aqueous humor production

Transient discomfort; systemic reactions (rarely reported) include bradycardia, heart block, pulmonary distress, headache, depression

Levobunolol (Betagan) Timolol maleate (Timoptic)

Noncardioselective β1-­ and β2-­ blockers; probably decrease aqueous humor production

Transient ocular discomfort, blurred vision, photophobia, blepharoconjunctivitis, bradycardia, decreased blood pressure, bronchospasm, headache, depression

Topical medications; minimal effect on pulmonary and cardiovascular parameters Contraindicated for use in patients with bradycardia, cardiogenic shock, or overt cardiac failure Systemic absorption can have additive effect with systemic β1-­adrenergic blocking medications. Topical drops; same effects and contraindications as for betaxolol; also contraindicated for use in patients with asthma or severe COPD

Apraclonidine (Iopidine) Brimonidine tartrate (Alphagan)

α-­Adrenergic agonists; probably decrease aqueous humor production

Ocular redness; irregular heart rate

Latanoprost (Xalatan)

Prostaglandin-­F analogue

Increased brown iris pigmentation, ocular discomfort and redness, dryness, itching, and sensation of foreign body

β-­Adrenergic Blockers

α-­Adrenergic Agonists

Topical drops; used to control or prevent acute rise in IOP after laser procedure (used before and immediately after ALT and iridotomy, Nd:YAG laser capsulotomy). For patient at risk for systemic reactions, teaching includes instructions to occlude puncta. Topical drops Teach patient not to take more than 1 drop per evening and to remove contact lens 15 min before instilling.

Cholinergic Medications (Miotics) Carbachol (Isopto Carbachol)

Pilocarpine (Isopto Carpine)

Parasympathomimetic; stimulates iris sphincter contraction, causing miosis and opening of trabecular meshwork, facilitating outflow of aqueous humor; also partially inhibits activity of cholinesterase Parasympathomimetic; stimulates iris sphincter contraction, causing miosis and opening of trabecular meshwork, facilitating outflow of aqueous humor

Transient ocular discomfort, headache, ache in brow area, blurred vision, decreased adaptation to darkness, syncope, excessive salivation, dysrhythmias, vomiting, diarrhea, hypotension, retinal detachment in susceptible individual (rare) Same as those of carbachol

Topical drops Caution patient about decreased visual acuity caused by miosis, particularly in dim light.

Decreases production of aqueous humor

Paresthesias, especially “tingling” sensation in extremities; hearing dysfunction or tinnitus; loss of appetite; taste alteration; GI disturbances; drowsiness; confusion

Oral nonbacteriostatic sulfonamides Anaphylaxis and other sulpha type of allergic reactions may occur in patient allergic to sulpha drugs. Diuretic effect can lower electrolyte levels. Ask patient about acetylsalicylic acid (ASA; Aspirin) use; medication should not be given to patient receiving high-­dose ASA (Aspirin) therapy.

Decreases production of aqueous humor

Transient stinging, blurred vision, redness

Same as for systemic medications

Combination of two medications (β-­adrenergic blocker and topical carbonic anhydrase inhibitors)

Same as those for timolol maleate and dorzolamide (described previously)

—

Nausea, vomiting, diarrhea, thrombophlebitis, hypertension, hypotension, tachycardia

Intravenous solution; used in acute glaucoma attacks or preoperatively when decreased IOP is desired Nurse must assess patient for susceptibility to pulmonary edema and HF before administering hyperosmolar medications.

Topical drops Same cautions as for carbachol

Carbonic Anhydrase Inhibitors Systemic Acetazolamide Methazolamide

Topical Brinzolamide (Azopt) Dorzolamide (Trusopt)

Combination Therapy Timolol maleate and dorzolamide (Cosopt)

Hyperosmolar Medications Mannitol solution (Osmitrol)

Increases extracellular osmolarity so that intracellular water moves to the extracellular and vascular spaces, reducing IOP

ALT, argon laser trabeculoplasty; COPD, chronic obstructive pulmonary disease; GI, gastrointestinal; HF, heart failure; IOP, intraocular pressure; Nd:YAG, neodymium:yttrium–aluminum–garnet (laser).

CHAPTER 24  Nursing Management: Visual and Auditory Conditions may become the primary providers of necessary care, such as eye drop administration, if the patient is unwilling or unable to accomplish these self-­care activities. The nurse also assesses visual acuity, visual fields, IOP, and fundus changes when appropriate.  NURSING DIAGNOSES Nursing diagnoses for the patient with glaucoma include but are not limited to the following: • Potential for injury as demonstrated by sensory integration dysfunction (visual acuity deficits) • Reduced self-­care resulting from perceptual disorders (visual impairment) • Preparedness for intensified self-­care • Acute pain resulting from physical injury agent (surgical process)  PLANNING The overall goals are that the patient with glaucoma will (a) have no progression of visual impairment, (b) understand the disease process and the rationale for therapy, (c) adhere to all aspects of therapy (including medication administration and follow-­up care), and (d) have no postoperative complications.  NURSING IMPLEMENTATION HEALTH PROMOTION.  Loss of vision from glaucoma is preventable. It is important to teach the patient and caregiver about the risk of vision loss from glaucoma and that this risk increases with age. The nurse should stress the importance of early detection and treatment in preventing visual impairment. A comprehensive ophthalmic examination is invaluable in identifying persons with glaucoma or those at risk of developing glaucoma. The Canadian Ophthalmological Society (2007) recommended an eye examination every 3 to 5 years until the age of 40 and then every 2 to 4 years until the age of 65. Patients with risk factors such as family history of glaucoma and those of African descent should have annual eye examinations. Because so many eye diseases tend to occur in older persons, those older than 65 should have an examination every 2 years (annually if they have any risk factors; Canadian Ophthalmological Society, 2007). Even though the Non-­Insured Health Benefits for First Nation and Inuit Program provides coverage for biennial eye exams for persons over 18 years of age (Indigenous Services Canada, 2020), Indigenous people may be at higher risk for not receiving screening eye examinations for several reasons—for example, lack of access to health care providers, comorbidities, and economic and cultural barriers (Campbell et al., 2020).  ACUTE INTERVENTION.  Acute nursing interventions are directed primarily toward patients with acute angle-­closure glaucoma and patients undergoing surgery for glaucoma. A patient with acute angle-­closure glaucoma requires immediate IOP-­lowering medication, which the nurse must administer in a timely and appropriate manner according to the ophthalmologist’s prescription. Most surgical procedures for glaucoma are outpatient procedures. In the acute situation, the patient needs postoperative instructions and may require nursing comfort measures to relieve discomfort related to the procedure. Patient and caregiver teaching after eye surgery is discussed in Table 24.5.  AMBULATORY AND HOME CARE.  Because of the chronic nature of glaucoma, the patient needs encouragement to follow the therapeutic regimen and follow-­ up recommendations prescribed by the ophthalmologist. The patient needs accurate information about the disease process and treatment options,

467

including the rationale underlying each option. In addition, the patient needs information about the purpose, frequency, and technique of administering prescribed antiglaucoma medications. In addition to verbal instructions, all patients should receive written instructions that contain the same information. The nurse can encourage adherence by helping the patient identify the most convenient and appropriate times for medication administration or by advocating a change in therapy if the patient reports unacceptable adverse effects.  EVALUATION The overall expected outcomes are that the patient with glaucoma will • Have no further loss of vision • Adhere to the recommended therapy • Safely function within their own environment • Obtain relief from pain associated with the disease and surgery 

AGE-­RELATED CONSIDERATIONS Many older patients with glaucoma have systemic illnesses or take systemic medications that may affect their glaucoma therapy. In particular, patients who take a β-­adrenergic blocking medication for glaucoma may experience an additive effect if they are also taking a systemic β-­adrenergic blocking medication. All β-­adrenergic blocking glaucoma medications are contraindicated for use in patients with bradycardia, a greater than first-­ degree heart block, cardiogenic shock, and overt cardiac failure. The non−cardioselective β-­adrenergic blocking glaucoma medications are also contraindicated in patients with severe chronic obstructive pulmonary disease (COPD) or asthma. The hyperosmolar medications may precipitate heart failure or pulmonary edema in susceptible patients. Older patients receiving high-­dose acetylsalicylic acid (ASA; Aspirin) therapy for rheumatoid arthritis should not take carbonic anhydrase inhibitors. The α-­adrenergic agonists can cause tachycardia or hypertension, which may have serious consequences in older patients. The nurse must teach older patients to occlude the lacrimal puncta to limit the systemic absorption of glaucoma medications. 

INTRAOCULAR INFLAMMATION AND INFECTION The term uveitis is used to describe inflammation of the uveal tract, the retina, the vitreous cavity, or the optic nerve. This inflammation may be caused by bacteria, viruses, fungi, or parasites. Cytomegalovirus retinitis is an opportunistic infection that occurs in patients with acquired immune deficiency syndrome (AIDS) and in other immunosuppressed patients. The causes of sterile intraocular inflammation include autoimmune disorders, AIDS, malignancies, or disorders associated with systemic diseases such as inflammatory bowel disease. Pain and photophobia are common symptoms. Endophthalmitis is an extensive intraocular inflammation of the vitreous cavity. Bacteria, viruses, fungi, or parasites can all induce this serious inflammatory response. The mechanism of infection may be endogenous, in which the infecting pathogen arrives at the eye through the bloodstream, or exogenous, in which the infecting pathogen is introduced through a surgical wound or a penetrating injury. Although rare, endophthalmitis is a devastating complication of intraocular surgery

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(e.g., cataract surgery) or penetrating ocular injury and can lead to irreversible blindness within hours or days. Manifestations include ocular pain, photophobia, decreased visual acuity, headaches, reddened and swollen conjunctiva, and corneal edema. Preoperative administration of prophylactic antibiotics is recommended (see the Evidence-Informed Practice box). When all the layers of the eye (vitreous humor, retina, choroid, and sclera) are involved in the inflammatory response, the patient has panophthalmitis. In the final stages of extensive cases, the scleral coat may undergo bacterial or inflammatory dissolution. Subsequent rupture of the globe spreads the infection into the orbit or eyelids. Treatment of intraocular inflammation depends on the underlying cause. Intraocular infections must be treated with antimicrobial medications, which may be delivered topically, subconjunctivally, intravitreally, systemically, or in some combination. Sterile inflammatory responses necessitate anti-­ inflammatory medications such as corticosteroids. The patient with intraocular inflammation is usually uncomfortable and may be noticeably anxious and frightened. The nurse must provide accurate information and emotional support to the patient and the family. In severe cases, enucleation may be necessary. When patients lose visual function or even the entire eye, they grieve over the loss. The nurse’s role includes helping patients through the grieving process. 

ENUCLEATION Enucleation is the removal of the eye. The primary indication for enucleation is the combination of blindness and pain in the eye. These may result from glaucoma, infection, or trauma. Enucleation may also be indicated in ocular malignancies, although many malignancies can be managed with cryotherapy, radiation, and chemotherapy. The surgical procedure includes severing the extraocular muscles close to their insertion on the globe, inserting an implant to maintain the intraorbital anatomy, and suturing the ends of the extraocular muscles over the implant. The conjunctiva covers the joined muscles, and a clear conformer is placed over the conjunctiva until the permanent prosthesis is fitted. A pressure dressing helps prevent postoperative bleeding. Postoperatively, the nurse observes the patient for signs of complications, including excessive bleeding or swelling, increased pain, displacement of the implant, or temperature elevation. Patient teaching should include instructions about the instillation of topical ointments or drops and wound cleansing. The nurse should also instruct the patient how to insert the conformer into the socket in case it falls out. The patient is often devastated by the loss of an eye, even when enucleation occurs after a lengthy period of painful blindness. The nurse should recognize and validate the patient’s emotional response and provide support to the patient and the family. Approximately 6 weeks after surgery, the wound is sufficiently healed for the permanent prosthesis. The prosthesis is fitted by an ocular specialist and designed to match the remaining eye. The prosthesis is gently cleansed with fingertips and warm water using mild soap and then dried lightly with a soft tissue. Solvents or alcohol-­based solutions are to be avoided as they can cause damage. The nurse should teach the patient how to remove, cleanse, and insert the prosthesis. Special polishing is required periodically to remove dried protein secretions. 

FIG. 24.9  Uveal melanoma. A large tumour in the choroid, the most com-

mon location in the eye for melanoma. Source: Courtesy Cory J. Bosanko, OD, FAAO, Eye Centers of Tennessee, Crossville, Tennessee.

OCULAR TUMOURS Benign and malignant tumours can occur in many areas of the eye, including the conjunctiva, retina, and orbit. Malignancies of the eyelid include basal cell and squamous cell carcinomas (see Chapter 26). Uveal melanoma is a cancerous neoplasm of the iris, choroid, or ciliary body. It is the most common primary intraocular malignancy in adults, but it is much rarer than skin melanoma. Approximately 200 cases are diagnosed in Canada each year (Melanoma Network of Canada, 2015). It is more frequently found in light-­skinned people older than 60 years of age with chronic exposure to ultraviolet light. Genetic factors such as a mutated gene may also increase a person’s risk (Nielsen et al., 2015). Uveal melanoma can arise from pre-­existing nevi in the eye. Tumours may be asymptomatic or associated with vision loss depending on their size and location and presence of hemorrhage and retinal detachment. As with other cancers, cancer stage and cell type are important variables in the patient’s prognosis. Diagnostic testing may include ultrasonography, magnetic resonance imaging (MRI), and fine-­needle aspiration biopsy. Uveal melanoma commonly appears as a dome-­shaped, well-­circumscribed, solid brown to golden pigment in the iris, choroid, or ciliary body (Figure 24.9). Many patients do not lose the affected eye, and some may experience good vision after treatment in that eye. Depending on the status of the involved eye, treatment options can include enucleation, plaque radiation therapy (brachytherapy), external beam radiation, transpupillary photocoagulation, eye wall resection, and exenteration. Within 15 years, approximately 50% of all patients with uveal melanoma will develop metastases, most commonly in the liver. 

OCULAR MANIFESTATIONS OF SYSTEMIC DISEASES Many systemic diseases are accompanied by significant ocular manifestations. Ocular signs and symptoms may be the first finding in or report by a patient with a systemic disease. One example is the patient with undiagnosed diabetes who seeks ophthalmic care for blurred vision. A thorough history and careful examination of the patient can reveal that the underlying cause of the blurred vision is lens swelling resulting from hyperglycemia. Another example is the patient who seeks care

CHAPTER 24  Nursing Management: Visual and Auditory Conditions for a conjunctival lesion. The ophthalmologist may be the first health care provider to make the diagnosis of AIDS on the basis of the presence of a conjunctival Kaposi’s sarcoma. 

  AUDITORY CONDITIONS EXTERNAL EAR AND CANAL External Otitis The skin of the external ear and the ear canal is subject to the same problems as skin anywhere on the body. External otitis involves inflammation or infection of the epithelium of the auricle and ear canal. Swimming may alter the flora of the external canal as a result of chemicals and contaminated water. This can result in an infection often referred to as “swimmer’s ear.” Trauma from picking the ear or using sharp objects (e.g., hairpins) to clean the ear frequently causes the initial break in the skin. Piercing of auricular cartilage carries a greater risk of infection than does soft-­tissue piercing (Hoover et al., 2017). Causes.  Infections and skin conditions may cause external otitis. Bacteria or fungi may be the cause. Pseudomonas aeruginosa is the most common bacterial cause. Fungi, including Candida albicans and Aspergillus species, especially thrive in warm, moist climates. The warm, dark environment of the ear canal provides a good medium for the growth of microorganisms. Malignant external otitis is a serious infection caused by P. aeruginosa. It occurs mainly in older patients with diabetes. The infection, which can spread from the external ear to the parotid gland and temporal bone (osteomyelitis), is usually treated with antibiotics.  Clinical Manifestations and Complications.  Ear pain (otalgia) is one of the first signs of external otitis. Even in mild cases, a patient may experience significant discomfort with chewing, moving the auricle, or pressing on the tragus. Swelling of the ear canal can muffle hearing. Drainage from the ear may be serosanguineous (blood-­tinged fluid) or purulent (white to green thick fluid). Fever occurs when the infection spreads to surrounding tissue. Facial nerve paralysis may occur with malignant external otitis. 

NURSING AND INTERPROFESSIONAL MANAGEMENT EXTERNAL OTITIS Diagnosis of external otitis is made by otoscopic examination of the ear canal. The nurse must be careful to avoid pain when pulling on the patient’s auricle to straighten out the canal or when inserting the otoscope speculum. The eardrum may be difficult to see because of swelling in the canal. Culture and sensitivity studies of the drainage may be done. Moist heat, mild analgesics, and topical anaesthetic drops usually control the pain. Topical antibiotics include polymyxin B (Polysporin), neomycin (Neosporin), and chloramphenicol (Chlor Palm 250). Nystatin (Nyaderm CRM) is used for fungal infections. Corticosteroids may also be used to decrease inflammation unless the infection is fungal, in which case their use is contraindicated. If the surrounding tissue is involved, systemic antibiotics are prescribed. Improvement should occur in 48 hours, but the patient must adhere to the prescribed therapy for 7 to 14 days for complete resolution. Hands should be washed before and after otic drops (eardrops) are administered. The drops should be administered at room temperature; cold drops can cause vertigo by stimulating the semicircular canals, and heated drops can burn the

469

TABLE 24.10    PATIENT & CAREGIVER

TEACHING GUIDE

Prevention of External Otitis Include the following instructions when teaching the patient and caregiver how to prevent external otitis. 1. Do not put anything in your ear canal unless requested by your health care provider. 2. Report itching if it becomes a problem. 3. Cerumen (earwax) is normal. • It lubricates and protects the canal. • Report chronic excessive cerumen if it impairs your hearing. 4. Keep your ears as dry as possible. • Use earplugs if you are prone to swimmer’s ear. • Turn your head to each side for 30 sec at a time to help water run out of the ears. • Do not dry with cotton-­tipped applicators. • A hair dryer set to low and held at least 6 in from the ear can speed water evaporation.

TABLE 24.11    MANIFESTATIONS OF CERUMEN

IMPACTION

• Hearing loss • Otalgia • Tinnitus • Vertigo • Cough • Cardiac depression (vagal stimulation)

tympanum. The tip of the dropper should not touch the ear during administration, to prevent contamination of the entire bottle. The ear is positioned so that the drops can run down into the canal. The patient should maintain this position for 2 minutes to allow the drops to spread. Sometimes drops are placed onto a wick of cotton that is placed in the canal. The nurse should instruct the patient not to push the cotton farther into the ear. Careful handling and disposal of material saturated with drainage is important. The nurse should also instruct the patient on methods to reduce the risk of external otitis (Table 24.10).

Cerumen and Foreign Bodies in the External Ear Canal Impacted cerumen can cause discomfort and decreased hearing. In older persons, the earwax becomes dense and drier. Hair becomes thicker and coarser, entrapping the hard, dry cerumen in the canal. Symptoms of cerumen impaction are outlined in Table 24.11. Management involves irrigation of the canal with body-­ temperature solutions to soften the cerumen. Special syringes, varying from a simple bulb syringe to special irrigating equipment, can be used. The patient is placed in a sitting position with an emesis basin under the ear. The auricle is pulled up and back, and the flow of solution is directed above or below the impaction. It is important that the ear canal not be completely occluded with the syringe tip. If irrigation does not remove the cerumen, mild lubricant drops may be used to soften it. Severe impaction may need to be removed by the health care provider. Attempts to remove a foreign object from the ear canal may result in pushing it farther into the canal. Vegetable matter in the ear tends to swell and may create a secondary inflammation, which makes removal more difficult. Mineral oil or lidocaine drops can be used to kill an insect before removal under microscope guidance. Removal of impacted objects should be performed by the health care provider.

470

SECTION 4  Conditions Related to Altered Sensory Input

Ears should be cleaned with a washcloth and finger. Cotton-­ tipped applicators should be avoided: Penetration of the middle ear by a cotton-­tipped applicator can cause serious injury to the tympanic membrane (TM) and ossicles. The use of cotton-­ tipped applicators can also cause cerumen to become impacted against the TM and impair hearing. 

Trauma Trauma to the external ear can cause injury to the subcutaneous tissue that may result in a hematoma. If the hematoma is not aspirated, inflammation of the membranes of the ear cartilage (perichondritis) can result. Blows to the ear can also cause a conductive hearing loss if the ossicles in the middle ear are damaged or the TM is perforated. Head trauma that injures the temporal lobe of the cerebral cortex can impair the ability to understand the meaning of sounds.  Malignancy of the External Ear Skin cancers are the only common malignancies of the ear. Rough sandpaper-­ like changes to the upper border of the auricle are premalignant lesions (actinic keratoses) associated with chronic sun exposure. They are often removed with liquid nitrogen. Malignancies in the external ear canal include basal cell carcinoma in the auricle and squamous cell carcinoma in the ear canal. If left untreated, they can invade underlying tissue. The nurse should teach the patient about the dangers of sun exposure and the importance of using hats and sunscreen when outdoors. 

MIDDLE EAR AND MASTOID Acute Otitis Media Acute otitis media (AOM) is an infection of the tympanum, ossicles, and space of the middle ear. Swelling of the auditory tube as a result of colds or allergies can trap bacteria, causing a middle ear infection. Pressure from the inflammation pushes on the TM, causing it to become red, bulging, and painful. AOM is usually a childhood disease; in children the auditory tube that drains fluids and mucus from the middle ear is shorter and narrower and its position is flatter than that in adults (Le Saux & Robinson, 2016). Pain, fever, malaise, and reduced hearing are signs and symptoms of infections. Referred pain from the temporomandibular joint, teeth, gums, sinuses, or throat may also cause ear pain. Clinical practice guidelines include strategies such as observation, antibiotics, and pain control (Deniz et al., 2018). Interprofessional care involves the use of antibiotics to eradicate the causative organism. Amoxicillin (Amoxil) is the current therapy of choice in North America. Surgical intervention is generally reserved for patients who do not respond to medical treatment. A myringotomy involves an incision in the tympanum to release the increased pressure and exudate from the middle ear. A tympanostomy tube may be placed for short-­or long-­term drainage. Prompt treatment of an episode of AOM generally prevents spontaneous perforation of the TM. In the adult patient for whom allergy may be a causative factor, antihistamines may also be prescribed. 

Otitis Media With Effusion Otitis media with effusion is an inflammation of the middle ear with a collection of fluid in the middle ear space. The fluid may be thin, mucoid, or purulent. If the Eustachian tube does not open and allow equalization of atmospheric pressure, negative

FIG. 24.10  Perforation of the tympanic membrane (TM) Source: Flint, P.,

Haughey, Lund, V., et al. (Eds.). (2010). Cummings otolaryngology: Head and neck surgery (5th ed.). Mosby.

pressure within the middle ear pulls fluid from surrounding tissues. This situation commonly follows upper respiratory tract or chronic sinus infections, barotrauma (caused by pressure change), or otitis media. Patients can experience a feeling of fullness of the ear, a “plugged” feeling or popping sensation, and decreased hearing. The patient does not experience pain, fever, or discharge from the ear. It is normal to have otitis media with effusion for weeks to months after an episode of AOM. It usually resolves in 75 to 90% of cases without treatment but may recur. 

Chronic Otitis Media and Mastoiditis Etiology and Pathophysiology.  Repeated attacks of AOM may lead to chronic otitis media, especially in adults who have a history of recurrent otitis in childhood. Organisms involved in chronic otitis media include S. aureus, Proteus mirabilis, and P. aeruginosa. Because the mucous membrane is continuous, both the middle ear and the air cells of the mastoid bone can be involved in the chronic infectious process.  Clinical Manifestations.  Chronic otitis media is characterized by a purulent exudate and inflammation that can involve the ossicles, Eustachian tube, and mastoid bone. It is often painless and may be accompanied by hearing loss, nausea, and episodes of dizziness. Hearing loss is a complication from inflammatory destruction of the ossicles, a TM perforation, or accumulation of fluid in the middle ear space.  Complications.  Untreated conditions can result in TM perforation and the formation of a cholesteatoma (a mass of epithelial cells and cholesterol in the middle ear). The cholesteatoma enlarges and can destroy the adjacent bones. Unless removed surgically, it can cause extensive damage to the ossicles and impair hearing.  Diagnostic Studies.  Otoscopic examination of the TM may reveal colour and mobility changes or a perforation (Figure 24.10). Culture and sensitivity tests of the drainage are necessary to identify the organisms involved so that the appropriate antibiotic therapy can be prescribed. Audiography may demonstrate a hearing loss as great as 50 to 60 decibels (dB) if the ossicles have been damaged or separated. Sinus radiographic studies, MRI, or computed tomography (CT) of the temporal bone may demonstrate bone destruction, absence of ossicles, or the presence of a mass.  Interprofessional Care.  The aims of treatment are to clear the middle ear of infection, repair the perforation, and preserve hearing (Table 24.12). Systemic antibiotic therapy is initiated on

CHAPTER 24  Nursing Management: Visual and Auditory Conditions TABLE 24.12    INTERPROFESSIONAL CARE Chronic Otitis Media Diagnostic Studies

Interprofessional Therapy

• History and physical examination • Otoscopic examination • Culture and sensitivity tests of middle ear drainage • Mastoid radiography

• Ear irrigations • Otic, oral, or parenteral antibiotics • Analgesics • Antiemetics • Surgery • Tympanoplasty* • Mastoidectomy

*See Table 24.13.

the basis of results of the culture and sensitivity tests. In addition, the patient may need to undergo frequent evacuation of drainage and debris in an outpatient setting. Otic and oral antibiotics are used to reduce infection. In many cases of chronic otitis media, the causative pathogen is resistant to antibiotics.  Surgical Therapy.  Chronic TM perforations often do not heal with conservative treatment, and surgery is necessary. Tympanoplasty (myringoplasty) involves reconstruction of the TM, the ossicles, or both. A mastoidectomy is often performed with a tympanoplasty to remove infected portions of the mastoid bone. Removal of tissue stops at the middle ear structures that appear capable of conducting sound. Sudden pressure changes in the ear and postoperative infections can disrupt the surgical repair during the healing phase or cause facial nerve paralysis. 

NURSING MANAGEMENT CHRONIC OTITIS MEDIA AFTER TYMPANOPLASTY Routine preoperative care is provided before tympanoplasty and includes teaching postoperative expectations (Table 24.13). After surgery, the patient is positioned flat and side-­lying with the operated side up. It is normal for hearing to be impaired during the postoperative period if there is packing in the ear. A cotton-­ball dressing is used for the incision made through the external auditory canal (endaural incision). The patient should be instructed to change the cotton packing and dressing daily. If a postauricular incision was used and a drain is in place, a mastoid dressing is used. A small gauze pad is cut to fit behind the ear, and fluffs are applied over the ear to prevent the outer circular head dressing from placing pressure on the auricle. The nurse should monitor the amount and type of drainage postoperatively, as well as the tightness of the dressing, to prevent tissue necrosis. 

Otosclerosis Otosclerosis is a hereditary autosomal dominant disease and the most common cause of hearing loss in young adults (Ferri, 2020). Spongy bone develops from the bony labyrinth, causing immobilization of the footplate of the stapes in the oval window. This reduces the transmission of vibrations to the inner ear fluids and results in conductive hearing loss. Although otosclerosis is typically bilateral, hearing loss may progress more rapidly in one ear. The patient is often unaware of the problem until the loss becomes so severe that communication is difficult. Otoscopic examination may reveal a reddish blush of the tympanum (Schwartz’s sign) caused by the vascular and bony changes within the middle ear. Tuning-­fork tests help identify the conductive component of the hearing loss. On Rinne test, sound is heard longer when the stem of the tuning fork is

471

TABLE 24.13    PATIENT & CAREGIVER

TEACHING GUIDE

After Ear Surgery Include the following instructions when teaching the patient and caregiver after ear surgery. 1. Avoid sudden head movements. 2. Do not try to get out of bed without assistance. 3. Take medications to reduce dizziness if prescribed. 4. Change positions slowly. 5. Avoid getting the head wet (including showering) until directed by surgeon. 6. Report fever, pain, an increase in hearing loss, or drainage from the ear. 7. Do not cough or blow the nose because this causes increased pressure in the Eustachian tube and middle ear cavity and disrupts healing. 8. If you need to cough or sneeze, leave the mouth open to help reduce the pressure. 9. Avoid crowds because respiratory infections may be contracted. 10. Avoid situations in which pressure or popping in the ears is normally experienced, such as high elevations or airplane travel.

TABLE 24.14    INTERPROFESSIONAL CARE Otosclerosis Diagnostic Studies

Interprofessional Therapy

• History and physical examination • Otoscopic examination • Rinne test • Weber test • Audiometry • Tympanometry

• Hearing aid • Surgery (stapedectomy or fenestration) • Medication therapy • Sodium fluoride with vitamin D • Calcium carbonate

touching the mastoid bone (bone conduction) than when placed next to the ear (air conduction). In the Weber test, the sound is heard better through the skull bone in the ear than through air when conductive hearing loss is greater. Audiography demonstrates good hearing by bone conduction but poorer hearing by air conduction (air–bone gap). The difference between air and bone conduction levels of hearing is usually at least 20 to 25 dB in otosclerosis. Interprofessional Care.  The hearing loss associated with otosclerosis may be stabilized by the use of sodium fluoride with vitamin D and calcium carbonate to retard bone resorption and encourage calcification of bony lesions. Amplification of sound by a hearing aid can be effective because the inner ear function is normal. Surgical treatment involves partial removal of the stapes (stapedectomy) or complete removal with prosthesis insertion (fenestration). Interprofessional care of otosclerosis is described in Table 24.14. These procedures are usually performed with the patient under conscious sedation. The ear with poorer hearing is repaired first, and the other ear may be operated on within a year. An endaural incision is made under visualization through the operating microscope. Gelfoam is used on the incision flap to limit bleeding. A cotton ball is placed in the ear canal, and a small dressing is used to cover the ear. During surgery, patients often report an immediate improvement in hearing in the operated ear. Because of the accumulation of blood and fluid in the middle ear, the hearing level decreases

472

SECTION 4  Conditions Related to Altered Sensory Input

postoperatively but improves with healing. After stapedectomy, 90% of patients experience an improvement in hearing, in many instances to near normal. 

NURSING MANAGEMENT OTOSCLEROSIS Nursing management of patients undergoing stapedectomy or fenestration is similar to that for patients who have undergone tympanoplasty. Postoperatively, patients may experience dizziness, nausea, and vomiting as a result of intraoperative stimulation of the labyrinth. Some patients demonstrate nystagmus because of disturbance of the perilymph fluid. The patient should take care to avoid sudden movements that may induce or exacerbate dizziness. The patient should avoid actions that increase inner ear pressure, such as coughing, sneezing, lifting, bending, and straining during bowel movements. 

INNER EAR CONDITIONS Three symptoms that indicate disease of the inner ear are vertigo, sensorineural hearing loss, and tinnitus. Symptoms of vertigo arise from the vestibular labyrinth, whereas hearing loss and tinnitus arise from the auditory labyrinth. Manifestations of inner ear conditions overlap with some manifestations of central nervous system disorders.

Ménière’s Disease Ménière’s disease (endolymphatic hydrops) is characterized by symptoms caused by inner ear disease, including episodic vertigo, tinnitus, fluctuating sensorineural hearing loss, and a sense of aural fullness. The patient experiences significant disability because of sudden, severe attacks of vertigo with nausea, vomiting, sweating, and pallor. Symptoms usually begin between the ages of 30 and 60 years (Di Berardino et al., 2020). The cause of the disease is unknown, but it results in an excessive accumulation of endolymph in the membranous labyrinth. The volume of endolymph increases until the membranous labyrinth ruptures. Attacks may be preceded by a sense of fullness in the ear, increasing tinnitus, and muffled hearing. Patients with Ménière’s disease may experience the feeling of being pulled to the ground (“drop attacks”). Some patients report that they feel as if they are whirling in space. Attacks may last hours or days and may occur several times a year. The clinical course of the disease is highly variable. 

NURSING AND INTERPROFESSIONAL MANAGEMENT MÉNIÈRE’S DISEASE Interprofessional care of Ménière’s disease (Table 24.15) includes diagnostic tests to rule out other causes of symptoms, including central nervous system disease. Audiography demonstrates a mild, low-­frequency sensorineural hearing loss. Vestibular tests indicate decreased function. A glycerol test may aid in the diagnosis. An oral dose of glycerol is given, followed by serial audiography over 3 hours. Improvement in hearing or speech discrimination supports a diagnosis of Ménière’s disease. The improvement is attributed to the osmotic effect of glycerol that pulls fluid from the inner ear. Although a positive test result is diagnostic of Ménière’s disease, a negative test result does not rule out the condition.

TABLE 24.15    INTERPROFESSIONAL CARE Ménière’s Disease Diagnostic Studies • History and physical examination • Audiometric studies (including speech discrimination, tone decay) • Vestibular tests (including caloric test, positional test) • Electronystagmography • Neurological examination • Glycerol test

Interprofessional Therapy Acute Care Medication Therapy (One or More Agents) • Sedatives • Benzodiazepines • Anticholinergics • Antiemetics • Antihistamines

Surgical Therapy Conservative Surgical Intervention • Endolymphatic shunt • Vestibular nerve section

Destructive Surgical Intervention • Labyrinthotomy • Labyrinthectomy

Ambulatory or Home Care • Diuretics • Antihistamines • Calcium channel blockers • Sedatives • Hydrops diet: restriction of sodium, caffeine, nicotine, alcohol, and foods with monosodium glutamate (MSG)

During the acute attack, antihistamines, anticholinergic medications, and benzodiazepines can be used to decrease the abnormal sensation and lessen symptoms such as nausea and vomiting. Acute vertigo is treated symptomatically with bed rest, sedation, and antiemetics or antivertigo medications for motion sickness. The patient requires reassurance and counselling that the condition is not life-­threatening. Management between attacks may include diuretics, antihistamines, calcium channel blockers, and a low-­sodium diet. Diazepam (Valium) may be used to reduce the vertigo. Over time, most patients respond to the prescribed medications, but the attacks and hearing loss remain unpredictable. Frequent and incapacitating attacks are indications for surgical intervention. Decompression of the endolymphatic sac and shunting are performed to reduce the pressure on the cochlear hair cells and to prevent further damage and hearing loss. If relief is not achieved, the vestibular nerve may be resected. When involvement is unilateral, surgical ablation of the labyrinth, resulting in loss of the vestibular and hearing cochlear function, is performed. Careful management can decrease the possibility of progressive sensorineural loss in many patients. Nursing interventions are planned to minimize vertigo and provide for patient safety. During an acute attack, the patient is kept in a quiet, darkened room in a comfortable position. The patient needs to be taught to avoid sudden head movements or position changes. Fluorescent or flickering lights or television may exacerbate symptoms and should be avoided. An emesis basin should be available because vomiting is common. To minimize the patient’s risk of falling, the nurse should keep the side rails up and the bed low in position when the patient is in bed. The patient should be instructed to call for assistance when getting out of bed. Medications and fluids are administered parenterally, and intake and output are monitored. When the attack subsides, the patient should be assisted with ambulation because unsteadiness may remain.

Benign Paroxysmal Positional Vertigo Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo. Approximately 50% of cases of vertigo may be

CHAPTER 24  Nursing Management: Visual and Auditory Conditions due to BPPV. In BPPV, free-­floating debris in the semicircular canal causes vertigo with specific head movements, such as those involved with getting out of bed, rolling over in bed, and sitting up from lying down (HealthLink BC, 2019). The debris (“ear rocks”) is composed of small crystals of calcium carbonate derived from the utricle in the inner ear. The utricle may be injured by head trauma, infection, or degeneration as a result of the aging process. However, for many patients, a cause cannot be found. Symptoms include dizziness, vertigo, light-­headedness, loss of balance, and nausea. Hearing loss is not characteristic, and symptoms tend to be intermittent. The symptoms of BPPV may be confused with those of Ménière’s disease. Diagnosis is based on the results of auditory and vestibular tests. Although BPPV is bothersome, it is rarely a serious problem unless an affected person falls. The Epley manoeuvre (canalith repositioning procedure) is effective in providing symptom relief for many patients (Balatsouras et al., 2018). In this manoeuvre, the ear debris is moved from areas in the inner ear that cause symptoms and repositioned into areas where they do not cause these problems. The Epley manoeuvre does not address the actual presence of debris; rather, it changes their location. A trained health care provider can instruct the patient in how to perform the Epley manoeuvre. 

Acoustic Neuroma An acoustic neuroma is a unilateral benign tumour that occurs where the vestibulocochlear nerve (cranial nerve VIII) enters the internal auditory canal. Early diagnosis is important because the tumour can compress the trigeminal and facial nerves and arteries within the internal auditory canal. Symptoms usually begin at 40 to 60 years of age. Early symptoms are associated with compression and destruction of cranial nerve VIII. They include unilateral, progressive, sensorineural hearing loss; reduced touch sensation in the posterior ear canal; unilateral tinnitus; and mild, intermittent vertigo. Diagnostic tests include neurological, audiometric, and vestibular tests; computed tomographic scans; and MRI. Surgery to remove small tumours generally preserves hearing and vestibular function. Large tumours (>3 cm) and the surgery required to remove them can leave the patient with permanent hearing loss and facial paralysis. The nurse should instruct the patient to report any clear, colourless discharge from the nose. This may be cerebrospinal fluid, and such leaks increase the risk of infection.  Hearing Loss and Deafness Hearing loss is the fastest growing and one of the most prevalent, chronic conditions facing Canadians today (Hearing Foundation of Canada, 2020). Hearing loss has many causes; age-­ related presbycusis and noise-­ induced hearing loss are two of the most common. Nearly half of the persons who need assistance with hearing disorders are 65 years of age or older. With the aging of the population, the prevalence of hearing loss is increasing. At age 50, one of every eight persons is hearing impaired. A disturbing trend is the number of young adults showing signs of hearing loss. The tiny hair cells located inside the ear pick up sound waves and convert them into electrical signals that the brain can interpret. When loud sounds are listened to constantly, the vibrations destroy the tiny hair cells, which contributes to hearing loss. Unlike other cells in the body,

External ear • Impacted cerumen • Foreign bodies • External otitis

Middle ear

473

Inner ear

• Otitis media • Ménière’s disease • Serous otitis • Noise-induced • Otosclerosis hearing loss • Tympanic • Presbycusis membrane • Ototoxicity trauma • Cholesteatoma • Acoustic neuroma

FIG. 24.11  Causes of hearing loss, by location.

hair cells never grow back once they are damaged (Government of Canada, 2020). Earbuds are of particular concern because volumes must be high in order to block out environmental distractions (Berg et al., 2016). Causes of hearing loss are listed in Figure 24.11. Types of Hearing Loss Conductive Hearing Loss.  Conductive hearing loss occurs when conditions in the outer or middle ear impair the transmission of sound through air to the inner ear. A common cause is otitis media with effusion. Other causes are impacted cerumen, TM perforation, otosclerosis, and narrowing of the external auditory canal (Kandaswamy et al., 2020)). Audiography demonstrates an air–bone gap of at least 15 dB. The term air–bone gap represents the situation in which hearing sensitivity is better by bone conduction than by air conduction. Patients may speak softly because they hear their own voices, which are conducted by bone, as being loud. These patients hear better in a noisy environment. If correction of the cause is not possible, a hearing aid may help if the loss is greater than 40 to 50 dB. Visit the Hearing Loss Sampler online to listen to simulated hearing loss sounds (see the Resources at the end of this chapter).  Sensorineural Hearing Loss.  Sensorineural hearing loss is caused by impairment of function of the inner ear or the vestibulocochlear nerve (cranial nerve VIII). Congenital and hereditary factors, noise trauma over time, aging (presbycusis), Ménière’s disease, and ototoxicity can cause sensorineural hearing loss. Ototoxic medications include ASA (Aspirin), nonsteroidal anti-­inflammatory drugs (NSAIDs), antibiotics (aminoglycosides, erythromycin, vancomycin), loop diuretics, and chemotherapy drugs. Systemic infections, such as Paget’s disease of the bone, immune diseases, diabetes mellitus, bacterial meningitis, and trauma, are associated with this type of hearing loss. The two main problems associated with sensorineural loss are (a) the

474

SECTION 4  Conditions Related to Altered Sensory Input

TABLE 24.16    CLASSIFICATION OF HEARING

LOSS

Decibel (dB) Loss

Meaning

0–15 16–25 26–40 41–55 56–70 71–90 >90

Normal hearing Slight hearing loss Mild impairment Moderate impairment Moderately severe impairment Severe impairment Profound deafness*

*Most people in this category have been deaf since birth (congenitally deaf).

inability to understand speech despite the ability to hear sound and (b) the lack of understanding of the condition by other people. The ability to hear high-­pitched sounds, including consonants, diminishes. Sounds become muffled and difficult to understand. An audiogram demonstrates a loss in dB levels at the 4 000-­Hz range and eventually the 2 000-­Hz range. A hearing aid may help some patients, but it only makes sounds and speech louder, not clearer.  Mixed Hearing Loss.  Mixed hearing loss results from a combination of conductive and sensorineural causes. Careful evaluation is needed if corrective surgery for conductive loss is planned because the sensorineural component of the hearing loss will still remain.  Central and Functional Hearing Loss.  Central hearing loss involves the inability to interpret sound, including speech, because of a disorder in the brain (central nervous system). Careful documentation of the history is helpful because there is usually a reference to deafness within the family. The patient should be referred to a qualified hearing and speech service if it is indicated. Functional hearing loss may be caused by an emotional or a psychological factor. The patient does not seem to hear or respond to pure-­tone subjective hearing tests, but no physical cause can be identified. Psychological counselling may help.  Classification of Hearing Loss.  Hearing loss can also be classified by the dB level or loss as recorded on the audiogram. Normal hearing is in the 0-­to 15-­dB range. Table 24.16 describes the levels of hearing loss.  Clinical Manifestations.  Common early signs of hearing loss are answering questions inappropriately, not responding when not looking at the speaker, asking others to speak up, and showing irritability with others who do not speak up. Other behaviours that suggest hearing loss include straining to hear, cupping the hand around the ear, reading lips, and an increased sensitivity to slight increases in noise level. Often, the patient is unaware of minimal hearing loss or may compensate by using these mannerisms. Family and friends who get tired of repeating or talking loudly are often first to notice hearing loss. Deafness is often called the “unseen handicap” because it is not until conversation is initiated with a deaf adult that the difficulty in communication is realized. It is important that the health care provider be aware of the need for thorough validation of the deaf person’s understanding of health teaching. Descriptive visual aids can be helpful. Interference in communication and interaction with others can be the source of many challenges for the patient and caregiver. Often the patient refuses to admit or may be unaware of impaired hearing. Irritability is common because the patient must concentrate very hard to understand speech. The loss of

clarity of speech is most frustrating to a patient with sensorineural hearing loss. The patient may hear what is said but not understand it. Withdrawal, suspicion, loss of self-­esteem, and insecurity are commonly associated with advancing hearing loss. 

NURSING AND INTERPROFESSIONAL MANAGEMENT HEARING LOSS AND DEAFNESS HEALTH PROMOTION

ENVIRONMENTAL NOISE CONTROL.  Noise is the most preventable cause of hearing loss. Figure 24.12 lists the levels of environmental noise generated by common indoor and outdoor sounds. Sudden severe loud noise (acoustic trauma) and chronic exposure to loud noise (noise-­induced hearing loss) can damage hearing. Acoustic trauma causes hearing loss by destroying the hair cells of the organ of Corti. Sensorineural hearing loss as a result of increased and prolonged environmental noise, such as amplified sound, is occurring in young adults at an increasing rate. Amplified music (e.g., on iPods or MP3 players) should not exceed 50% of maximum volume. Health teaching must emphasize avoidance of continued exposure to noise levels greater than 70 dB. Young adults should be encouraged to keep amplified music at a reasonable level and limit their exposure time. Hearing loss caused by noise is irreversible. In work environments known to have high noise levels (>85 dB), ear protection should be worn. Canadian Occupational Health and Safety regulations Part VII, Sections 7.1 to 7.8, address workplace noise (Department of Justice Canada, 2021). A variety of protectors that are worn over the ears or in the ears to prevent hearing loss are available. Periodic audiometric screening should be part of the health maintenance policies of industry. This provides baseline data on hearing to measure subsequent hearing loss. Employees should participate in hearing conservation programs in work environments. Such programs should include noise exposure analysis, provision for control of noise exposure (hearing protectors), measurements of hearing, and employee– employer notification and education.  IMMUNIZATIONS.  Various viruses in utero can cause deafness as a result of damage and malformations affecting the ear. The nurse should promote childhood and adult immunizations, including the measles-­mumps-­rubella (MMR) vaccine. Rubella infection during the first 8 weeks of gestation is associated with an 85% incidence of congenital rubella syndrome, which causes sensorineural deafness. Women of childbearing age should be tested for antibodies to these viral diseases. Women should avoid pregnancy for at least 3 months after being immunized. Immunization must be delayed if the woman is pregnant. Women who are susceptible to rubella can be vaccinated safely during the postpartum period.  OTOTOXIC SUBSTANCES.  Medications commonly associated with ototoxicity include salicylates, NSAIDs, loop diuretics, chemotherapy drugs, and antibiotics. Chemicals used in industry (e.g., toluene, carbon disulphide, mercury) may damage the inner ear. Patients who are receiving ototoxic drugs or are exposed to ototoxic chemicals should be monitored for signs and symptoms associated with ototoxicity, including tinnitus, diminished hearing, and changes in equilibrium. If these symptoms develop, immediate withdrawal of the drug may prevent further damage and may cause the symptoms to disappear. 

CHAPTER 24  Nursing Management: Visual and Auditory Conditions Outdoor sounds

NOISE LEVEL (dB)

475

Indoor sounds

110

Rock concert

100

Indoor subway

90

Blender at 1 metre

80

Shouting at 1 metre

70

Vacuum cleaner at 3 metres Normal speech at 1 metre

B-747-200 takeoff Gas lawnmower at 1 metre Noisy urban daytime

Commercial area

60 Large business office

Quiet urban daytime 50

Small theatre 40 Library

Quiet suburban nighttime 30 Quiet rural nighttime

20 Broadcast and recording studio 10

Hearing threshold FIG. 24.12  Levels of common environmental sounds.

ASSISTIVE DEVICES AND TECHNIQUES HEARING AIDS.  The patient with a suspected hearing loss should have a hearing assessment by a qualified audiologist. If a hearing aid is indicated, it should be fitted by an audiologist or by a speech and hearing specialist. Many types of hearing aids are available, each with advantages and disadvantages (Table 24.17). The conventional hearing aid serves as a simple amplifier. For patients with bilateral hearing impairment, binaural hearing aids provide the best sound lateralization and speech discrimination. The nurse must give careful instruction on its use and maintenance and must assist the patient during the period of adjustment. The goal of hearing aid therapy is improved hearing with consistent use. Patients who are motivated and optimistic about using a hearing aid are more successful users. The nurse should determine the patient’s readiness for hearing aid therapy, including acknowledgement of a hearing impairment, the patient’s feelings about wearing a hearing aid, the degree to which hearing loss affects life, and any difficulties the patient has manipulating small objects, such as putting a battery in a hearing aid. Initially, use of the hearing aid should be restricted to quiet situations in the home. The patient must first adjust to voices (including the patient’s own) and household sounds. The patient should also experiment by increasing and decreasing the volume, as situations require. As the patient adjusts to the increase in sounds and background noise, they can progress to situations in which several people are talking simultaneously. Next, the

environment can be expanded to the outdoors and then to such environments as a shopping mall or grocery store. Adjustment to different environments occurs gradually, depending on the individual patient. When the hearing aid is not being worn, it should be placed in a dry, cool area where it will not be inadvertently damaged or lost. The battery should be disconnected or removed when not in use. Battery life averages 1 week, and patients should be advised to purchase only a month’s supply at a time. Ear moulds should be cleaned weekly or as needed. Toothpicks or pipe cleaners may be used to clear a clogged ear tip.  SPEECH READING.  Speech reading, commonly called lip reading, can be helpful in increasing communication. It enables patients to achieve approximately 40% understanding of the spoken word. Individuals are able to use visual cues associated with speech, such as gestures and facial expression, to help clarify the spoken message. In speech reading, many words look alike to the person (e.g., “rabbit” and “woman”). If the person wears glasses, the glasses should be used to facilitate speech reading. The nurse can help the patient by using and teaching verbal and nonverbal communication techniques as described in Table 24.18.  SIGN LANGUAGE.  Sign language is used as a form of communication for people with profound hearing impairment. It involves gestures and facial features such as eyebrow motion and lip-­mouth movements. There is no one universal sign language. American Sign Language is used in the United States and the English-­speaking

476

SECTION 4  Conditions Related to Altered Sensory Input

TABLE 24.17    TYPES OF HEARING AIDS Type

Advantages

Disadvantages

Completely in the canal (mild to moderate hearing loss)

Smallest and least visible aid Protected from sounds such as wind noise

Costly No space for add-­ons such as directional microphones or volume controls Small, short-­lived batteries

More powerful than aids completely in the canal Has adjustable features such as noise reduction

Small size of aid with its additional features may be difficult to operate for patients with visual loss or arthritis

In the canal (mild to severe hearing loss)

TABLE 24.18    COMMUNICATION WITH

PATIENTS WHO HAVE HEARING IMPAIRMENTS

Nonverbal Aids

Verbal Aids

• Draw attention with hand movements. • Have speaker’s face in good light. • Avoid covering mouth or face with hands. • Avoid chewing, eating, and smoking while talking. • Maintain eye contact. • Avoid distracting environments. • Avoid careless expression that the patient may misinterpret. • Use touch. • Move close to better ear. • Avoid light behind speaker.

• Speak normally and slowly. • Do not overexaggerate facial expressions. • Do not overenunciate. • Use simple sentences. • Rephrase sentence; use different words. • Write name or difficult words. • Do not shout. • Speak in normal voice directly into better ear.

Electrode system Microphone Implant Headpiece Auditory nerve

In the ear (mild to severe hearing loss)

Powerful amplification Inserts and adjusts easily Longer-­lasting batteries

Visible May pick up wind noise readily

Cochlea Sound processor

FIG. 24.13  Cochlear implant.

Behind the ear (all types of hearing loss)

Most powerful aid Adjusts easily Longest battery life

Largest, most visible aid Newer models may be smaller and less obvious

parts of Canada. Quebec Sign Language, known in French as Langue des signes québécoise or Langue des signes du Québec (LSQ), is the sign language of deaf communities in francophone Canada, primarily in Quebec. Also, some Indigenous people have created their own sign language (e.g., Oneida sign language) (Albert, 2018).  COCHLEAR IMPLANT.  The cochlear implant is used as a hearing device for people with severe to profound sensorineural hearing loss in one or both ears. The system consists of an external microphone placed behind the ear, a speech processor and a transmitter implanted under the skin that change sounds into electrical impulses, and a group of electrodes placed within the cochlea that stimulate the auditory nerves in the ear (Figure 24.13). Cochlear implants send information that covers the entire range of sound frequencies. The cochlear implant electrodes are inserted as far as possible into the cochlea to send both high-­and low-­frequency information. For patients with conductive and mixed hearing loss, the cochlear Baha system may be surgically implanted. The system works through direct bone conduction and becomes integrated with the skull bone over time.

CHAPTER 24  Nursing Management: Visual and Auditory Conditions Extensive training and rehabilitation are essential in order to receive maximum benefit from these implants. The positive aspects of a cochlear implant include providing sound to the person who heard none, improving lip-­reading ability, monitoring the loudness of the person’s own speech, improving the sense of security, and decreasing feelings of isolation. With continued research, the cochlear implant may offer the possibility of aural rehabilitation for a wider range of hearing-­impaired individuals. The U.S. Food and Drug Administration has created an informational website on cochlear implants (see the Resources at the end of this chapter). The site includes an animated movie to help visualize the implants and how they work.  ASSISTED LISTENING DEVICES.  Numerous devices are now available to assist hearing-­impaired persons. Direct amplification devices, amplified telephone receivers, alerting systems that flash when activated by sound, an infrared system for amplifying the sound of the television, and a combination FM receiver and hearing aid are all devices that the nurse can explore on the basis of the patient’s needs. People with profound deafness may be assisted by text-­telephone alerting systems that flash when activated by sound, by closed captioning on television, and by specially trained dogs. Such dogs are trained to alert their owners to specific sounds within the environment, which thus increases the person’s safety and independence. 

AGE-­RELATED CONSIDERATIONS HEARING LOSS Presbycusis, hearing loss associated with aging, includes the loss of peripheral auditory sensitivity, a decline in word recognition ability, and associated psychological and communication issues. Because consonants (high-­frequency sounds) are the letters by which spoken words are recognized, an older person with presbycusis has a diminished ability to understand the spoken word. Vowels are heard, but some consonants fall into the high-­frequency range and cannot be differentiated. This may lead to confusion and embarrassment because of the difference in what was said and what was heard (Óberg, 2015). The cause of presbycusis is related to degenerative changes in the inner ear. Noise exposure is thought to be a common factor. Table 24.19 describes the classification of specific causes and associated hearing changes of presbycusis. Many patients have

477

TABLE 24.19    CLASSIFICATION OF

PRESBYCUSIS

Type

Hearing Change

Prognosis

Loss of high-­pitched sounds

Little effect on speech understanding; good response to sound amplification

Loss of speech discrimination

Amplification alone not sufficient

Uniform loss for all frequencies accompanied by recruitment*

Good response to hearing aid

Range of hearing loss increases from low to high frequencies; speech discrimination affected with higher frequency losses

Ameliorated by appropriate forms of amplification

Sensory Atrophy of auditory nerve; loss of sensory hair cells

Neural Degenerative changes in cochlea and spinal ganglion

Metabolic Degenerative changes in cochlea and spinal ganglion

Cochlear Stiffening of basilar membrane, which interferes with sound transmission in the cochlea

*Abnormally rapid increase in loudness as sound intensity increases.

more than one type of presbycusis. The prognosis for hearing depends on the cause of the loss. Sound amplification with the appropriate device is often helpful in improving the understanding of speech. In other situations, an audiological rehabilitation program can be valuable. Many older people are reluctant to use a hearing aid for sound amplification. Reasons cited most often include cost, appearance, insufficient knowledge about hearing aids, amplification of competing noise, and unrealistic expectations. Most hearing aids and batteries are small, and neuromuscular changes such as stiff fingers, enlarged joints, and decreased sensory perception often make the care and handling of a hearing aid a difficult and frustrating experience for an older person. Some older persons may also tend to accept their losses as part of aging and believe there is no need for improvement.

CASE STUDY Glaucoma and Diabetic Retinopathy Patient Profile

Objective Data

L. A. (pronouns she/her), 68 years old, has osteoarthritis and type 2 diabetes mellitus, diagnosed 15 years earlier. Her current diagnosis is diabetic retinopathy. L. A. returns to the eye clinic for continued evaluation and care of her primary open-­angle glaucoma (POAG) and re-­examination for changes in diabetic retinopathy. L. A.’s current medical regimen for POAG includes topical timolol maleate, 0.5% extended (Timoptic XE), once daily in each eye, and latanoprost (Xalatan), 0.005%, in each eye, at bedtime. At L. A.’s last examination, microaneurysms and hard exudates of the retina were noted. 

• D  istant and near visual acuity are stable at 20/60 in the right eye and 20/50 in the left eye. This is a reduction from 20/40 in both eyes since last visit. • Intraocular pressures (IOPs) are stable at 20 mm Hg in both eyes. Visual field testing in the left eye reveals a new scotoma. • Fluorescein angiography reveals diabetic macular edema in both eyes. 

Subjective Data • C  an no longer read the newspaper and reports that medication labels are difficult to read. • States limited success in getting the eye drops instilled because hands are stiff and painful from osteoarthritis. 

Interprofessional Care • B  rimonidine (Alphagan), 0.15%, in left eye 15 min before and immediately after argon laser trabeculoplasty (ALT) • Argon laser treatment in left eye to seal leaking microaneurysm from macular edema • Checking IOP after ALT • Continuing previous glaucoma drop regimen • Follow-­up examination for glaucoma in 2 weeks for possible ALT in right eye • Follow-­up examination for diabetic macular edema in 8 weeks 

Continued

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SECTION 4  Conditions Related to Altered Sensory Input

CASE STUDY Glaucoma and Diabetic Retinopathy—cont’d Discussion Questions . W 1  hat is the cause of L. A.’s new nonproliferative retinopathy? 2. Why might laser photocoagulation be an appropriate therapy for macular edema? 3. What is the purpose of the fluorescein angiography? 4. Priority decision: What priority topics should be discussed in discharge teaching? 5. In what way could glaucoma cause vision loss if L. A.’s eye pressures are not properly monitored?

6. Priority decision: What are the priority nursing interventions for L. A.? 7. Priority decision: On the basis of the assessment data, what are the priority nursing diagnoses? Are there any interprofessional problems? 8. Evidence-­informed practice: L. A. wants to know if glaucoma is related to diabetes. How should the nurse respond to the patient’s question?

Answers are available at http://evolve.elsevier.com/Canada/Lewis/medsurg.

 REVIEW QUESTIONS 7. The nurse would suspect otosclerosis from assessment findings of hearing loss in which of the following clients? a. A 26-­year-­old woman with three biological children younger than 5 years of age b. A 52-­year-­old man whose hearing loss is accompanied by vertigo and tinnitus c. A 42-­year-­old woman who has a history of serous otitis media d. A 63-­year-­old man who can hear high-­pitched sounds more effectively than low-­pitched sounds 8. Which of the following statements best describes a client who has a sensorineural hearing loss? a. The client has difficulty understanding speech. b. The client experiences clearer sounds with the use of a hearing aid. c. The client may have a reversal of damage caused by ototoxic drugs. d. The client hears low-­pitched sounds better than high-­pitched sounds. 9. Which of the following would the nurse tell the client who is newly fitted with bilateral hearing aids? (Select all that apply.) a. Replace the batteries monthly. b. Clean the ear moulds weekly or as needed. c. Clean ears with cotton-­tipped applicators daily. d. Disconnect or remove the batteries when not in use. e. Initially restrict usage to quiet listening in the home. 10. Which strategies would best assist the nurse in communicating with a client who has a hearing loss? (Select all that apply.) a. Overenunciate speech. b. Exaggerate facial expression. c. Raise the voice to a higher pitch. d. Write out names or difficult words. e. Speak normally and slowly. 11. Which of the following statements best describes clients with permanent visual impairment? a. They feel most comfortable with other visually impaired persons. b. They may feel threatened when others make eye contact during a conversation. c. They usually need others to speak louder so they can communicate appropriately. d. They may experience the same grieving process that is associated with other losses. 1. b; 2. d; 3. d; 4. a, d; 5. d; 6. b; 7. a; 8. a; 9. b, d, e; 10. d, e; 11. d.

The number of the question corresponds to the same-­numbered objective at the beginning of the chapter. 1. Why does presbyopia occur in older individuals? a. The retina degenerates. b. The lens becomes inflexible. c. The corneal curvature becomes irregular. d. It is associated with cataract development. 2. What is the most important nursing intervention for clients with epidemic keratoconjunctivitis? a. Applying patches to the affected eyes b. Accurately measuring intraocular pressure c. Monitoring near visual acuity every 4 hours d. Teaching client and family members good hygiene techniques 3. What should clients with eye inflammation or an eye infection be taught? a. Wear dark glasses to prevent irritation from ultraviolet light. b. Acute conditions commonly lead to chronic problems. c. Apply a cold compress with pressure to the inflamed area frequently. d. Regular, careful hand hygiene may prevent the infection from spreading. 4. Which of the following client behaviours would the nurse promote for healthy eyes and ears? (Select all that apply) a. Wearing protective sunglasses when bicycling. b. Supplemental intake of B vitamins and magnesium c. Playing amplified music at 75% of maximum volume d. Notifying the health care provider if tinnitus occurs during antibiotic therapy e. For women, avoiding pregnancy for 4 weeks after receiving measles-­mumps-­rubella (MMR) immunization 5. What should the nurse do to prepare clients for retinal detachment surgery? a. Explain how to care for an ocular prosthesis. b. Assure clients that they can expect 20/20 vision after surgery. c. Teach the family how to recognize when the client is hallucinating. d. Assess the client’s level of knowledge about retinal detachment and provide information appropriate to the situation. 6. What should be included in the nursing plan for a client who needs to administer antibiotic eardrops? a. Cool the drops so that they decrease swelling in the canal. b. Be careful to avoid touching the tip of the dropper bottle to the ear. c. Placement of a cotton wick to assist in administering the drops is not recommended. d. Keep the head tilted for 5 to 7 minutes after administering the drops to prevent them from running out of the ear canal.

For even more review questions, visit http://evolve.elsevier.com/Canada/ Lewis/medsurg.

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Devenyi, R., Maberley, D., Sheidow, T. G., et al. (2016). Real-­world utilization of ranibizumab in wet age-­related macular degeneration patients from Canada. Canadian Journal of Ophthalmology, 51(2), 55–57. https://doi.org/10.1016/j.jcjo.2015.11.008 Di Berardino, F., Conte, G., Turati, F., et al. (2020). Cochlear implantation in Ménière’s disease: a systematic review of literature and pooled analysis. International Journal of Audiology, 59(6), 40–415. https://doi.org/10.1080/14992027.2020.1720992 Eydelman, M., Hilmantel, G., Tarver, M. E., et al. (2017). Symptoms and satisfaction of patients in the patient-­reported outcomes with laser in situ keratomileusis (PROWL) studies. JAMA Ophthalmology, 135(1), 13–22. https://doi.org/10.1001/jamaophthalmol.2016.4587 Ferri, F. (2020). Ferri’s clinical advisor 2020. Elsevier. Freund, P., & Chen, S. (2018). Herpes zoster ophthalmicus. CMAJ, 190(21), E656. https://doi.org/10.1503/cmaj.180063 Gagnon-­Roy, M., Hami, B., Genereaux, M., et al. (2018). Preventing emergency department (ED) visits and hospitalisations of older adults with cognitive impairment compared with the general senior population: What do we know about avoidable incidents? Results from a scoping review (e019908) BMJ Open, 8. https://doi. org/10.1136/bmjopen-­2017-­019908 Glaucoma Research Society of Canada. (2021). Learning about glaucoma. https://www.glaucomaresearch.ca/about/about-­glaucoma/ Government of Canada. (2020). Noise and your health. https://www.canada.ca/en/health-­canada/services/noise-­your-­ health.html HealthLink BC. (2019). Benign paroxysmal positional vertigo (BPPV). https://www.healthlinkbc.ca/health-­topics/hw263714 Hearing Foundation of Canada. (2020). Statistics. http://www.hearing­ foundation.ca/statistics/ Hoover, C., Rademayer, C., & Farleu, C. (2017). Body piercing: Motivations and implications for health. Journal of Midwifery & Women’s Health, 62(5), 521–530. https://doi.org/10.1111/jmwh.12630 Indigenous Services Canada. (2020). Guide to vision care benefits. https://www.sac-­isc.gc.ca/eng/1579545788749/1579545817396#s2-­2 Jin, S., Chan, S., & Gupta, N. (2019). Distribution gaps in surgery care and impact on seniors across Ontario. Canadian Journal of Ophthalmology, 54(4), 451–475. https://doi.org/10.1016/j. jcjo.2018.10.022 Kandaswamy, B., Miane Ng, M. Y., & Nash, R. (2020). Assessing and treating adults with hearing loss in primary care. Practice Nursing, 31(3). https://doi.org/10.12968/pnur.2020.31.3.106 Le Saux, N., & Robinson, J. L. (2016). Management of acute otitis media in children six months of age and older. Paediatrics & Child Health, 21(1), 39–50. https://www.cps.ca/documents/position/acu te-­otitis-­media Lian, J. (2018). Keeping eye injuries at bay. Occupational Health and Safety Canada. https://www.ohscanada.com/overtime/keeping-­ eye-­injuries-­bay/ Mayo Clinic (2019). Cataract surgery. https://www.mayoclinic.org/tests-­ procedures/cataract-­surgery/about/pac-­20384765 Melanoma Network of Canada. (2015). A guide to uveal melanoma. https://www.melanomanetwork.ca/wp-­content/uploa ds/2015/04/140622-­MNC_UvealGuideBooklet_FIN2_lr1.pdf National Eye Institute. (2019a). Amblyopia (lazy eye). https://www.nei.nih.gov/learn-­about-­eye-­health/eye-­conditions-­ and-­diseases/amblyopia-­lazy-­eye National Eye Institute. (2019b). Corneal conditions. https://www.nei.nih.gov/learn-­about-­eye-­health/eye-­conditions-­ and-­diseases/corneal-­conditions

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National Eye Institute. (2019c). Macular edema. https://www.nei.nih.gov/learn-­about-­eye-­health/eye-­conditions-­ and-­diseases/macular-­edema National Eye Institute. (2020). Retinal detachment. https://www.nei.nih.gov/learn-­about-­eye-­health/eye-­conditions-­ and-­diseases/retinal-­detachment National Eye Institute. (2021). Age-­related macular degeneration. https://www.nei.nih.gov/learn-­about-­eye-­health/eye-­conditions-­ and-­diseases/age-­related-­macular-­degeneration Nielsen, M., Dogrusöz, M., Bleeker, J. C., et al. (2015). The genetic basis of uveal melanoma. Journal Français d’Ophthalmologie, 38(6), 516–521. https://doi.org/10.1016/j.jfo.2015.04.003 Öberg, M. (2015). Hearing care for older adults: Beyond the audiology clinic. American Journal of Audiology, 24(2), 104–107. https:// doi.org/10.1044/2015_AJA-­14-­0077 Sella, R., Chou, L., Schuster, A. K., et al. (2020). Accuracy of IOL power calculations in the very elderly. Eye. https://doi.org/10.1038/ s41433-­019-­0752-­0 Statistics Canada. (2018). New data on disability in Canada, 2017. https:// www150.statcan.gc.ca/n1/pub/11-­627-­m/11-­627-­m2018035-­eng.htm Tognarelli, E. I., Palomino, T. F., Corrales, N., et al. (2019). Herpes simplex virus evasion of early host antiviral responses. Frontiers in Cellular and Infection Microbiology, 9, 27. https://doi.org/10.3389/ fcimb.2019.00127 Touhy, T., Jett, K., Boscart, V., et al. (2019). Ebersole and Hess’ gerontological nursing and healthy aging in Canada (2nd ed.). Elsevier. Varu, D., Rhee, M., Akpek, E., et al. (2019). Conjunctivitis preferred practice pattern. Ophthalmology, 126(1), 94–169. https://doi. org/10.1016/j.ophtha.2018.10.020 Welp, A., Woodbury, R. R., McCoy, M. A., et al. (2016). Making eye health a population health imperative. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK385157/ World Health Organization. (2021). Trachoma. https://www.who.int/news-­room/fact-­sheets/detail/trachoma

RESOURCES Alberta Association of the Deaf http://www.aadnews.ca/ Alliance for Equality of Blind Canadians http://www.blindcanadians.ca/ BC and Alberta Guide Dog Services. http://www.bcguidedog.com/ Bob Rumball Canadian Centre of Excellence for the Deaf https://www2.bobrumball.org/ Canadian Association of the Deaf http://www.cad.ca/ Canadian Association of Optometrists http://opto.ca/ Canadian Council of the Blind (CCB) http://ccbnational.net Canadian Glaucoma Society http://www.cgs-­scg.org/ Canadian Hard of Hearing Association http://www.chha.ca/chha/ Canadian Hearing Society http://www.chs.ca/

Canadian Helen Keller Centre http://www.chkc.org/ Canadian National Institute for the Blind (CNIB) http://www.cnib.ca Canadian Ophthalmological Society http://www.cos-­sco.ca Foundation Fighting Blindness http://www.blindness.org/ Hearing Foundation of Canada http://hearingfoundation.ca Misericordia Health Centre: Buhler Eye Care Centre https://misericordia.mb.ca/programs/acute-­care/eye-­care/ Misericordia Health Centre: Focus on Falls Prevention Vision Screening Program https://misericordia.mb.ca/programs/clinical-­services/focus-­on-­ falls/ Montreal Association for the Blind: MAB-­Mackay Rehabilitation Centre https://www.llmrc.ca/program-­and-­services/by-­impairment/visual-­ impairment/ The Ottawa Hospital Eye Institute http://www.ottawahospital.on.ca/wps/portal/Base/TheHospital/Cli nicalServices/DeptPgrmCS/Programs/EyeInstitute Society of Deaf and Hard of Hearing Nova Scotians http://sdhhns.org/ American Academy of Audiology http://www.audiology.org American Academy of Ophthalmology http://www.aao.org/ American Society of Cataract and Refractive Surgery http://ascrs.org/ American Society of Ophthalmic Registered Nurses http://www.asorn.org/ Glaucoma Research Foundation http://www.glaucoma.org/ Hearing Loss Sampler http://www.uww.edu/comdis/radio/hlsimulation/ International Hearing Society http://ihsinfo.org/IhsV2/Home/Index.cfm The Macula Foundation http://maculafoundation.org/ National Eye Institute of the National Institutes of Health http://www.nei.nih.gov/ National Center on Deaf-­Blindness http://www.nationaldb.org/ University of Michigan Kellogg Eye Center https://www.umkelloggeye.org/ U.S. Food and Drug Administration: Cochlear Implants http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedur es/ImplantsandProsthetics/CochlearImplants/default.htm VisionSimulations.com http://visionsimulations.com/ For additional Internet resources, see the website for this book at http://evolve.elsevier.com/Canada/Lewis/medsurg.

CHAPTER

25

Nursing Assessment

Integumentary System Susannah McGeachy Originating US chapter by Mariann M. Harding

WEBSITE http://evolve.elsevier.com/Canada/Lewis/medsurg • R  eview Questions (Online Only) • Key Points

• A  nswer Guidelines for Case Study • Conceptual Care Map Creator

• A  udio Glossary • Content Updates

LEARNING OBJECTIVES . Describe the structures and the functions of the integumentary system. 1 2. Link the age-­related changes in the integumentary system to differences in assessment findings. 3. Identify the significant subjective and objective data regarding the integumentary system that should be obtained from a patient. 4. Identify appropriate techniques used in the physical assessment of the integumentary system.

5. Compare the critical components for describing primary and secondary lesions. 6. Differentiate normal from common abnormal findings of a physical assessment of the integumentary system. 7. Summarize the structural and assessment differences in individuals of varying skin tones. 8. Describe the purpose, significance of results, and nursing responsibilities related to diagnostic studies of the integumentary system.

KEY TERMS alopecia clubbing cyanosis dermis epidermis erythema

  

hirsutism intertriginous jaundice keratinocytes melanocytes mole (nevus)

The integumentary system is the largest body organ and comprises skin, hair, nails, and glands. The skin is further divided into two layers: the epidermis and the dermis. The subcutaneous tissue is immediately under the dermis (Figure 25.1). The skin is as complex as any organ but, unlike the others, it is readily visible. Being able to see and touch the skin assists the nurse in an integumentary assessment, as abnormalities are readily apparent and their detection enables early intervention.

STRUCTURES AND FUNCTIONS OF THE SKIN AND APPENDAGES Structures The epidermis is the outermost layer of the skin. The dermis, the second skin layer, contains collagen bundles and supports

pallor pruritus sebaceous glands vitiligo

the nerve and vascular network. Subcutaneous tissue lies below the dermis and is composed primarily of fat and loose connective tissue. Epidermis.  The epidermis, the outer layer of the skin, is relatively thin, ranging from 0.05 mm on the eyelids to 0.1 mm on the soles of the feet (Habif, 2016). There are no lymphatic or vascular structures in the epidermis. It is supported by passive circulation from the dermis. The epidermis is divided into five distinct but interrelated layers. Two of the layers are the stratum corneum (the surface layer) and the stratum germinativum (deepest, basal layer) (see Figure 25.1). Most epithelial cells are keratinocytes (90%). The remaining cells are melanocytes, Langerhans cells, and Merkel cells. Keratinocytes form in the basal layer. Initially, they are undifferentiated and shaped like columns. As they mature

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SECTION 4  Conditions Related to Altered Sensory Input

Hair shaft Horny cell layer Basal cell layer

Epidermis

Melanocyte Sebaceous gland Eccrine sweat gland

Dermis

Subcutaneous tissue

Apocrine sweat gland

Connective tissue Arrector pili muscle

Blood vessels Adipose tissue Nerves

Hair follicle

FIG. 25.1  Microscopic view of the skin in longitudinal section. Source: Jarvis, C., Browne, A. J., MacDonald-­Jenkins, J. et al. (2019). Physical examination & health assessment (3rd Canadian ed., p. 226). Elsevier.

(keratinize), they move to the surface, where they flatten and die to form the outer skin layer (stratum corneum). Keratinocytes make a fibrous protein, keratin, which is vital to the skin’s protective barrier function. The upward movement of keratinocytes from the basal layer to the outermost levels of the stratum corneum takes about 14 days. The keratinocytes stay there for another 14 days, allowing the epidermis to regenerate every 28 days. Thus, each month, a new layer of skin is created. Many skin conditions result from changes in this cell cycle. If dead cells slough off too rapidly, the skin appears thin and eroded. If new cells form faster than old cells are shed, the skin becomes scaly and thickened. Failure of the epidermis to function normally occurs with skin cancer and psoriasis (discussed in Chapter 26). Melanocytes are found in the deep, basal layer. They contain melanin, a pigment that gives colour to the skin and hair and protects the body from damaging ultraviolet (UV) sunlight. Sunlight and hormones stimulate the melanosome (within the melanocyte) to increase the production of melanin. People of all skin tones have similar numbers of melanocytes. In darker skin, the melanosomes are larger and more numerous, thus producing more melanin (Gawkrodger & Ardern-­Jones, 2016). This increased melanin forms a natural sun shield for dark skin and results in a decreased incidence of skin cancer. Langerhans cells are a type of dendritic cell (discussed in Chapter 16). They are immunocompetent cells that recognize antigens. When they are depleted, the skin cannot initiate an immune response. The Langerhans cells in bioengineered skin grafts have been removed to prevent graft rejection. In skin diseases such as psoriasis and sarcoidosis, there

are decreased numbers of Langerhans cells. Merkel cells are found in the basal layer and are involved in the sensation of light touch. They are used when a person is feeling the texture of an object and figuring out what it is. The basement membrane zone is between the epidermis and dermis. This structure provides for (1) exchange of fluids between the epidermis and dermis and (2) structural support for the epidermis. The basement membrane helps to secure the two layers together. Inflammation and separation of the epidermal and dermal layers result in the blisters seen in conditions such as burns, full-­thickness wounds, and mechanical trauma.  Dermis.  The dermis is the connective tissue below the epidermis. The dermis is highly vascular, with a thickness varying from 0.3 to 3 mm (Habif, 2016). It also contains nerves, lymphatic vessels, hair follicles, sebaceous glands, and specialized cells such as mast cells and macrophages that protect the body from external stimuli. The dermis has two layers: an upper thin papillary layer and a deeper, thicker reticular layer. The papillary layer is arranged haphazardly in ridges, or papillae, which extend into the outer epidermal layer. These elevated surface ridges form fingerprints and footprints. The reticular layer forms the bulk of the dermis. It is made up of thick collagen bundles arranged parallel to the skin’s surface. The dermis is made of three types of connective tissue: collagen, elastic fibers, and reticular fibers. Collagen forms the greatest part of the dermis. It gives the skin toughness and strength and is critical in wound healing. The primary cell type in the dermis is the fibroblast, which makes collagen and elastin. The dermis also contains nerves, lymphatic vessels,

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CHAPTER 25  Nursing Assessment: Integumentary System hair follicles, sebaceous glands, and specialized cells such as mast cells and macrophages that protect the body from external stimuli.  Subcutaneous Tissue.  While not part of the skin, the subcutaneous tissue is often discussed with the integument because it attaches the skin to underlying tissues such as the muscle and bone. It contains loose connective tissue and fat cells that provide insulation, cushioning, temperature regulation, and energy storage. The distribution of subcutaneous tissue varies with gender, heredity, age, and nutritional status.  Skin Appendages.  Skin appendages include the hair, nails, and glands (sebaceous, apocrine, and eccrine). These appendages are epidermal extensions that have their roots in the dermis. These structures receive nutrients, electrolytes, and fluids from the dermis. Hair and nails form from specialized keratin. Systemic diseases can affect the condition and health of both hair and nails. Hair grows on most of the body; the density and pattern of distribution varies depending on age, sex, and race. Hair colour is a result of heredity and determined by the type and amount of melanin in the hair shaft. Hair grows about 1 cm per month. People lose about 100 hairs each day (Alikhan & Hocker, 2016). Alopecia (partial or complete lack of hair) results when lost hair is not replaced, for example, with normal aging or anticancer medications. Nails are made of heavily keratinized cells. The visible part of the nail is the nail body; the rest is the nail root. A fold of skin, bordered by the cuticle, hides most of the nail root. The portion of the nail root that can be seen is called the lunula. This white, crescent-­shaped area is the site of mitosis and nail growth (Figure 25.2). Under the nail is a highly vascular area of epidermis called the nail bed. Fingernails grow slowly, at a rate of 0.5 to 2 mm per week (Habif, 2016). A lost fingernail usually regenerates in 3 to 6 months, while a lost toenail may require 12 months or longer to regenerate. Nail growth varies on the basis of a person’s age and health. Nails grow faster in men and in warm weather. Nail colour ranges from pink to yellow or brown depending on skin colour. Colour and texture variations in the nails may represent normal or abnormal conditions. Pigmented longitudinal bands (melanonychia striata) occur in the nail bed of 90% of people with dark skin (Figure 25.3) (Bishop & Tosti, 2017). There are two major types of glands in the skin: sebaceous and sweat glands. Sebaceous glands secrete sebum, which is emptied into the hair follicles. Sebum waterproofs and lubricates the skin and promotes the absorption of fat-­soluble substances. Sebum is somewhat bacteriostatic and fungistatic. These glands depend on sex hormones, particularly testosterone, to regulate sebum secretion and production. Actual production varies depending on age, sex, and testosterone and estrogen levels. Sebaceous glands are present on all areas of the skin except the palms and soles and dorsum of the feet. These glands are most abundant on the face, scalp, upper chest, and back. The apocrine sweat glands are mainly found in the axillary, genital, and breast areas. They are always connected to a hair follicle. These glands enlarge and become active at puberty with the increased activity of reproductive hormones. They secrete a thick milky substance that is naturally odorless. Odor occurs when skin surface bacteria alter the secretions. The eccrine sweat glands are found on most of the body, except the lips, ear canals, nail beds, labia minora, glans penis, and prepuce. One square inch of skin has about 3 000 eccrine sweat glands. Their main function is to cool the body by evaporation,

Nail plate Lunula Cuticle Nail root

Nail matrix Nail root

Cuticle Nail plate Nail bed

Bone

FIG. 25.2  Structure of a nail. Source: Patton, K. T., & Thibodeau, G. A. (2016). Essentials of anatomy and physiology (9th ed., p. 196). Mosby.

FIG. 25.3  Pigmented nail bed normally seen with dark skin colour. Source: Habif, T. P. (2016). Clinical dermatology: A color guide to diagnosis and therapy (6th ed., p. 766). Mosby.

excrete waste products, and moisturize surface cells. Sweat is a transparent watery solution composed of salts, ammonia, urea, and other wastes. In extreme situations, the body can make 2 to 4 L of sweat per hour or up to 12 L in 24 hours. Heat, certain mental stimuli, and ingestion of hot, spicy foods stimulate sweat secretion. 

Functions of the Integumentary System The skin’s primary function is to protect the underlying tissues of the body from the external environment. The skin acts as a barrier against invasion by bacteria and viruses and prevents excessive water loss. The fat in the subcutaneous layer insulates the body and provides protection from trauma. Melanin screens and absorbs ultraviolet radiation. Nerve endings and receptors located within the skin provide sensory information on environmental stimuli to the brain related to pain, temperature, touch, pressure, and vibration. In addition, the skin regulates heat loss by responding to changes in internal and external temperature with vasoconstriction, vasodilation, and excretion of sweat. Evaporation of water from the lungs and skin results in the loss of 600 to 900 mL of water daily. Sebum and sweat lubricate the skin surface. Furthermore, endogenous synthesis of vitamin D, which is critical to calcium and phosphorus balance, occurs in the epidermis. 

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SECTION 4  Conditions Related to Altered Sensory Input

TABLE 25.1    AGE-­RELATED DIFFERENCES

IN ASSESSMENT

Integumentary System Changes

Differences in Assessment Findings

Skin • Decreased subcutaneous fat, muscle laxity, degeneration of elastic fibres, collagen stiffening

• Decreased extracellular water, surface lipids, and sebaceous gland activity • Decreased activity of apocrine and sebaceous glands • Increased capillary fragility and permeability • Increased focal melanocytes in basal layer with pigment accumulation • Diminished blood supply

• Decreased proliferative capacity • Decreased immunocompetence

Increased wrinkling, sagging breasts and abdomen, redundant flesh around eyes, slowness of skin to flatten when pinched (tenting) Dry, flaking skin with possible signs of excoriation caused by scratching Dry skin with minimal to no perspiration, uneven skin coloration Bruising Solar lentigines on face and backs of hands Decrease in rosy appearance of skin and mucous membranes; skin cool to touch; diminished awareness of pain, touch, temperature, and peripheral vibration Diminished rate of wound healing Increase in neoplasms

Hair • Decreased melanin and melanocytes • Decreased oil • Decreased density of hair • Cumulative androgen effect; decreasing estrogen levels

Grey or white hair Dry, coarse hair; scaly scalp Thinning and loss of hair Facial hirsutism, baldness

Nails • Decreased peripheral blood supply • Increased keratin • Decreased circulation

Thick, brittle nails with diminished growth Longitudinal ridging Prolonged return of blood to nails on blanching

AGE-­RELATED CONSIDERATIONS EFFECTS OF AGING ON THE INTEGUMENTARY SYSTEM Skin changes related to aging include decreased turgor, thinning, dryness, wrinkling, vascular lesions, increased skin fragility, and benign neoplasms. Although many changes are only of cosmetic concern, others can be serious and need careful evaluation. Age-­related changes of the integumentary system and differences in assessment findings are listed in Table 25.1. With advancing age, the junction between the dermis and the epidermis becomes flattened, and the epidermis contains fewer melanocytes. In addition, the dermis loses volume and has fewer blood vessels. Scalp, pubic, and axillary hair becomes depigmented and thinner. A loss of melanin results in fading hair colour. The nail plate thins, and nails become brittle, thicker, and more prone to splitting and yellowing. Chronic UV exposure is the major contributor to photoaging and wrinkling of the skin (Canadian Dermatology Association [CDA], 2021b). Sun damage to the skin is cumulative (Figure 25.4). Inadequate nutrition, with decreased intake of protein, calories, and vitamins, further contributes to aging

FIG. 25.4  Photoaging. Various pigmented spots, such as freckles, solar lentigines (known as age or liver spots), and uneven skin colour. Source: (c) iStock.com/weerapatkiatdumrong

of the skin. With aging, collagen fibres stiffen, elastic fibres degenerate, and the amount of subcutaneous tissue decreases. These changes, with the added effects of gravity, lead to wrinkling. The visible effects of aging on the skin and hair may result in an altered self-­image and may have a profound psychological effect. Benign neoplasms related to the aging process can occur. These growths include seborrheic keratoses, vascular lesions such as cherry angiomas, and skin tags. Actinic keratoses appear on areas of chronic sun exposure, especially in people with a light complexion. These premalignant cutaneous lesions place an individual at increased risk for squamous cell and basal cell carcinomas. The photoaged person is more susceptible to skin cancers because of decreased capacity to repair cellular deoxyribonucleic acid (DNA) damage caused by UV exposure (CDA, 2021a). Chronic UV exposure from tanning beds causes the same damage as UV from the sun. Subcutaneous fat decreases with age, leading to increased risk of traumatic injury, hypothermia, and skin shearing, which may lead to pressure injuries. With aging, the apocrine and eccrine sweat glands atrophy, causing dry skin and decreased body odour. The growth rate of the hair and nails decreases as a result of atrophy of the involved structures. Hormonal and vitamin deficiencies can cause dry, thin hair and alopecia. 

ASSESSMENT OF THE INTEGUMENTARY SYSTEM The general skin assessment begins with the nurse’s first contact with the patient and continues throughout the examination. As this is the first meeting with the patient, the overall condition of the patient’s skin and hair should be noted. Specific areas of the skin will be assessed when examining other body systems, unless the chief complaint is a skin problem. The nurse needs to record a general statement about the skin’s physical condition (Table 25.2). The nurse can investigate further by asking the health history questions presented in Table 25.3 when a skin condition is noted.

Subjective Data Past Medical History.  Past medical history reveals previous trauma, surgery, or disease that involves the skin. Many diseases

CHAPTER 25  Nursing Assessment: Integumentary System TABLE 25.2    NORMAL PHYSICAL

ASSESSMENT OF THE INTEGUMENTARY SYSTEM

Skin: Evenly pigmented; no petechiae, purpura, lesions, or excoriations; warm; good turgor Nails: Pink; oval; adhere to nail base with 160° angle Hair: Shiny and full; amount and distribution appropriate for age and gender; no flaking of scalp, forehead, or pinna

CASE STUDY Patient Introduction D. A. (pronouns she/her), 74 years old, comes to the primary care clinic with concerns about various “spots” on her face. She says they have been there for a while and thought they were just “age spots,” but she got concerned after a friend was diagnosed with a malignant melanoma.

Critical Thinking The following questions should be kept in mind while studying this assessment chapter: 1. What are the possible causes of D. A.’s facial lesions? 2. What subjective data should the nurse gather from the patient to help determine possible causes? 3. What should be included in the physical assessment? What specific characteristics of the skin lesions should the nurse look for? 4. What diagnostic studies might be ordered? See Case Study: Subjective Data and Case Study: Objective Data for more information on D. A.

Answers available at http://evolve.elsevier.com/Canada/Lewis/medsurg.

have dermatological manifestations. The nurse needs to determine if the patient has noticed any issues such as jaundice (yellowing of the skin and/or sclera associated with increased bilirubin levels), delayed wound healing, cyanosis (bluish colour resulting from hypoxia), erythema (redness), or pallor (paleness). It is important to obtain specific information regarding sensitivities, allergies, and skin reactions to insect bites and stings. Any history of chronic or unprotected exposure to UV light, including tanning bed use or radiation treatments, should be noted.  Medications.  A thorough medication history is important. The nurse should ask the patient about skin-­related issues that occurred from taking a medication. Many hormones, antibiotics, corticosteroids, and antimetabolites have adverse effects that manifest in the skin. Medications may contain fragrances and preservatives that can cause skin reactions. The nurse should document the use of medications specifically used to treat a primary skin condition, such as acne, or a secondary skin condition, such as itching. The medication’s name, length of use, method of application, and effectiveness should be recorded.  Surgery or Other Treatments.  The nurse needs to determine if any surgical procedures, including cosmetic surgery, were done on the skin. Biopsy results should be recorded. The nurse needs to note any treatments specific for a skin condition (e.g.,

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phototherapy) or for a health condition (e.g., radiation therapy). Any treatments undergone primarily for cosmetic purposes, such as tanning booth use, laser resurfacing, or cosmetic “peels,” also need to be documented.  Family History.  The nurse should obtain information about any family history of skin diseases or systemic diseases with dermatological manifestations. Any family or personal history of skin cancer, particularly melanoma, must also be noted.  Self-­Care History.  The patient should be tactfully questioned about health and hygiene practices related to the integumentary system, including the type, quantity, and frequency of use of personal care products (e.g., shampoos, moisturizing agents, cosmetics). Any current skin conditions, including onset, symptoms, course, and treatment, should be recorded, as well as frequency of use and the sun protection factor (SPF) of sunscreen products.  Nutritional History.  A diet history reveals the adequacy of nutrients essential to healthy skin, such as vitamins A, D, E, and C; dietary fat; and protein. The nurse should question the patient regarding recent dietary changes, any food allergies that cause a skin reaction, and conditions of the skin such as dryness, edema, erythema, and pruritus (itching), which can indicate alterations in fluid balance. If the patient is experiencing incontinence, the nurse should determine the condition of the skin in the anal and perineal areas.  Social, Environmental, and Occupational Health History.  The patient should be questioned about environmental factors that affect the skin, such as occupational exposure to chemicals, irritants, sun, insects, animals, extreme temperatures, and prolonged pressure. For example, during the COVID-­19 pandemic, increased facial pressure injuries in health care providers occurred, as a result of prolonged use of personal protective equipment (Desai et al., 2020). Contact dermatitis caused by allergies and irritants is a common condition associated with occupation, as well as with some hobbies. The patient’s participation in any recreational activities involving significant sun exposure should be determined and documented. Indigenous populations in Canada face particular challenges to skin health that result from poor water quality, inadequate housing, lack of access to fresh foods, and limited access to culturally safe health care. Contamination of drinking and bathing water in northern Indigenous communities has been implicated in a higher incidence of eczema, skin cancers (Bradford et al., 2016), and invasive cutaneous infections such as methicillin-­ resistant Staphylococcus aureus (Kirlew et al., 2014).  Cognitive–Perceptual.  The patient’s perception of the sensations of health, cold, pain, and touch should be determined. The nurse should note any discomfort associated with a skin condition, especially when observed in intact skin. As well, joint pain and the mobility of joints should be assessed and recorded, since a skin condition may cause alterations in mobility.  Coping Abilities.  The nurse needs to assess the role that stress may play in creating or worsening the skin condition. The patient should be asked what coping strategies they use to manage the skin condition. For example, pruritus can be distressing and cause major alterations in normal sleep patterns, and acne can be disfiguring and lead to a significant threat to self-­image. 

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SECTION 4  Conditions Related to Altered Sensory Input

TABLE 25.3    HEALTH HISTORY Integumentary System: Questions for Obtaining Subjective Data General • Describe any current skin condition, including when it started, how it has progressed, and how you have treated it. • Describe any changes in the condition of your skin, hair, and nails. • Have you noticed any changes in the way sores or lesions heal?*

Past History • Do you have any history of previous trauma, surgery (including cosmetic surgery), or prior disease that involves the skin?* • Do you have any body art, piercings, or tattoos?* If yes, were they completed in a regulated business? • Do you have any chronic diseases that affect your skin health? (For example, liver disease, diabetes mellitus, respiratory disorders, anemia?) • Do you have a history of significant sun exposure, tanning bed use, or history of radiation treatments?* • Have you ever had a skin biopsy?* If so, what were the results? • Have you used prescription or OTC medications to treat a skin condition?* • Have you had any treatments specifically for a skin condition (e.g., phototherapy, radiation therapy, cosmetic “peels”)?

Family History • Do you have a family history of any skin diseases, including congenital and familial diseases (e.g., alopecia and psoriasis) and systemic diseases with dermatological manifestations (e.g., diabetes, thyroid disease, cardiovascular diseases, immune disorders)? • Do you have any family or personal history of skin cancer, particularly melanoma?

Self-­Care History • Describe your daily hygiene practices. • What skin products are you currently using? • Do you do anything to protect yourself from the sun?* How frequently do you use sun protection, and what is the SPF number of your sunscreen products?

Nutritional History • Are there any changes in the condition of your skin, hair, or nails that might be related to changes in your diet?* • Do you have food allergies that cause a skin reaction?

Social, Environment, or Occupational History • Do you have any pets? • Do you have any food, pet, or medication allergies, or allergy to insect bites or stings?* • Do your leisure or work activities involve the use of any chemicals or devices that might irritate your skin?* • Do you have any close household or sexual contacts with a similar skin condition?*

Cognitive–Perceptual • Do you have any unusual sensations of heat, cold, or touch?* • Do you have any pain associated with your skin condition?* • Do you have any joint pain?*

Coping Abilities • Are you aware of any situation or stressor that changes your skin condition? • Does your skin condition keep you awake or awaken you after you have fallen asleep?* • How does your skin condition make you feel about yourself? • What strategies have you used to manage your skin condition? *If yes, describe. OTC, over-­the-­counter; SPF, sun protection factor; UV, ultraviolet. Source: Based on Jarvis, C., Browne, A., MacDonald-­Jenkins, J., et al. (2019). Physical examination & health assessment (3rd Canadian ed.). Elsevier.

Objective Data Physical Examination.  A physical examination of the skin begins with a systematic, general inspection and then a more specific assessment of problem areas. The nurse should note changes in the colour, turgor, temperature, dryness, thickness, and vascularity of the skin. The findings may be normal, relative to age, genetic factors, and environmental exposures, or may represent primary or secondary skin lesions. General principles when conducting an assessment of the skin are as follows: 1. Use a private examination room of moderate temperature with good lighting. 2. Ensure that the patient is comfortable and in a gown that allows easy access to all skin areas. 3. Use gloves when palpating nonintact skin and rashes. 4. Perform a general inspection followed by a lesion-­specific examination. 5. Use the metric system when taking measurements. 6. Use appropriate terminology when reporting or documenting. 

Clinical Photography.  Photographs are an adjunct to documentation and promote communication among the interprofessional team. They are used to assess and monitor skin conditions and determine if the condition has improved or declined with treatment. They can be used to track moles and precancerous lesions and detect any changes early. The nurse needs to follow facility policy for obtaining a patient’s consent to photograph lesions. Inspection.  The skin is inspected for general colour and pigmentation, vascularity, bruising, and the presence of lesions or discolorations. The critical factor in assessment of skin colour is change. A skin colour that is normal for a particular patient can be a sign of a pathological condition in another patient. The most reliable areas in which to assess erythema, cyanosis, pallor, and jaundice are the areas of least pigmentation, such as sclerae, conjunctivae, nail beds, lips, and buccal mucosa. The true skin colour is best observed in photoprotected areas, such as the buttocks. Activity, sun

CHAPTER 25  Nursing Assessment: Integumentary System CASE STUDY Subjective Data A focused subjective assessment of D. A. reveals the following: •  P  ast medical history: Negative except for an appendectomy at age 16. •  M  edications: None at present. No known allergies. •  S  elf-­care: Currently washes face with a skin cleanser in the morning and at nighttime. After cleansing, applies a moisturizer with SPF 15. She has used these facial products for the past 3 years, since small age spots were first noticed. Before that, she used just soap and water. • Nutritional: D. A. reports that skin seems to be drier with age, but otherwise no changes besides the “age spots or whatever they are.” Denies any changes in the way cuts or sores heal. No weight loss. Takes 400 IU of vitamin D daily; does not take any other supplemental vitamins or minerals. • Elimination: Although skin is a little dry, does not perceive it to be excessively dry. Denies excessive sweating or any swelling. • Social, environmental, and occupational: Loves to garden and go for walks outdoors. Reports a history of frequent, sometimes severe, sunburns as a child. No use of sunscreen growing up but does remember being made to wear T-­shirts over bathing suits to help prevent sunburn. Has used sunscreen for the past 20 years when outdoors. Reapplies as needed. • Coping abilities: Denies any pain or discomfort associated with skin lesions. Fearful of the possibility of skin cancer. See Case Study: Patient Introduction and Case Study: Objective Data for more information on D. A.

GENETICS IN CLINICAL PRACTICE Skin Malignancies • T  he primary risk factor leading to skin cancers, including melanoma, is environmental exposure to UV radiation. UV radiation damages DNA, causing an error in the genetic code and resulting in abnormal skin cells (Coit et al., 2016). • Inherited genetic factors can increase the risk for skin cancer. A person has an increased risk for developing melanoma if they have a first-­ degree relative (e.g., parent, full sibling) who had a melanoma (CDA, 2021a). • The risk for skin cancer is also increased in people who have a fair complexion (light-­coloured skin that easily freckles, red or blond hair, and blue or light-­coloured eyes).

(UV) exposure, emotions, smoking, and edema, as well as respiratory, renal, cardiovascular, and hepatic disorders, can all directly affect the skin colour. In the general inspection, the nurse should note the presence of body art such as piercings and tattoos. The nose, ears, eyebrows, lips, navel, and nipples are common sites of piercing. Tattoos and needle track marks should be identified, and their location and the characteristics of the surrounding skin area noted. Tattoo pigments deposited in the skin may cause itching, pain, and sensitivity for several weeks after the tattoo is placed. The skin is examined for conditions related to vascularity, including bruising and vascular and purpuric lesions such as angioma (benign tumor of blood or lymph vessels), petechiae (tiny, flat, purplish red pinpoint lesions on skin), ecchymosis (bruise larger than petechiae), or purpura (purple-­coloured spots and patches characterized by ecchymosis or other small

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hemorrhages). The reaction to direct pressure on the lesion should be noted. If a lesion blanches on direct pressure and then refills, the redness is due to dilated blood vessels. If the discoloration stays, it is the result of subcutaneous or intradermal bleeding or a nonvascular lesion. The nurse should note any pattern of bruising, such as discoloration in the shape of the hand or fingers or bruises at different stages of resolution. These may indicate other health concerns or abuse and need further investigation. The colour, size, height, distribution, location, and shape of any lesions should be noted. Lesions may be primary or secondary lesions. Primary skin lesions develop on previously unaltered skin. The common characteristics of primary skin lesions are shown in Table 25.4. Secondary skin lesions are lesions that change with time or occur because of scratching or infection. Secondary skin lesions are shown in Table 25.5. Skin lesions are usually described in terms of their configuration (shape, whether solitary or forming a pattern in relation to other lesions) and distribution (arrangement of lesions over an area of skin) (Table 25.6). For example, herpes zoster (shingles) lesions are characteristically vesicular and have a linear distribution clustered along one or more dermatomes (Figure 25.5). Any unusual odours should also be noted. Skin sites with lesions, such as rashes, may be colonized with yeast or bacteria, which can be associated with distinctive odours in intertriginous areas (Figure 25.6), where skin surfaces overlap and rub on each other (e.g., below the breasts, axillae, and groin). The nurse needs to inspect all body hair, noting the distribution, texture, and quantity of hair. Changes in the normal distribution of body hair and growth may indicate an endocrine or vascular disorder. Any nail grooves, pitting, ridges, or detachment from nail bed should be noted. Changes in nail smoothness or thickness can occur with anemia, psoriasis, thyroid conditions, decreased vascular circulation, and some infections. Clubbing (a distortion of the nail angle at the cuticle resulting in bulbous-­appearing nails and fingertips caused by chronic hypoxemia) may occur with various respiratory and cardiac conditions.  Palpation.  Palpating the skin provides information about temperature, turgor and mobility, moisture, and texture. The nurse should use the back of their own hand to gauge skin temperature, since the skin on the back of the examiner’s hand is thinner than on the palm and more sensitive to temperature changes. The patient’s skin should be warm, not hot. Localized temperature increase occurs with burns and local inflammation. A generalized increase will result from fever. A decreased skin temperature may occur when shock or other circulatory problems, chilling, or infection is present. Turgor refers to the elasticity of the skin. Turgor is assessed by gently pinching an area of skin under the clavicle or on the back of the hand. Skin with good turgor should move easily when lifted and immediately return to its original position when released. In patients with dehydration and aging, a loss of turgor occurs and can cause tenting of the skin (Table 25.7). Skin moisture (level of dampness or dryness of the skin) increases in intertriginous areas and with high humidity and varies with environmental temperature, muscular activity, body weight, and body temperature. The skin should be intact with no flaking, scaling, or cracking. Skin generally becomes drier with increasing age.

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SECTION 4  Conditions Related to Altered Sensory Input

TABLE 25.4    PRIMARY SKIN LESIONS

TABLE 25.5    SECONDARY SKIN LESIONS

Lesion

Description

Lesion

Description

Macule

Circumscribed, flat area with a change in skin colour; 50% of body involved). Cosmetics and stains to conceal vitiliginous areas.

Hyperpigmented, brown to black, flat macule or patch. Single or multiple. Typically on sun-­ exposed areas.

Evaluate carefully for progression. Treatment (only for cosmetic purposes) is liquid nitrogen or laser resurfacing. May recur. Biopsy if suspicious of melanoma.

Acne Vulgaris Inflammatory disorder of sebaceous glands. More common in adolescents but possible development and persistence in adulthood. Flare can occur before menses, with use of corticosteroids, or with use of androgen-­dominant oral contraceptives.

Nevi (Moles) Grouping of normal cells derived from melanocyte-­like precursor cells.

Psoriasis Autoimmune chronic dermatitis. Involves excessively rapid turnover of epidermal cells. Genetic predisposition. Usually develops before age 40.

Seborrheic Keratoses Benign, familial growths. Exact etiology is unknown. Increasing number with age; no association with sun exposure.

Acrochordons (Skin Tags) Common after midlife. Appearance on neck, axillae, and upper trunk secondary to mechanical friction or redundant skin. Correlated with obesity.

Lipoma Benign tumour of adipose tissue, often encapsulated. Most common in 40-­ to 60-­yr-­old age group.

Vitiligo Unknown cause; genetically influenced. Most noticeable in dark-­skinned people and those with a tan. Complete absence of melanocytes. Noncontagious.

Lentigo Increased number of normal melanocytes in basal layer of epidermis. Related to sun exposure and aging. Also called “liver spots” or “age spots.”

PUVA, psoralen plus ultraviolet A light; UVA, ultraviolet A light; UVB, ultraviolet B light.

previously chronic, untreatable conditions. Many therapies require specialized equipment and are usually reserved for use by a dermatologist. Phototherapy.  UV light of different wavelengths may be used to treat many dermatological conditions, including

psoriasis, cutaneous T-­cell lymphoma, atopic dermatitis, vitiligo, and pruritus. One form of phototherapy involves the use of psoralen plus UVA light (PUVA). Psoralen is a photosensitizing medication given to patients for a prescribed amount of time before exposure to UVA.

CHAPTER 26  Nursing Management: Integumentary Conditions

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TABLE 26.11    SKIN CONDITIONS TREATED BY

LASER

• Acne scars • Skin lesions • Hemangiomas • Spider veins or telangiectasias • Rosacea • Pigmented nevi • Hair removal

FIG. 26.12  Psoriasis. Characteristic inflammation and scaling. Source: Habif,

T. P. (2011). Clinical dermatology: A color guide to diagnosis and therapy (5th ed.). Mosby.

Treatments are generally given two to four times a week. Adverse effects of oral psoralen include nausea and vomiting, sunburn, and persistent pruritus. Nurses should perform frequent skin assessments on all patients receiving phototherapy since erythema is an adverse effect of treatment. Topical corticosteroids may reduce painful erythema. Psoralen is used with extreme caution in patients with liver or renal disease because slower metabolism and excretion can lead to prolonged photosensitivity. Prior to initiating phototherapy, the patient should understand the risks and benefits associated with UV exposure. Patients should be cautioned about the potential hazards of using photosensitizing chemicals and of further exposure to UV rays from sunlight or artificial UV light during therapy. Because the lens of the eye absorbs psoralen, patients receiving PUVA need prescription protective eyewear that blocks 100% of UV light to prevent cataract formation. Patients should be instructed to use the eyewear for 24 hours after taking the medication when outdoors or even when near a bright window because UVA penetrates glass. Ongoing monitoring is essential because of the immunosuppressive effects of PUVA, including an increased risk of SCC, BCC, and melanoma. Photodynamic therapy is a special type of phototherapy used to treat actinic keratosis and some malignant skin tumours. This therapy uses a photosensitizing agent in a different way than other phototherapy treatments. The patient receives the photosensitizing agent intravenously or topically, depending on the area being treated. Time is allowed for the drug to be absorbed by the target cells, and light is then applied to the area, causing the medication to react with oxygen. This starts a reaction that kills the cells (Abrahamse & Hamblin, 2016).  Radiation Therapy.  The use of radiation therapy to treat BCC and SCC varies. The best candidates are patients with lesions in challenging locations, such as the ear, nose, scalp, neck, and shin; those who may have trouble with wound healing; or those with medical comorbidities who cannot undergo surgery (Stegman, 2017). Use is limited in patients with melanoma to palliative pain control or treating brain metastases. Radiation therapy usually requires multiple visits to a radiology department. It can produce permanent hair loss (alopecia) in the irradiated areas. Other adverse effects, depending on anatomical location and dose of radiation delivered, include

• Port wine stain • Vascular lesions • Tattoo removal • Rough or scarred skin • Psoriasis • Wrinkles • Pigment discoloration in epidermis

telangiectasia, atrophy, hyperpigmentation, depigmentation, ulceration, hearing impairment, ocular damage, atrophy, and mucositis. Careful shielding is necessary to prevent ocular lens damage if the irradiated area is around the eyes. (Radiation therapy is discussed in Chapter 18). Total-­body skin irradiation (in which the body is bombarded with high-­energy electrons) is one treatment for cutaneous T-­cell lymphoma. Treatment follows a lengthy course. Patients experience varying degrees of hair loss and radiation dermatitis with transient loss of sweat gland function. This treatment causes premature aging of the skin.  Laser Technology.  Laser treatment is an efficient surgical tool for many types of dermatological conditions (Table 26.11). Depending on the type of laser and the wavelength, lasers serve a wide variety of functions. Lasers are able to produce measurable, repeatable, consistent zones of tissue damage. They can cut, coagulate, and vaporize tissue to some degree. Laser light does not accumulate in body cells and cannot cause cumulative cellular changes or damage. With less damage to surrounding tissue, there is a decreased risk for scarring. The surgical use of laser energy requires a focusing device to produce a small, high-­density spot of energy. Several types of lasers are available. The CO2 laser, the most common, has numerous applications as a vaporizing and cutting tool for most tissues. The argon laser emits light that is primarily absorbed by hemoglobin. It helps in the treatment of vascular and other pigmented lesions. Other, less common lasers include copper and gold vapours and neodymium: yttrium–aluminum–garnet (Nd:YAG). Written policies and procedures should cover laser safety and be reviewed by all interprofessional team members working with laser equipment. Laser technology is increasingly being used for cosmetic treatments such as hair removal. The effectiveness of the treatment depends on a variety of factors, including choice of the correct laser equipment, training and skills of the laser operator, beam wavelength, power settings, duration of the energy pulse, and colour of the skin or hair. The patient must be informed about the risks of laser treatments, which include pain; reddened, bruised, and swollen skin; burns; infection; and temporary scarring and skin discoloration (CDA, 2021a).  Medication Therapy Antibiotics.  Antibiotics are used both topically and systemically to treat dermatological conditions, and they are often used in combination. If used, topical antibiotics should be applied lightly in a thin film to clean skin. The most common OTC topical antibiotics are polymyxin B sulphate–neomycin sulphate and bacitracin zinc (Polysporin). Prescription topical antibiotics include mupirocin (Bactroban; used for superficial Staphylococcus such as impetigo) and erythromycin (used for Gram-­positive cocci [staphylococci and streptococci] and Gram-­negative cocci and

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SECTION 4  Conditions Related to Altered Sensory Input

bacilli). Topical metronidazole (Metrogel, Flagyl) is used to treat rosacea and bacterial vaginosis. Though used historically, topical antibiotics such as clindamycin (Clindoxyl, Benzaclin) are now rarely recommended for the treatment of acne vulgaris because of ineffectiveness and concerns about antibiotic resistance (Asai et al., 2016). If there are manifestations of systemic infection, a systemic antibiotic should be used. They have a role in treating bacterial infections, such as erysipelas, cellulitis, abscesses, and certain wound infections. They are also indicated in the treatment of severe or treatment-­resistant acne vulgaris (Asai et  al., 2016). Culture and sensitivity of the lesion can guide the choice of antibiotic. The most frequently used are cephalexin (Keflex), clindamycin, erythromycin (Eryc), minocycline, and doxycycline (Apprilon, Doxycin). These medications are particularly useful for erysipelas, cellulitis, carbuncles, and severe, infected eczema (see Chapter 16). Patients require medication-­specific instructions on the proper technique of taking or applying antibiotics.  Corticosteroids.  Corticosteroids are particularly effective in treating a wide variety of dermatological conditions and can be used topically, intralesionally, or systemically. Topical corticosteroids are used for their local anti-­inflammatory action as well as for their antipruritic effects. Attempts to diagnose a lesion should be made before a corticosteroid preparation is applied because corticosteroids may alter the clinical manifestations. Once a sufficient amount of medication is dispensed, limits should be set on the duration and frequency of application. The potency of a particular preparation is related to the concentration of active drug in the preparation. With prolonged use, the more potent corticosteroid formulations can cause adrenal suppression, especially if a large surface area is covered and occlusive dressings are used. High-­ potency corticosteroids may produce adverse effects when their use is prolonged, including atrophy of the skin resulting from impaired cell mitosis and capillary fragility and susceptibility to bruising. Other adverse effects include rosacea eruptions, severe exacerbations of acne vulgaris, and dermatophyte infections. In general, dermal and epidermal atrophy does not occur until a corticosteroid has been used for 2 to 3 weeks. If medication use is discontinued at the first sign of atrophy, recovery usually occurs in several weeks. Rebound dermatitis is not uncommon when therapy is stopped; this can be reduced by tapering the use of high-­potency topical corticosteroids when the patient improves. Low-­ potency corticosteroids such as hydrocortisone act more slowly but can be used for a longer period without producing serious adverse effects. Low-­ potency corticosteroids are safe to use on the face and intertriginous areas, such as the axillae and groin. The most potent delivery system for a topical corticosteroid is an ointment form. Creams and ointments are applied in thin layers and slowly massaged into the site one to three times a day. Accurate and adequate topical therapy is often the key to a successful outcome. Intralesional corticosteroids are injected directly into or just beneath the lesion. This method provides a reservoir of medication with an effect lasting several weeks to months. Intralesional injection is commonly used in the treatment of psoriasis, alopecia areata (patchy hair loss), hypertrophic scars, and keloids. Triamcinolone acetonide (Kenalog) is the most common medication used for intralesional injection. Systemic corticosteroids can have remarkable results in the treatment of dermatological conditions. However, they often

have undesirable systemic effects (see Chapter 51). Corticosteroids can be administered as short-­term therapy for acute conditions such as contact dermatitis caused by poison ivy. Long-­term corticosteroid therapy for dermatological conditions is reserved for chronic bullous (blistering) disorders.  Antihistamines.  Oral antihistamines are helpful in treating urticaria, angioedema, and pruritus that can occur with conditions such as atopic dermatitis, contact dermatitis, and other allergic cutaneous reactions. Antihistamines compete with histamine for the receptor site, thus preventing its effects. Antihistamines may have anticholinergic or sedative effects or both. Several different antihistamines may have to be tried before the satisfactory therapeutic effect is achieved. Sedating antihistamines such as hydroxyzine hydrochloride and diphenhydramine (Benadryl) are often preferred for pruritus because the tranquilizing and sedative effects offer symptomatic relief. The patient should be warned about sedative effects, a particular problem when driving or operating heavy machinery. Antihistamines such as fexofenadine (Allegra), cetirizine (Reactine), and loratadine (Claritin) bind to peripheral histamine receptors, providing antihistamine action without sedation. These nonsedating antihistamines are generally not effective for controlling pruritus. Antihistamines should be used with caution in older people because of the medications’ long half-­life and their anticholinergic effects.  Topical Fluorouracil.  Fluorouracil (Efudex) is a topical cytotoxic agent with selective toxicity for sun-­damaged cells. It is used for the treatment of premalignant (especially actinic keratosis) and some malignant skin diseases. Because systemic absorption of the drug is minimal, systemic adverse effects are virtually nonexistent. Patient adherence can be a challenge because fluorouracil causes erythema and pruritus within 3 to 5 days and painful, eroded areas over the damaged skin within 1 to 3 weeks, depending on skin thickness at the site. Treatment must continue with applications one to two times a day for 2 to 4 weeks. Healing may take up to 4 weeks after medication is stopped (Luger et  al., 2017). Low-­potency topical steroids are often prescribed and can increase patient adherence to therapy and can be applied 20 minutes after fluorouracil application. Because fluorouracil is a photosensitizing medication, the patient must be educated to avoid sunlight during treatment. Patients should also be informed of the effect of the medication, including a warning that they will look worse before they look better. Adherence depends on thoroughness of the instruction, which should include a written handout. After effective treatment, treated skin is smooth and free of actinic keratosis. Recurrence in treated areas is possible, and multiple courses of therapy may be necessary over the years for individuals with severely sun-­damaged skin.  Immunomodulators.  Topical immunomodulators, such as pimecrolimus (Elidel) and tacrolimus (Protopic), are used to treat atopic dermatitis, psoriasis, and rosacea (Luger et al., 2017). They work by suppressing an overreactive immune system. The adverse effects are minimal and may include a transient burning or feeling of heat at the application site. An increased risk of skin cancer and precancerous lesions may be associated with long-­term use of these medications. The topical immunomodulator imiquimod (Aldara P) is used to treat external genital warts, AK, and superficial BCC. It stimulates the production of α-­interferon and other cytokines to enhance cell-­mediated immunity. It boosts the immune response only where applied and is safe for transplant patients.

CHAPTER 26  Nursing Management: Integumentary Conditions

509

Most patients using this cream experience skin reactions, including redness, swelling, blistering, peeling, itching, and burning. Dosing varies depending on the type of lesion treated and the strength of medication prescribed (Habif, 2016). 

Diagnostic and Surgical Therapy Skin Scraping.  Scraping is done with a scalpel blade to obtain a sample of surface cells (stratum corneum) for microscopic inspection and diagnosis. The most common tests of skin scrapings are KOH for fungus and mineral oil examination for scabies.  Electrodesiccation and Electrocoagulation.  Electrical energy can be converted to heat by the tip of an electrode. The heat burns and destroys tissue. The major uses of this type of therapy are point coagulation of bleeding vessels to obtain hemostasis and destruction of small telangiectasias (dilation of groups of superficial capillaries and venules). Electrodesiccation uses a monopolar electrode and usually involves more superficial destruction. Electrocoagulation uses a dipolar electrode and has a deeper effect, with better hemostasis but an increased possibility of scarring. While minor electrosurgery on patients with a pacemaker poses minimal risk, the electrical energy can affect both pacemakers and internal defibrillators.  Curettage.  Curettage is the removal and scooping away of tissue using an instrument called a curette. A curette looks like a small spoon with very sharp edges. Although a curette is not usually strong enough to cut normal skin, it can remove many types of small, soft skin tumours and superficial lesions, such as warts, AK, seborrheic keratosis, and small BCCs and SCCs. The area to be curetted is anaesthetized before the procedure. The health care provider removes the lesion and then cauterizes the skin. The removed tissue is usually sent for biopsy. A dressing may be applied, and the nurse needs to teach the patient wound care. A small scar and hypopigmentation can result.  Punch Biopsy.  Punch biopsy is a common procedure used to obtain a tissue sample for histological study or to remove small lesions (Figure 26.13). The procedure is simple. The health care provider marks the biopsy area and then anaesthetizes it so that the anaesthetic will not obscure the landmarks. The health care provider then rotates the punch into the skin and removes a small cylinder of skin. The core of skin is snipped from the subcutaneous fat and appropriately preserved for examination in a fixative solution. Hemostasis is achieved with pressure or absorbable gelatin (Gelfoam) packing. Sites of 4 mm or larger are usually closed with sutures. Punch biopsies are not done below the knee if other sites are available. Circulatory changes can make evaluating the tissue sample more difficult.  Cryosurgery.  Cryosurgery is the use of subfreezing temperatures to destroy epidermal lesions. Cryosurgery is a useful treatment for common benign, precancerous conditions including common and genital warts, cutaneous tags, thin seborrheic keratoses, lentigines, actinic keratoses, BCC, and SCC. Topical liquid nitrogen is the agent most commonly used for cryosurgery (Stegman, 2017). Damage occurs in treated tissue because of intracellular ice formation. It causes the cell to rupture during thaw, leading to cell death and necrosis. The degree of damage depends on the rate of cooling and the minimum temperature achieved. Liquid nitrogen can be applied topically (directly onto the lesion) with a direct spray or cotton-­tipped applicator. Patients usually feel a stinging cold sensation. The lesion will first become swollen and red, and it may blister. A scab forms and

A

B FIG. 26.13  Punch biopsy. A, Removal of skin for diagnostic purposes. B, Specimen obtained. Source: Graham-­Brown, R., Bourke, J., & Cunliffe, T. (2008). Dermatology: Fundamentals of practice. Mosby.

falls off in 1 to 3 weeks. The skin lesion is sloughed off along with the scab. Growth of new skin follows. The low temperature of the liquid nitrogen easily destroys melanocytes, leaving an area of hypopigmentation resembling a scar in lighter skinned individuals and hyperpigmentation in darker skinned individuals (Prohaska & Badri, 2020). The size of the area to be treated may limit the use of cryotherapy. Other disadvantages of this treatment are lack of a tissue specimen for histological confirmation of cell type before destruction and potential for destruction of adjacent healthy tissue.  Excision.  Excision is an option if the lesion involves the dermis. Complete closure of the excised area usually results in a good cosmetic outcome. One type of excision is Mohs surgery (Figure 26.14), which is a microscopically controlled removal of a skin cancer. In this procedure, the health care provider removes tissue sections in thin horizontal layers. All of the specimen’s margins are examined to determine whether any malignant cells remain. Any residual tumour not removed by the first surgical excision is removed in serial excisions performed the same day. Benefits of Mohs surgery are preserving normal tissue, producing the smallest possible wound, and completely removing the cancer before surgical closure. Although this can become a lengthy procedure, it is done in an outpatient setting using local anaesthesia. 

NURSING MANAGEMENT DERMATOLOGICAL CONDITIONS AMBULATORY AND HOME CARE Dermatological conditions are not usually a primary reason for hospitalization. Nevertheless, many hospitalized patients will exhibit concurrent skin conditions that warrant nursing intervention and patient education. Nursing interventions related to dermatological conditions fall into broad categories. They are

510

SECTION 4  Conditions Related to Altered Sensory Input TABLE 26.12    MEDICATION THERAPY Common Bases for Topical Medications Agent

Therapeutic Considerations

Powder

Promotion of dryness. Lubrication of skinfold areas to prevent irritation. Common base for antifungal preparations. Patient must be protected from inhalation. Oil, alcohol, and water emulsions. Cooling and drying effect, with residual powder film after evaporation of water. Useful in subacute pruritic eruptions. Oil and water emulsions. Most common base for topical medications. Affords lubrication and protection. Oil with differing amounts of water added in suspension. Lubrication and prevention of dehydration. Petrolatum most common. Preferred for delivering high-­potency medication. Mixture of powder and ointment. Useful when drying effect necessary because moisture is absorbed. Nongreasy combination of propylene glycol and water. May contain alcohol. Used for acute exudative inflammation (e.g., poison ivy contact dermatitis).

Lotion

A

Cream Ointment

Paste Gel

B FIG. 26.14  A, Removal of melanoma by Mohs surgery. B, Following plastic surgery using a skin flap to repair defect. Source: Courtesy Peter Bonner.

applicable to many skin conditions in both inpatient and outpatient settings. A nursing care plan for the patient with chronic skin lesions is available on the Evolve website. Wet Dressings.  For superficial skin conditions that involve inflammation, itching, and infection, wet compresses (dressings) are commonly used. They are appropriate for damaged, oozing skin. Wet compresses are an excellent way to remove crusts and scabs that are adhering to the wound surface. Wet compresses provide comfort and treatment of conditions such as poison ivy, insect bites, and skin infections. It is important to understand how to do a wet dressing correctly. Unless there is a concern about water quality, tap water at room temperature is the best choice. If drinkable water is not available, filtered, bottled, or sterile water may be used. Depending on the skin concern, additives may be used. Common solutions include (1) saline, (2) Burow’s solution (Domeboro powder [aluminum acetate; calcium acetate]), (3) acetic acid (vinegar), and (4) silver nitrate (Habif, 2016). Close attention to appropriate concentrations is critical when additives are used. Wet compresses should generally be tepid (lukewarm). However, when an anti-­ inflammatory effect is desired, the wet dressing should be cool. The material for wet compresses should be four to eight layers thick and slightly larger than the area being treated. Gauze or any clean material (e.g., thin cotton sheeting, thermal underwear, tube socks) may be used. Ingenuity is sometimes required when covering odd-­shaped body parts. Gauze sponges with fillers (abdominal pads) should be avoided for this purpose because they will retain too much solution, and fibres can be left in the wound if the skin is open. Compress material is placed into fresh solution and excess liquid squeezed out. The goal is a wet compress—not simply damp and not dripping. Wet compresses are applied continuously or intermittently. When used continuously, new solution should be used as needed but no additional solution added since doing so can

alter the concentration and damage the skin. Depending on the desired effect, intermittent compresses are placed for 10 to 30 minutes two to four times a day, always using clean materials. Careful monitoring of the skin is important. If the skin appears macerated (softens and turns white), the dressings should be discontinued for 2 to 3 days. The patient should be protected from discomfort and chilling. A water-­resistant pad will help protect the mattress, linens, and furniture.  Baths.  Baths are appropriate when large body areas need to be treated. They also have sedative and antipruritic effects. Some medications, such as colloidal oatmeal (Aveeno) and sodium bicarbonate, can be added directly to the bath water. The tub should be filled enough to cover affected areas. Both the bath water and the prescribed solution should be a tepid temperature. The patient can soak for 15 to 20 minutes three or four times a day, depending on the severity of the dermatitis and the patient’s discomfort. It is important to stress to the patient that the skin must not be rubbed dry with a towel but gently patted to prevent increasing irritation and inflammation. Adding oils increases the risk for falls and should thus be avoided. To sustain the hydrating effect, cream, ointment emollients (moisturizers), or other prescribed topical agents are applied after the bath. This helps seal the moisture in the hydrated cells and increases the absorption of any topical agents.  Topical Medications.  Topical medications are commonly used to treat cutaneous conditions. The effectiveness of topical therapy depends on which base the medication is prepared in. Table 26.12 summarizes the common agents used as bases for topical preparations and their therapeutic considerations. The base selected depends on the properties needed. Creams are very versatile and most commonly prescribed. Ointments are more lubricating than creams and offer enhanced potency of the active ingredient. They may be too occlusive for conditions with high levels of exudate or in body creases. Gels work well on the scalp, where other compounds may mat the hair, and for acute exudative conditions such as poison ivy. Lotions can be a mix of water, alcohols, and oils. They are also appropriate for the scalp but may cause stinging and drying when used in skinfolds. Pastes are a compound of 50% or more powder in an ointment base. They are good for protecting the skin but are messy. A limited number of foams are available.

CHAPTER 26  Nursing Management: Integumentary Conditions Some of these medications are very costly. Proper administration, as directed, will yield best results, maintain consistency, and avoid waste. As a general rule, topical medication should be applied in a thin film to clean skin and spread evenly in a downward motion in the direction of hair growth, using a gloved hand. Thick creams will spread more easily if the skin is still damp. If a secondary dressing is going to be used, the medication may be applied directly onto a dressing. The patient and caregiver will need to be taught proper dosing, application technique, anticipated results, and common reactions. Patients and caregivers should be reminded to wash their hands with soap and water after applying topical medications at home. Occlusion with a plastic wrap is an effective way of increasing the absorption of topical corticosteroids or simple emollients. The plastic wrap traps perspiration against the outer layer of the epidermis. Applying preparations to moist skin increases absorption 10-­fold. Tape or stretch wraps can keep the plastic wrap in place. For conditions on the feet or lower legs, socks can be worn over the plastic wrap. Wraps applied multiple times daily are kept in place for 2 to 8 hours. Some patients choose to use the occlusion technique at bedtime. Occlusion is recommended with discretion because it is not appropriate in areas prone to infection, such as skin creases, or when high-­potency corticosteroids or antibiotics are used.  Control of Pruritus.  Many conditions cause pruritus, including dry skin, almost any physical or chemical stimulus to the skin (such as drugs or insects), and any scaling skin disorder. The itch sensation is carried by the same nonmyelinated nerve fibres as pain and temperature. The patient will have pain rather than an itch if the epidermis is damaged or absent. It is important to assess whether itching preceded a skin lesion. Itching can lead to scratching that results in an excoriated and inflamed lesion. The itch/scratch cycle must be broken to prevent excoriation and lichenification. Control of pruritus is also important because it is difficult to diagnose a lesion that is excoriated and inflamed. Certain circumstances make itching worse. Anything that causes vasodilation, such as heat or rubbing, should be avoided. Dryness of the skin lowers the itch threshold and increases the itch sensation. There are several approaches to help break the itch/scratch cycle. A cool environment may cause vasoconstriction and decrease itching. Hydration, wet compresses, and moisturizers (including antipruritic lotions) are normally helpful. Topical and injectable corticosteroids are occasionally ordered. Topically applied menthol, camphor, or phenol can be used to numb the itch receptors. Systemic antihistamines may provide relief while the underlying cause of the pruritus is being diagnosed and treated. The principal adverse effect of most antihistamines is sedation, although this effect may be desirable because pruritus is often worse at night and can interfere with sleep. Lichenification is a thickening of epidermis with exaggerated markings resembling a washboard. It is caused by chronic scratching or rubbing of the skin. Lichenification is often associated with atopic dermatoses and other pruritic conditions. Although any area of the body may be affected, the hands, forearms, shins, and nape of the neck are common sites. Itching may become habitual. The persistent scratching can cause excoriations. Treating the cause of the itching is the key to preventing lichenification.  Prevention of Spread.  Although most skin conditions are not contagious, infection control precautions indicate wearing gloves when working with any open wounds or lesions with

511

drainage. Procedures should be explained to avoid discouraging patients who may be sensitive about skin lesions. Careful hand hygiene and proper disposal of soiled dressings are the best means of preventing the spread of infections or infestations. The most common contagious lesions include impetigo, streptococcal infections, staphylococcal infections (e.g., MRSA), fungal infections, primary chancre, scabies, and pediculosis.  Prevention of Secondary Infections.  Open skin lesions are susceptible to invasion by other viral, bacterial, or fungal organisms. Meticulous hygiene, hand hygiene, and dressing changes are important to minimize potential for secondary infections. Patients should be warned against scratching lesions, which can cause excoriations and create a portal of entry for pathogens. The patient’s nails should be kept short to minimize trauma from scratching. Prevention of Pressure Injuries.  Prevention and treatment of pressure injuries is an important nursing role, particularly when caring for the hospitalized patient. Pressure injuries tend to develop over boney prominences and where skin and underlying tissue is in prolonged contact with a weight-­bearing surface such as a bed or chair. Risk factors include increased moisture, decreased sensation, decreased activity and mobility, poor nutritional status, and friction and shear (see Chapter 14, Table 14.14, for the Braden Scale for Predicting Pressure Sore Risk). Sites where devices (e.g., nasal prongs, masks, intravenous lines, feeding tubes) are in prolonged contact with skin also present risk for pressure injuries. Health care and other essential workers using personal protective equipment such as masks for prolonged periods may experience pressure injuries, often on the face or ears (Desai et al., 2020). Older patients are at particular risk for pressure injury and skin tears due to age-­related changes to the skin such as thinning, loss of elasticity, and decreased subcutaneous fat. A variety of devices and care strategies may be used to reduce risk of developing these injuries including offloading, frequent repositioning, and use of skin barriers. If these injuries do occur, the patient is at risk for secondary infection, pain, and loss of function. Wound care and management of these injuries may involve a variety of approaches depending on level of injury and may be complex and prolonged (see Chapter 14).  Specific Skin Care.  Nurses are often in a position to advise patients regarding skin care following simple surgical procedures such as skin biopsy, excision, and cryosurgery. Patient follow-­up should be individualized. In general, instructions include dressing changes, use of topical medications, and the signs and symptoms of infection. After a dermatological procedure, any oozing wound should be cleansed twice a day with a saline solution or as ordered by the health care provider. Soap and potable (safe for drinking) water can be used to clean a non-­ oozing wound. An antibiotic ointment or plain petroleum jelly may then be applied with a dressing that is both absorbent and nonadherent. Wounds that are kept moist and covered heal more rapidly and with less scarring. The initial crust that forms should be left undisturbed as a protective coating for the damaged skin beneath. Healing crusts that have been moisturized and protected will separate naturally from healed epidermis. A sutured wound may be covered with a variety of dressings. Sutures are generally removed within 4 to 14 days depending on the site. Sometimes alternating sutures are removed after the third day. Incision lines may require daily cleansing, usually with plain tap water. If necessary, a topical

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SECTION 4  Conditions Related to Altered Sensory Input

antibiotic is applied and the wound either covered with a dry sterile dressing or left open to air. The patient may experience some swelling and discomfort in the first 24 hours during the first phase of wound healing. Intermittent application of cold (ice packs) over the surgical dressing may reduce edema and promote comfort. Mild analgesics such as acetaminophen or a nonsteroidal anti-­inflammatory medication should control discomfort. The nurse should instruct the patient on how to differentiate normal inflammation from an infection. A slight red border during the first few days after a procedure is normal inflammation. Redness that persists longer than a week or extends beyond a 1-­cm border, a temperature above 38°C, increased pain, pronounced swelling, and purulent drainage are all signs and symptoms of a possible infection. If these occur, they should be promptly reported to the health care provider.  PSYCHOLOGICAL EFFECTS OF CHRONIC DERMATOLOGICAL CONDITIONS Emotional stress can occur for people who suffer from chronic skin conditions such as psoriasis, atopic dermatitis, or acne. The sequelae of chronic skin conditions can include social and employment problems with subsequent financial implications, a poor self-­image, challenges with sexuality, and increasing and progressive frustration. The usual lack of overt systemic illness coupled with the visibility of the skin lesions often presents a real problem to the patient. Nurses are positioned to help the patient remain optimistic and adhere to the prescribed regimen. The patient must be allowed to verbalize the “Why me?” question, even though there is no ready answer. Dermatology patient support groups are listed on the CDA website (see the Resources at the end of this chapter). These groups are extremely helpful in providing patient support and accurate educational materials. The location of lesions and scars is the determining factor with respect to cosmetic implications. Facial scars are the most damaging psychologically because they are so visible.

Creative use of cosmetics can do much to mask lesions and scarring. Individual sensitivity to product ingredients must be considered when selecting cosmetics. Oil-­free, hypoallergenic cosmetics are available and may be beneficial for the allergic patient. Rehabilitative cosmetics are available to help camouflage and de-­emphasize such lesions as vitiligo (loss of pigmentation), melasma (tan to brown patches on the face), and healed postoperative wound sites. These commercially available products are opaque, smudge resistant, and water resistant.  PHYSIOLOGICAL EFFECTS OF CHRONIC DERMATOLOGICAL CONDITIONS Scarring and lichenification are the result of chronic dermatological conditions. Scars occur when ulceration takes place and reflect the pattern of healing in the area. Scars are pink and vascular at first. With time, in lighter-­skinned people, they become avascular and white, and in individuals with darker skin, they may become hyperpigmented. Different regions of the body scar differently, such as the face and neck, which heal fairly well because they are well vascularized. Scar formation is described in Chapter 14. 

COSMETIC PROCEDURES A vast array of cosmetic procedures is available, including chemical peels, toxin injections, collagen fillers, laser surgery, breast augmentation and reduction (see Chapter 54), laser surgery, facelift, eyelid lift, and liposuction. Common cosmetic topical procedures are presented in Table 26.13. Other types of common cosmetic injection procedures include the injection of botulinum toxins (Botox), collagenase (Xiaflex), deoxycholic acid (Belkyra), and hyaluronic acid fillers (Costa et al., 2016). Transitory adverse effects such as mild redness, pain, swelling, and bruising may occur. The reasons for undergoing these procedures are as varied as the techniques. The most common reason that people suffer

TABLE 26.13    COMMON COSMETIC TOPICAL PROCEDURES Procedure

Indications

Description

Adverse Effects

Patient Teaching

Tretinoin (Retin-­A)

Improves appearance of photodamaged skin, especially fine wrinkling. Reduces actinic keratosis.

Applied initially every other day, nightly as tolerated. Treatment stopped if inflammation is severe. Maximum response in 8–12 mo.

Chemical peels

Improves appearance of aged and photodamaged skin, acne scarring, freckles, actinic and seborrheic keratoses. Smooths appearance of photodamaged and wrinkled skin, acne scarring.

Solution applied in varying amounts to the skin, causing a controlled burn. Loss of melanin occurs.

Erythema, swelling, flaking, photosensitivity, pigmentation changes. Teratogenic. Increases phototoxicity if also taking other photosensitive medications (see Table 26.2). Moderate swelling and crusting for 1 wk. Redness persisting 6–8 wk. Pink tone possible for several months. Photosensitivity. Light pink tone that resolves within 24 hr. Photosensitivity.

Apply at night as light causes photodegradation. Sunscreen (SPF 30 or higher), sun-­avoidance measures. Avoid use of abrasive or drying facial cleanser if severe sensitivity. Use sunscreen; avoid sun for 6 mo to prevent hyperpigmentation.

Photosensitivity, irritation at lower concentrations. Severe redness, oozing, and flaking skin possible with higher concentrations.

Sunscreen and sun avoidance.

Microdermabrasion

Alpha-­hydroxy acids (e.g., glycolic acid, lactic acid)

SPF, sun protection factor.

Smooths appearance of photodamaged and wrinkled skin, acne scarring.

Removal of the epidermis and top dermal layer by application of aluminum oxide or baking soda crystals. Re-­epithelialization of abraded surface then occurs. Low concentrations (50) on back, legs, and arms • Has four dysplastic nevi on back 

Diagnostic Studies • Excisional biopsy confirmed superficial spreading melanoma.

• S  entinel node biopsy results were negative. • Diagnostic tests indicate melanoma stage 1. 

Discussion Questions . W 1  hat risk factors for malignant melanoma does G. L. have? 2. What are the usual clinical manifestations associated with malignant melanoma? 3. What is the prognosis for a patient with this stage of malignant melanoma? 4. What treatment options are available for him? 5. Priority decision: What is the priority of care for G. L.? 6. How would the nurse address his anxiety about the treatment outcomes? 7. Which members of the interprofessional team might the nurse involve to support G. L.’s care? 8. What should the nurse include in the patient teaching plan to address future sun exposure? 9. Evidence-­informed practice: G. L. wants to know whether regularly applying sunscreen will reduce the risk of developing a second melanoma. How should the nurse reply?

Answers available at http://evolve.elsevier.com/Canada/Lewis/medsurg.

 REVIEW QUESTIONS The number of the question corresponds to the same-­numbered objective at the beginning of the chapter. 1. Which sun-­safety practices would the nurse include in the teaching plan for a client who has photosensitivity? (Select all that apply.) a. Wear protective clothing. b. Apply sunscreen liberally and often. c. Use tanning booths only for short durations. d. Avoid exposure to the sun, especially during midday. e. Wear any sunscreen as long as it is purchased at a drugstore. 2. What measurement is the prognosis of a client with melanoma most dependent on? a. The thickness of the lesion b. The degree of asymmetry in the lesion c. How much the lesion has spread superficially d. The amount of ulceration in the lesion 3. The nurse determines that a client with a diagnosis of which disorder is most at risk for spreading the disease? a. Tinea pedis b. Impetigo on the face c. Candidiasis of the nails d. Psoriasis on the palms and soles 4. A mother and her two children have been diagnosed with pediculosis corporis at a health centre. Which of the following is an appropriate measure in treating this condition? a. Application of pyrethrins to the body b. Topical application of an antifungal ointment

c. Moist compresses applied frequently d. Administration of systemic antibiotics 5. What is a common site for the lesions associated with atopic dermatitis? a. Buttocks b. Temporal area c. Antecubital space d. Plantar surface of the feet 6. During assessment of a client, the nurse notes on the client’s knee and elbow red, sharply defined plaques covered with silvery scales that the client reports as mildly itchy. What should the nurse recognize this finding to be? a. Lentigo b. Psoriasis c. Actinic keratosis d. Seborrheic keratosis 7. A patient with acne vulgaris tells the nurse that she has quit her job as a receptionist because she feels her appearance is disgusting to customers. Which of the following nursing diagnoses best describes this patient’s response? a. Ineffective coping resulting from insufficient social support b. Impaired skin integrity as a result of inadequate nutrition c. Anxiety resulting from unmet needs (lack of knowledge about the disease process) d. Social isolation due to alteration in physical appearance

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8. W  hat important point should client teaching after a chemical peel include? a. Avoidance of sun exposure b. Application of firm bandages c. Limitation of vigorous exercise d. Use of moist heat to prevent discomfort 1. a, b, d; 2. a; 3. b; 4. a; 5. c; 6. b; 7. d; 8. a. For even more review questions, visit http://evolve.elsevier.com/Canada/ Lewis/medsurg.

REFERENCES Abrahamse, H., & Hamblin, M. R. (2016). New photosensitizers for photodynamic therapy. Biochemical Journal, 473(4), 347–364. https://doi.org/10.1042/BJ20150942 Alberta Health Services. (2020). Laboratory testing for Lyme disease in Alberta–June 2020. https://www.albertahealthservices.ca/assets /wf/plab/wf-­provlab-­appendix-­laboratory-­testing-­of-­lyme-­disease-­in-­alberta.pdf Allford, J. (2019). Reclaiming Inuit culture one tattoo at a time. CTV News. https://www.ctvnews.ca/lifestyle/reclaiming-­inuit-­culture-­ one-­tattoo-­at-­a-­time-­1.4651750 Asai, Y., Baibergenova, A., Dutil, M., et al. (2016). Management of acne: Canadian clinical practice guidelines. Canadian Medical Association Journal, 188(2), 118–126. https://doi.org/10.1503/ cmaj.140665 Bryant, R., & Nix, D. (2016). Acute and chronic wound (5th ed.). Mosby. Canadian Cancer Society (CCS). (2021). Risk factors for non-­ melanoma skin cancer. http://www.cancer.ca/en/cancer-­ information/cancer-­type/skin-­non-­melanoma/risks/?region=on Canadian Cancer Statistics Advisory Committee. (2019). Canadian cancer statistics 2019. https://cdn.cancer.ca/-­/media/files/resear ch/cancer-­statistics/2019-­statistics/canadian-­cancer-­statistics-­2019-­en.pdf Canadian Dermatology Association (CDA). (2021a). Hair removal. https://dermatology.ca/public-­patients/hair/hair-­removal/#!/skin-­ hair-­nails/hair/hair-­removal/lasering Canadian Dermatology Association (CDA). (2021b). Indoor tanning is out. https://dermatology.ca/public-­patients/sun-­ protection/indoor-­tanning-­is-­out/ Canadian Dermatology Association (CDA). (2021c). Psoriasis. https://dermatology.ca/public-­patients/skin/psoriasis/#!/skin-­hair-­ nails/skin/psoriasis/living-­with-­psoriasis Canadian Dermatology Association (CDA). (2021d). Sun safety for every day. https://dermatology.ca/public-­patients/sun-­ protection/sun-­safety-­every-­day/ Cantrell, W. (2017). Psoriasis and psoriatic therapies. The Nurse Practitioner, 42(7), 35–39. Chalmers, S., Harwood, A., Morris, N., et al. (2019). Do tattoos impair sweating? Journal of Science and Medicine in Sport, 22(11), 1173–1174. https://doi.org/10.1016/j.jsams.2019.08.001 Chia, C. T., Neinstein, R. M., & Theodorou, S. J. (2017). Evidence-­ based medicine: Liposuction. Plastic and Reconstructive Surgery, 139(1), 267–274. https://doi.org/10.1097/PRS.0000000000002859 Coit, D., Thompson, J. A., Algazi, A., et al. (2016). Melanoma. Journal of the National Comprehensive Cancer Network, 14(4), 450–473. https://doi.org/10.6004/jnccn.2016.0051 Costa, C. R., Kordestani, R., Small, K. H., et al. (2016). Advances and refinement in hyaluronic acid facial fillers. Plastic and Reconstructive Surgery, 138(2), 233–236. https://doi.org/10.1097/ PRS.0000000000002008

Desai, S. R., Kovarik, C., Brod, B., et al. (2020). COVID-­19 and personal protective equipment: Treatment and prevention of skin conditions related to the occupational use of personal protective equipment. Journal of the American Academy of Dermatology, 83(2), 675–677. Environment and Climate Change Canada. (2017). The UV index. ht tps://www.canada.ca/content/dam/eccc/migration/main/meteo-­ weather/80b0f2af-­9697-­4bee-­ab17-­d401ebba5b4b/4281_uv_index _poster_en_print.pdf Frank, C., Sundquist, J., Hemminki, A., et al. (2017). Risk of other cancers in families with melanoma: Novel familial links. Scientific Reports, 7, 42601. https://doi.org/10.1038/srep42601 Gilpin, E. (2018). Reawakening cultural tattooing of the Northwest. Canada’s National Observer. https://www.nationalobserver.com/2 018/08/23/these-­five-­indigenous-­tattoo-­artists-­are-­reawakening-­ cultural-­practices Government of Canada. (2017a). Sunglasses. https://www.canada. ca/en/health-­canada/services/sun-­safety/sunglasses.html Government of Canada. (2017b). Sunscreens. https://www.canada.ca/en/health-­canada/services/sun-­safety/suns creens.html Government of Canada. (2019). Tanning beds and equipment. https://www.canada.ca/en/health-­canada/services/sun-­ safety/tanning-­beds-­lamps.html Green, A. C., & Olsen, C. M. (2017). Cutaneous squamous cell carcinoma: An epidemiological review. British Journal of Dermatology, 177(2), 373–381. https://doi.org/10.1111/bjd.15324 Habif, T. P. (2016). Clinical dermatology (6th ed.). Saunders. Kirlew, M., Rea, S., Schroeter, A., et al. (2014). Invasive CA-­MRSA in northwestern Ontario: A 2-­year prospective study. Canadian Journal of Rural Medicine, 19(3), 99–102. Luger, T. A., McDonald, I., & Steinhoff, M. (2017). Clinical and basic immunodermatology. Springer. Porter, J. (2015). Bad water in First Nations leads to high rate of invasive infection, doctor says. CBC News. October 26, 2015 https://www.cb c.ca/news/canada/thunder-­bay/bad-­water-­in-­first-­nations-­leads-­to-­ high-­rate-­of-­invasive-­infection-­doctor-­says-­1.3286337 Prohaska, J., & Badri, T. (2020). Cryotherapy. StatPearls. https://www.n cbi.nlm.nih.gov/books/NBK482319/ Stegman, L. (2017). Electronic brachytherapy for nonmelanoma skin cancer. Oncology Times, 39(9), 38–39. Verkouteren, J. A., Ramdas, K. H., Wakkee, M., et al. (2017). Epidemiology of basal cell carcinoma: Scholarly review. British Journal of Dermatology, 177(2), 359–372. https://doi.org/10.1111/bjd.15321

RESOURCES Canadian Cancer Society https://www.cancer.ca Canadian Dermatology Association https://www.dermatology.ca Canadian Dermatology Foundation https://www.cdf.ca Canadian Society of Aesthetic Specialty Nurses https://www.csasn.org/ Canadian Society of Plastic Surgeons https://www.plasticsurgery.ca Eczema Society of Canada https://www.eczemahelp.ca Environment and Climate Change Canada https://www.canada.ca/en/environment-­climate-­change.html International Skin Tear Advisory Panel https://www.skintears.org

CHAPTER 26  Nursing Management: Integumentary Conditions Melanoma Network of Canada https://www.melanomanetwork.ca Nurses Specialized in Wound Ostomy and Continence Canada https://nswoc.ca Psoriasis Society of Canada https://www.psoriasissociety.org Save Your Skin Foundation https://www.saveyourskin.ca Wounds Canada https://www.woundscanada.ca

National Pressure Injury Advisory Panel https://npiap.com Wounds International https://www.woundsinternational.com For additional Internet resources, see the website for this book at http://evolve.elsevier.com/Canada/Lewis/medsurg.

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CHAPTER

27

Nursing Management

Burns

Krista Gushue Originating US chapter by Cecilia Bidigare

WEBSITE http://evolve.elsevier.com/Canada/Lewis/medsurg • Review Questions (Online Only) • Key Points • Answer Guidelines for Case Study

• •

 tudent Case Study S • Burns Customizable Nursing Care Plan • Patient with Thermal Burn Injury

• C  onceptual Care Map Creator • Audio Glossary • Content Updates

LEARNING OBJECTIVES 1. Explain the causes of burn injuries and prevention strategies. 2. Differentiate between partial-­and full-­thickness burns. 3. Apply the parameters used to determine the severity of burns. 4. Compare the pathophysiological processes, clinical manifestations, complications, and interprofessional management throughout the three burn phases. 5. Compare the fluid and electrolyte shifts during the emergent and the acute burn phases. 6. Differentiate the nutritional needs of the patient with a burn injury throughout the three burn phases.

7. Compare the various burn wound care techniques and surgical options for partial-­thickness versus full-­thickness burn wounds. 8. Prioritize nursing interventions in the management of the physiological and psychosocial needs of the patient throughout the three burn phases. 9. Examine the various physiological and psychosocial aspects of burn rehabilitation. 10. Design a plan of care to prepare the burn patient and family for discharge.

KEY TERMS burn chemical burns contracture cultured epithelial autograft (CEA)

  

debridement electrical burns escharotomy excision and grafting

A burn is an injury to the tissues of the body caused by heat, chemicals, electric current, or radiation. The resulting effects are influenced by the temperature of the burning agent, the duration of contact time, and the type of tissue that is injured. A burn injury occurs in more than two to three million people in North America each year (Arno & Knighten, 2020). There is a lack of current, precise data on the number of Canadians burned each year. According to Statistics Canada (Billette & Janz, 2015), 127 000 Canadians over the age of 12 years stated that they had an activity-­limiting injury due to a burn, scald, or chemical burn in the previous 12 months. The highest incidence occurred within the 20-­to 64-­year age group, and treatment occurred predominantly in the emergency department. An estimated 486 000 Americans seek medical care each year for burns (American Burn Association [ABA], 2016).

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full-­thickness burn partial-­thickness burn smoke and inhalation injuries thermal burns

Accounting for the 2016 population difference between the United States and Canada (324 million versus 36 million), the burn incidence data appear to be similar. Around the world, nearly 11 million people need medical attention annually for burn injuries, and about 180 000 die as a result of burns (World Health Organization, 2018). Although burn incidence has decreased over the past 20 years, burn injuries still occur too frequently, mainly to persons living at lower socioeconomic levels and with histories of substance misuse or mental illness. Most burn incidents are preventable (Grant, 2017). The focus of burn prevention has shifted from blaming individuals and changing behaviours to making legislative changes and collecting global burn data to address the unique prevention needs of low-­and middle-­income countries (Peck & Tophi, 2020).

CHAPTER 27  Nursing Management: Burns TABLE 27.1    COMMON LOCATIONS AND

SOURCES OF BURN INJURY*

Home Hazards Kitchen and Bathroom

• Flammables (e.g., starter fluid, gasoline, kerosene) • Carelessness with cigarettes, matches, candles

TABLE 27.2    TYPES OF BURN INJURY AND

BURN RISK–REDUCTION STRATEGIES Inhalation

Flame or Contact

*List is not all-­inclusive.

• Never smoke in bed. • Use child-­resistant lighters. • Hold regular fire exit drills in the home. • Never leave hot oil unattended while cooking. • Never use gasoline or other flammable liquids to start a fire. • Never leave candles unattended or near open windows or curtains. • Consider a flame-­retardant smoking apron for older or at-­risk people. • Exercise caution when microwaving food and beverages as they can get very hot.

Coordinated national programs in developed countries have focused on use of child-­resistant lighters, nonflammable children’s clothing, tap water anti-­scald devices, stricter building codes, hard-­ wired smoke detectors and alarms, and fire sprinklers. Nurses can advocate for and teach about burn risk–reduction strategies in the home and at work (Tables 27.1 and 27.2).

• Lower hot water temperature to the “lowest point” or 40°C. • Use “anti-­scald” devices with showerhead or faucet fixtures. • Supervise bathing of small children, older persons, or anyone with impaired physical movement, physical sensation, or judgement. • After running bath water, check temperature with back of hand or bath thermometer.

• Microwaved food • Steam, hot grease, or liquids from cooking • Hot water heaters set at 60°C or higher

General Household • Heat lamps • Fireplaces (e.g., gas, wood) • Open space heaters • Radiators (e.g., home, automobile) • Outdoor grills (e.g., propane, charcoal) • Frayed or defective wiring • Multiple extension cords per outlet

Occupational Hazards • Tar • Cement • Chemicals • Hot metals • Steam pipes • Combustible fuels • Fertilizers, pesticides • Electricity from power lines • Sparks from live electric sources

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Scald

• Install smoke and carbon monoxide detectors and change batteries annually (if appropriate).

Chemical

• Store chemicals safely in approved containers and label clearly. • Ensure safety of workers and students handling chemicals (e.g., provide education, protective eyewear, gloves, masks, clothing).

Electrical

• Avoid or repair frayed wiring. • Avoid outdoor activities during electrical (i.e., lightning) storms. • Ensure electrical power source is shut off before beginning repairs. • Wear protective eyewear and gloves when making electrical repairs.

TYPES OF BURN INJURY Thermal Burns Thermal burns are caused by flame, flash fire, scald, or contact with hot objects. They are the most common type of burn injury (Figure 27.1; see Table 27.2). The severity depends on the temperature of the burning agent and duration of contact time. Scald injuries can occur in the bathroom or while cooking. Flash, flame, or contact burns can occur while cooking, smoking, burning leaves in the backyard, or using gasoline or hot oil. 

Chemical Burns Chemical burns are the result of contact with acids and alkalis. Acids can be found in the home and at work—in car batteries, bleach, chemical laboratories, vinegar, and glass polish. The chemical compounds include hydrochloric, sulphuric, acidic, and hydrofluoric acid. Alkali substances are found in cement, drain cleaners, cleaning agents, and fertilizer and include calcium hydroxide (lime), ammonia, or ammonia hydroxide (Ramponi, 2017).  Smoke and Inhalation Injury Smoke and inhalation injuries from breathing noxious chemicals or hot air can cause damage to the tissues of the respiratory tract. Fortunately, gases are cooled to body temperature before they reach the lung tissue. The vocal cords and glottis close as a protective mechanism, so damage to the respiratory mucosa occurs less often. Smoke inhalation injuries are a major predictor of mortality in burn patients. Rapid initial and

TABLE 27.3    MANIFESTATIONS OF

RESPIRATORY INJURY ASSOCIATED WITH BURNS

Upper Airway Injury Edema, hoarseness, difficulty swallowing, copious secretions, stridor, substernal and intercostal retractions, total airway obstruction

Lower Airway Injury Strongly assumed if patient was trapped in a fire in an enclosed space or clothing caught fire and if patient has facial burns or singed nasal or facial hair; symptoms include dyspnea, carbonaceous sputum, wheezing, hoarseness, altered mental status

ongoing assessment are critical (Table 27.3). Prompt assessment for signs and symptoms of airway compromise is imperative because severe edema, bronchospasm, or a mucous plug can occur within minutes to days after the initial exposure (Dyamenahalli, 2019). There are three types of smoke and inhalation injuries: 1. Carbon monoxide poisoning. Carbon monoxide poisoning and asphyxiation account for the majority of deaths at a fire scene. Carbon monoxide is produced by the incomplete combustion of burning materials. It is subsequently inhaled and displaces oxygen (O2) on the hemoglobin molecule, causing carboxyhemoglobinemia, hypoxia, and, when the carbon monoxide levels exceed 20%, death. With severe

520

SECTION 4  Conditions Related to Altered Sensory Input

A

A

B

B FIG. 27.2 Electrical injury produces heat coagulation of the blood supply

and contact area as electric current passes through the skin. A, Back and buttock (arrows). B, Leg (arrow). Source: Courtesy Judy A. Knighton, RN, MScN, Toronto.

C FIG. 27.1 Types of burn injury. A, Superficial, partial-­thickness scald burn to

thigh. B, Deep partial-­thickness flame burn to hand. C, Full-­thickness flame burn secondary to posterior chest and arm. Source: Courtesy Judy A. Knighton, RN, MScN, Toronto.

carbon monoxide poisoning, skin colour is often described as “cherry red” in appearance. Carbon monoxide poisoning may occur in the absence of burn injury to the skin (e.g., smoke inhalation during a fire). 2. Inhalation injury above the glottis. In general, an inhalation injury above the glottis (upper airway injury) is thermally produced and may be caused by the inhalation of hot air, steam, or smoke. Mucosal burns of the oropharynx and larynx are manifested by redness, blistering, and edema. Mechanical obstruction can occur quickly, which represents a true medical emergency. Clues to the occurrence of this injury include the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, and clothing burns around the chest and neck. 3. Inhalation injury below the glottis. An inhalation injury below the glottis (lower airway injury) is usually chemically produced. Tissue damage is related to the duration of exposure to smoke or toxic fumes. Clinical manifestations such as pulmonary edema may not appear until 12 to 24 hours after the burn, and then they may manifest as acute respiratory distress syndrome (see Chapter 71). 

Electrical Burns Electrical burns result from intense heat generated from an electric current and are considered the most severe type of thermal trauma, generally associated with greater damage of functional structures, such as muscle and bone (Foncerrada et  al., 2017). Direct damage to nerves and vessels can cause tissue anoxia and death. The severity of the electrical injury depends on the amount of voltage, tissue resistance, current pathways, surface area in contact with the current, and length of time that the current flow was sustained (Figure 27.2). Tissue density affects the amount of resistance to electric current. For example, fat and bone offer the most resistance, whereas nerves and blood vessels offer the least resistance. Current that passes through vital organs (e.g., brain, heart, kidneys) produces more life-­threatening sequelae than that which passes through other tissues. In addition, electric sparks may ignite the patient’s clothing, causing a flame injury. As with inhalation injury, a rapid assessment of the patient with an electrical injury should be performed. Transfer to a burn centre is indicated. The severity of an electrical injury can be difficult to determine since most of the damage is below the skin (known as the iceberg effect). Determination of electric current contact points and history of the injury may help reveal the likely path of the current and potential areas of injury. Contact with electric current can cause muscle contractions strong enough to fracture the long bones and vertebrae. Another reason to suspect long bone or spinal fractures is a fall resulting from the electrical injury. For this reason, all patients with electrical burns should be considered at risk for a cervical spine injury. Cervical spine immobilization is used during transport and subsequent diagnostic testing until injury is ruled out.

CHAPTER 27  Nursing Management: Burns Electrical injury can range from minor skin burns to life-­ threatening injuries. Cardiac arrhythmias are the most common complication from electric shock and can be sudden or delayed. Delayed arrythmias can occur without warning during the first 24 hours after injury. Ventricular fibrillation and sudden cardiac death can be caused by both high-­and low-­voltage currents (Waldmann et  al., 2018). Direct nerve damage can result and manifest as a peripheral nerve injury, spinal cord damage, cerebellar ataxia, hypoxic encephalopathy, or intracerebral hemorrhage (Yang et al., 2018). Myoglobin from injured muscle and hemoglobin from damaged red blood cells (RBCs) are released into the circulation whenever massive muscle and blood vessel damage occurs. The released myoglobin travels to the kidneys and can block the renal tubules. This can result in acute tubular necrosis (ATN) and acute kidney injury (see Chapter 49). 

521

Guidelines” (see Table 27.4). A list of provincial burn units and centres across Canada is provided in Table 27.5. Goals of care include wound healing, prevention of infection, pain management, prevention of complications, and return to preinjury function.

Depth of Burn Burn injury involves the destruction of the integumentary system. The skin is divided into three layers: epidermis, dermis, and subcutaneous tissue (Figure 27.3; see Figure 25.1). The epidermis, or nonvascular outer layer of the skin, is approximately as thick as a sheet of paper. It is composed of many layers of nonliving epithelial cells that provide a protective barrier to the skin, hold in fluids and electrolytes, help regulate body temperature, and keep harmful agents in the external environment from

Cold Thermal Injury Cold thermal injury, or frostbite, is discussed in Chapter 72. 

TABLE 27.5    CANADIAN BURN UNITS OR

CLASSIFICATION OF BURN INJURY

Province

City

Hospital

Treatment of burns is related to the severity of the injury. Severity is determined by (a) depth of burn, (b) extent of burn calculated in percentage of total body surface area (TBSA), (c) location of burn, and (d) patient risk factors (e.g., age, past medical history). Health Canada uses referral criteria to determine which burn injuries should be treated in burn centres (Table 27.4). Critical Care Services Ontario (CCSO) has adapted the American Burn Association (ABA) “Burn Center Referral Criteria” to develop “Burns Centre Consultation

Alberta

Calgary Calgary

Calgary Foothills Medical Centre Alberta Children’s Hospital Burn Treatment Services Edmonton Firefighters’ Burn Treatment Unit B.C. Professional Fire Fighters’ Burn, Trauma, and High Acuity Unit, Vancouver General Hospital B.C. Children’s Hospital Burn Unit Complex Wound and Burn Clinic, Royal Jubilee Hospital Manitoba Firefighters’ Burn Unit Winnipeg Children’s Hospital Burn Unit Saint John Regional Hospital Plastic and Burns Unit General Hospital Health Sciences Centre Queen Elizabeth II Health Sciences Centre IWK Health Centre Hamilton Health Sciences Centre Burn Unit London Health Sciences Centre Burn Unit Children’s Hospital of Eastern Ontario Hospital for Sick Children (Sick Kids) Burn Unit Sunnybrook Health Sciences Centre Ross Tilley Burn Centre Hôtel-­Dieu du CHUM Montreal Burn Unit CHU Sainte-­Justine Burn Clinic McGill University Health Centre Centre d’expertise pour victimes de brulures graves de l’Est du Québec Hôpital de L’Enfant-­Jésus du CHU de Québec Unité des grands brûlés South Saskatchewan Firefighters’ Burn Unit Royal University Hospital

TABLE 27.4    CRITERIA FOR TRANSFER OF THE

PATIENT WITH BURN INJURIES*

Consider transfer to a major burn centre: • ≥20% TBSA partial-­ and/or full-­thickness at any age • ≥10% TBSA partial-­ and/or full-­thickness for ages ≤10 and ≥50 years • Full-­thickness burns ≥5% TBSA at any age • Burns to face, hands, feet, joints, genitalia, perineum • Electrical burns [including lightning injury] • Chemical burns • Inhalation injury • Burns with comorbidity • Burns with patients who require special social, emotional, or rehabilitation care Consider transfer to a minor burn centre: • Burns >10% but 15% TBSA. 14. Elevate burned limb above level of heart to decrease edema. 15. Administer IV analgesic drug and assess effectiveness frequently. 16. Contact poison control centre for assistance.

Ongoing Monitoring • Monitor airway if patient was exposed to chemicals. • Monitor urine output. • Consider possibility of systemic effect of identified chemical, and monitor and treat accordingly. • Monitor pH of eye if eye was exposed to chemicals. • Monitor pain level. IV, intravenous; TBSA, total body surface area.

CHAPTER 27  Nursing Management: Burns

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TABLE 27.8    EMERGENCY MANAGEMENT Inhalation Injury Cause

Assessment Findings

Interventions

• Exposure of respiratory tract to intense heat or flames • Inhalation of noxious chemicals, smoke, or carbon monoxide

• History of being trapped in an enclosed space, of being in an explosion, or of clothing catching fire • Rapid, shallow respirations • Increasing hoarseness • Coughing • Singed nasal or facial hair • Darkened oral or nasal membranes • Smoky breath • Carbonaceous sputum • Productive cough with black, grey, or bloody sputum • Irritation of upper airways or burning pain in throat or trunk • Difficulty swallowing • Cherry-­red skin colour (carbon monoxide levels >20%) • Restlessness, anxiety • Altered mental status, including confusion, coma • Decreased oxygen saturation • Dysrhythmias

Initial 1. If unresponsive, assess circulation, airway, and breathing. 2. If responsive, monitor airway, breathing, and circulation. 3. Stabilize cervical spine. 4. Assess for inhalation injury. 5. Assess for concurrent thermal burn. 6. Provide 100% humidified oxygen. 7. Monitor vital signs, level of consciousness, oxygen saturation, and cardiac rhythm. 8. Remove nonadherent clothing, jewellery, and, if face was exposed, glasses or contact lenses. 9. Establish IV access with two large-­bore catheters if burn >15% TBSA. 10. Begin fluid replacement. 11. Insert urinary catheter if burn >15% TBSA. 12. Elevate burned limb(s) above level of heart to decrease edema. 13. Measure arterial blood gas and carboxyhemoglobin levels, and obtain chest radiograph. 14. Administer IV analgesic drug and assess effectiveness frequently. 15. Identify and treat other associated injuries (e.g., fractures, pneumothorax, head injury). 16. Cover burned areas with dry dressings or clean sheet if TBSA is large or patient is hypothermic; can cover with normal saline–moistened gauze and clean sheet if TBSA is small. 17. Anticipate need for fibre-­optic bronchoscopy or intubation.

Ongoing Monitoring • Monitor airway, breathing, and circulation. • Monitor urine output. • Monitor vital signs, level of consciousness, respiratory status, oxygen saturation, and cardiac rhythm. • Monitor pain level. IV, intravenous; TBSA, total body surface area.

(see Chapter 69). If it is not corrected, irreversible shock and death may result. The circulatory status is also impaired because of hemolysis of RBCs. The RBCs are hemolyzed by circulating factors (e.g., oxygen free radicals) released at the time of the burn, as well as by the direct insult of the burn injury. Thrombosis in the capillaries of burned tissue causes an additional loss of circulating RBCs. Elevation of the hematocrit is commonly caused by hemoconcentration, which results from fluid loss. After fluid balance has been restored, hematocrit levels lower as a result of dilution. Major shifts in sodium and potassium also occur during this phase. Sodium rapidly shifts to the interstitial spaces and remains there until edema formation ceases (Figure 27.7). A potassium shift develops initially because injured cells and hemolyzed RBCs release potassium into the circulation. (Fluid and electrolyte shifts are discussed in Chapter 19.) Toward the end of the emergent phase, capillary membrane permeability is restored if fluid replacement is adequate. Fluid loss and edema formation cease. Interstitial fluid gradually returns to the vascular space (see Figure 27.7). Clinically, diuresis is noted with low urine specific gravities.  Inflammation and Healing.  Burn injury causes coagulation necrosis, in which tissues and vessels are damaged or destroyed. Neutrophils and monocytes accumulate at the site of injury. Fibroblasts and newly formed collagen fibrils appear and

begin wound repair within the first 6 to 12 hours after injury. (The inflammatory response is discussed in Chapter 14.)  Immunological Changes.  Burn injury causes widespread impairment of the immune system. The skin barrier to invading organisms is destroyed, bone marrow depression occurs, and circulating levels of immunoglobulins decrease. The function of white blood cells (WBCs) becomes defective. The inflammatory cytokine cascade triggered by tissue damage impairs the function of lymphocytes, monocytes, and neutrophils. This impaired function increases the patient’s risk for infection.  Clinical Manifestations.  Patients with burns are likely to be in shock from hypovolemia. In many cases, areas of full-­ thickness and deep partial-­thickness burns are initially anaesthetic because nerve endings have been destroyed. Superficial to moderate partial-­thickness burns are painful. Blisters, filled with fluid and protein, may develop in partial-­thickness burns. Fluid is not actually lost from the body as much as it is sequestered in the interstitium and third spaces. Patients with a larger burn area may have signs of adynamic ileus, such as absent or decreased bowel sounds, as a result of the body’s response to massive trauma and potassium shifts. Shivering may occur as a result of chilling caused by heat loss, anxiety, or pain. Ongoing nursing assessment of the ABCs, vital signs, cardiac rhythm, oxygenation, and level of consciousness are priorities during the emergent phase of burn care.

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SECTION 4  Conditions Related to Altered Sensory Input

TABLE 27.9    EMERGENCY MANAGEMENT Electrical Burns Cause

Assessment Findings

Interventions

Alternating Current

• Leathery, white, or charred skin • Burn odour • Loss of consciousness • Impaired touch sensation • Minimal or no pain • Dysrhythmias • Cardiac arrest • Location of contact points • Diminished peripheral circulation in injured extremity • Thermal burns if clothing ignited • Fractures or dislocations from force of current • Head or neck injury if fall occurred • Depth and extent of wound difficult to visualize (injury should be presumed more severe than what is seen)

Initial

• Electrical wires • Utility wires

Direct Current • Lightning • Defibrillator

1. Remove patient from electric source while protecting rescuer. 2. If unresponsive, assess circulation, airway, and breathing. 3. If responsive, monitor airway, breathing, and circulation. 4. Stabilize cervical spine. 5. Provide supplemental oxygen as needed. 6. Monitor vital signs, level of consciousness, respiratory status, oxygen saturation, and cardiac rhythm. 7. Check pulses distal to burns. 8. Remove nonadherent clothing, shoes, watches, jewellery, and, if face was exposed, glasses or contact lenses. 9. Cover burned areas with dry dressing or clean sheet if TBSA is large or patient is hypothermic; can cover with normal saline–moistened gauze and dry sheet if TBSA is small. 10. Establish IV access with two large-­bore catheters if burn >15% TBSA. 11. Begin fluid replacement. 12. Measure arterial blood gas to assess acid–base balance. 13. Insert urinary catheter if burn >15% TBSA. 14. Elevate burned limb(s) above level of heart to decrease edema. 15. Administer IV analgesic drug and assess effectiveness frequently. 16. Identify and treat other associated injuries (e.g., fractures, pneumothorax, head injury).

Ongoing Monitoring • Monitor airway, breathing, and circulation. • Monitor vital signs, cardiac rhythm, level of consciousness, respiratory status, oxygen saturation, and neuro-­vascular status of injured limbs. • Monitor urine output. • Monitor serum creatine kinase for development of myoglobinuria secondary to muscle breakdown and urine for hemoglobinuria secondary to RBC breakdown. • Anticipate possible administration of NaHCO3 to alkalinize the urine and maintain serum pH >6.0. • Monitor pain level. IV, intravenous; NaHCO3, sodium bicarbonate; RBC, red blood cell; TBSA, total body surface area.

Most patients with burn injuries are quite alert and can provide answers to questions shortly after the injury or until they are intubated. They are often frightened and benefit from calm reassurance and simple explanations by all health care providers. Unconsciousness or altered mental status in a patient with burn injury is usually not a result of the burn. The most common reason for unconsciousness or altered mental status is hypoxia associated with smoke inhalation. Other possibilities include head trauma, history of substance misuse, or excessive amounts of sedation or pain medication.  Complications.  The three major organ systems most susceptible to complications during the emergent phase of burn injury are the cardiovascular, respiratory, and urinary systems. Cardiovascular System.  Cardiovascular system complications include dysrhythmias and hypovolemic shock, which may progress to irreversible shock. Circulation to the extremities can be severely impaired by deep, circumferential burns and subsequent edema formation. These processes occlude the blood supply by acting like a tourniquet. If they are untreated, ischemia, paresthesias, and necrosis can occur. To restore circulation to compromised extremities, an escharotomy (a scalpel or electrocautery incision into necrotic tissue)

is frequently performed after the patient’s transfer to a burn unit (Figure 27.8). Initially, blood viscosity increases with burn injuries because of fluid loss occurring in the emergent period. Microcirculation is impaired because of damage to skin structures containing small capillary systems. These two events result in a phenomenon termed sludging. Sludging can be corrected by adequate fluid replacement.  Respiratory System.  The respiratory system is especially vulnerable to two types of injury: (a) upper airway burns, which cause edema formation and obstruction of the airway, and (b) lower airway injury (see Table 27.3). Upper airway distress may occur with or without smoke inhalation, and airway injury at either level may occur in the absence of burn injury to the skin. Upper Airway Injury.  Upper airway injury results from an inhalation injury to the mouth, oropharynx, or larynx. The injury may be caused by thermal burns or the inhalation of hot air, steam, or smoke. Mucosal burns of the oropharynx and larynx are manifested by redness, blistering, and edema. The swelling can be massive, and the onset rapid. Flame burns to the neck and chest may make breathing more difficult because of burn eschar, which becomes tight and constricting from underlying edema. Swelling from scald burns to the face and neck can also

CHAPTER 27  Nursing Management: Burns

527

TABLE 27.10    EMERGENCY MANAGEMENT Thermal Burns Cause

Assessment Findings

Interventions

• Hot liquids or solids • Flash flame • Open flame • Steam • Hot surface • UV rays

Partial-­Thickness Burn Superficial; First-­Degree Burn

Initial

• Redness • Pain • Moderate to severe tenderness • Minimal edema • Blanching with pressure

Deep; Second-­Degree Burn • Moist blebs, blisters • Mottled white, pink to cherry red • Hypersensitive to touch or air • Moderate to severe pain • Blanching with pressure

Full-­Thickness; Third-­ or Fourth-­Degree Burn • Dry, leathery eschar • White, waxy, dark brown, or charred appearance • Strong burn odour • Impaired sensation when touched • Absence of pain with severe pain in surrounding tissues • Lack of blanching with pressure

1. If unresponsive, assess circulation, airway, and breathing. If responsive, monitor airway, breathing, and circulation. 2. Stabilize cervical spine. 3. Assess for inhalation injury. 4. Provide supplemental oxygen as needed. 5. Anticipate endotracheal intubation and mechanical ventilation with circumferential, full-­thickness burns to the neck, trunk, or both or with large TBSA. 6. Monitor vital signs, level of consciousness, respiratory status, oxygen saturation, and cardiac rhythm. 7. Remove nonadherent clothing, shoes, watches, jewellery, and, if face was exposed, glasses or contact lenses. 8. Cover burned areas with dry dressings or clean sheet if TBSA is large or patient is hypothermic; cover with normal saline–moistened gauze and dry sheet if TBSA is small. 9. Establish IV access with two large-­bore catheters if burn >15% TBSA. 10. Begin fluid replacement. 11. Insert urinary catheter if burn >15% TBSA. 12. Elevate burned limb(s) above level of heart to decrease edema. 13. Administer IV analgesic drug and assess effectiveness frequently. 14. Identify and treat other associated injuries (e.g., fractures, pneumothorax, head injury).

Ongoing Monitoring • Monitor airway, breathing, and circulation. • Monitor vital signs, cardiac rhythm, level of consciousness, respiratory status, and oxygen saturation. • Monitor urine output. • Monitor pain level. IV, intravenous; TBSA, total body surface area; UV, ultraviolet.

be lethal, as can external pressure from edema pressing on the airway. Mechanical obstruction can occur quickly, presenting a true airway emergency. The patient must be carefully assessed for facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, and clothing burns around the neck and trunk.  Lower Airway Injury.  An inhalation injury to the trachea, bronchioles, and alveoli is usually caused by breathing in toxic chemicals or smoke. Tissue damage is related to the duration of exposure to toxic fumes or smoke. Clinical manifestations of lower airway lung injury are presented in Table 27.3. Pulmonary edema may not appear until 12 to 48 hours after the burn and may manifest as acute respiratory distress syndrome (ARDS) (see Chapter 71).  Other Cardiopulmonary Complications.  Burn-­injured patients with pre-­existing heart disease (e.g., myocardial infarction) or lung disease (e.g., chronic obstructive pulmonary disease) are at risk for complications. If fluid replacement is too vigorous, these patients can develop heart failure or pulmonary edema. Invasive measures (e.g., hemodynamic monitoring) may be necessary to monitor fluid resuscitation. Burn-­injured patients with pre-­existing respiratory conditions are more likely to develop a respiratory infection.

Pneumonia is a common complication of major burns and the leading cause of death in patients with inhalation injury. Debilitation, abundant microbial flora, and relative immobility predispose such patients to development of pneumonia.  Urinary System.  The most common complication of the urinary system in the emergent phase is ATN. If the patient becomes hypovolemic, blood flow to the kidneys decreases, causing renal ischemia. If the decreased flow rate continues, acute kidney injury may develop. With full-­thickness and electrical burns, myoglobin (from muscle cell breakdown) and hemoglobin (from RBC breakdown) are released into the bloodstream and occlude renal tubules. Adequate fluid replacement and diuretics can counteract myoglobin and hemoglobin obstruction of the tubules. 

NURSING AND INTERPROFESSIONAL MANAGEMENT EMERGENT PHASE

In the emergent phase, patient survival depends on rapid and thorough assessment and intervention (Fahlstrom et al., 2013). The nurse and physician make the initial assessment of depth and extent of the burn and coordinate the actions of the health care team. In a community hospital, decisions must be made as to whether the patient requires inpatient or outpatient care and, in the case of inpatient care, whether the patient remains in that

528

SECTION 4  Conditions Related to Altered Sensory Input Extracellular space

PATHOPHYSIOLOGY MAP

Capillary

BURN

Na Capillary seal lost

↑ Vascular permeability

K H2O Na Albumin

Cell

H2O ↓ Intravascular volume

Edema

Na Cell

Albumin K ↓ Blood volume

↑ Hematocrit

Na FIG. 27.7  The effects of burn shock are shown above the dotted line. As

↑ Viscosity

↑ Peripheral resistance

the capillary seal is lost, interstitial edema develops. The cellular integrity is also altered, with sodium (Na) moving into the cell in abnormal amounts and potassium (K) leaving the cell. The shifts after the resolution of burn shock are shown below the dotted line. The water and sodium move back into the circulating volume through the capillary. The albumin remains in the interstitium. Potassium is transported into the cell, and sodium is transported out as the cellular integrity returns.

Burn shock FIG. 27.5 At the time of a major burn injury, there is increased capillary

permeability. All fluid components of the blood begin to leak into the interstitium, causing edema and a decrease in blood volume. Hematocrit increases, and the blood becomes more viscous. The combination of decreased blood volume and increased viscosity produces increased peripheral resistance. Burn shock, a type of hypovolemic shock, rapidly ensues, and, if it is not corrected, death can result.

FIG. 27.8  Escharotomies of the anterior chest and arm (indicated by arrows). Source: Courtesy Judy A. Knighton, RN, MScN, Toronto.

A

B

FIG. 27.6  A, Facial edema before fluid resuscitation. B, Facial edema after 24 hours. Source: Courtesy Judy Knighton, Toronto, Canada.

hospital or is transferred to the closest regional burn unit (see Table 27.5). From the onset of the burn event until the patient is stabilized, nursing and interprofessional management consist predominantly of airway management, fluid therapy, and wound care (Table 27.11). Although burn management can be chronologically categorized as emergent, acute, and rehabilitative, overall care requirements are not so easily classified. Depending on the severity of the patient’s condition, the duration of time spent in each phase varies greatly, and conditions improve and worsen unpredictably on a daily basis. Care changes accordingly. Whereas physiotherapy and occupational therapy are a focus of the acute and rehabilitative phases, proper positioning and splinting begin at the time of admission. Support and teaching of patients and caregivers begin on admission and intensify in the rehabilitative phase. See the accompanying nursing care

CHAPTER 27  Nursing Management: Burns

529

TABLE 27.11    INTERPROFESSIONAL CARE Patient With Burn Injury Emergent Phase

Acute Phase

Rehabilitation Phase

Fluid Therapy

Fluid Therapy

• Assess fluid needs.* • Begin IV fluid replacement. • Insert urinary catheter. • Monitor intake and output.

• Continue to monitor intake and output. • Continue to replace fluids, depending on patient’s clinical response.

Wound Care

• Continue daily shower and wound care. • Assess wound daily and adjust dressing protocols as necessary. • Observe for complications (e.g., infection). • Continue debridement (if necessary).

• Continue to counsel and teach patient and caregiver about wound care. • Discuss possible need for home care to continue wound care in the community. • Continue to counsel and teach patient and family. • Continue to encourage and assist patient in resuming self-­care. • Continue to prevent or minimize contractures (surgery, physiotherapy and occupational therapy, splinting, or pressure garments), and assess likelihood for scarring. • Discuss possible reconstructive surgery. • Prepare for discharge home or transfer to rehabilitation unit or hospital.

• Start daily shower/cleansing and wound care. • Debride as necessary. • Assess extent and depth of burns. • Administer tetanus toxoid or tetanus antitoxin.

Pain and Anxiety

Wound Care

Pain and Anxiety

• Assess and manage pain and anxiety.

• Continue to assess for and treat pain and anxiety.

Psychosocial Care

Psychosocial Care

• Provide support to patient and family during initial crisis phase.

• Continue to provide ongoing support, counselling, and education to patient and family about physical and emotional aspects of care and recovery. • Begin to anticipate discharge needs.

Respiratory Therapy • Assess oxygenation needs. • Provide supplemental oxygen as needed. • Intubate if necessary. • Monitor respiratory status.

Physiotherapy and Occupational Therapy

Respiratory Therapy • Continue to assess oxygenation needs. • Continue to monitor respiratory status. • Monitor for signs of complications (e.g., pneumonia).

Physiotherapy and Occupational Therapy

• Place patient in position that prevents contracture formation and reduces edema. • Assess need for splints or devices such as pressure relief/reduction mattresses to decrease tissue ischemia and potential for skin breakdown. • Turn and reposition patient frequently to allow for appropriate circulation to tissues.

• Have patient begin daily therapy program for maintenance of range of motion. • Assess need for splints and anticontracture positioning. • Encourage and assist patient with self-­care as possible.

Nutritional Therapy

• Provide temporary homografts. • Provide permanent autografts. • Care for donor sites.

• Assess nutritional needs and begin feeding patient by most appropriate route as soon as possible.

Nutritional Therapy • Continue to assess diet to support wound healing.

Other Therapy Early Excision and Grafting*

Medication Therapy* • Assess need for medications. • Continue to monitor effectiveness of and necessity for medications. • Titrate medications and discontinue as appropriate.

IV, intravenous. *See Tables 27.12, 27.13, and 27.14.

plan NCP 27.1 (Patient With a Thermal Burn Injury) on the Evolve website. AIRWAY MANAGEMENT Airway management frequently involves early endotracheal (preferably orotracheal) intubation. Early intubation eliminates the necessity for emergency tracheostomy after respiratory complications have become apparent. In general, patients with major injuries that include burns to the face and neck require intubation within 1 to 2 hours after burn injury. (Intubation is

discussed in Chapter 68.) After intubation, such patients are placed on ventilatory assistance, and the delivered oxygen concentration is determined from an assessment of arterial blood gas (ABG) values. Extubation may be indicated when the edema resolves, usually 3 to 6 days after burn injury, unless severe inhalation injury is involved. Escharotomies of the trunk may be needed to relieve respiratory distress secondary to circumferential, full-­thickness burns to the neck and trunk (see Figure 27.8). Within 6 to 12 hours after injury in which smoke inhalation is suspected, a fibre-­optic bronchoscopy should be performed to

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SECTION 4  Conditions Related to Altered Sensory Input

assess the lower airway. Significant findings include the appearance of carbonaceous material, mucosal edema, vesicles, erythema, hemorrhage, and ulceration. When intubation is not performed, treatment of inhalation injury includes administration of 100% humidified oxygen as needed. Patients should be placed in a high Fowler’s position unless it is contraindicated (e.g., because of spinal injury), and coughing and deep breathing every hour should be encouraged. Patients should be repositioned every 1 to 2 hours and chest physiotherapy and suctioning performed as necessary. If respiratory failure develops, intubation and mechanical ventilation are initiated. Positive end-­expiratory pressure (PEEP), a method of ventilation in which airway pressure is maintained above atmospheric pressure at the end of exhalation by mechanical means, may be used to prevent collapse of the alveoli and progressive respiratory failure (see Chapter 68). Bronchodilators may be administered to treat severe bronchospasm. Carbon monoxide poisoning is treated by administering 100% oxygen until carboxyhemoglobin levels return to normal. The use of hyperbaric oxygen therapy to treat carbon monoxide poisoning is contraindicated in the presence of a body burn as it delays important burn care.  FLUID THERAPY Establishing intravenous (IV) access that can accommodate large volumes of fluid is critical for fluid resuscitation and medication administration. At least two large-­bore IV access routes must be obtained for patients with burns over more than 15% TBSA. For patients with burns over more than 30% TBSA, a central line for fluid and medication administration, as well as a line for blood sampling, should be considered if frequent ABGs or invasive BP monitoring is needed. A standardized chart is used to assess the extent of the burn wound (see Figure 27.4), allowing for accurate estimation of fluid resuscitation requirements. The type of fluid replacement is determined by size and depth of burn, age of the patient, and individual considerations, such as pre-­existing chronic illness. Fluid replacement is accomplished with crystalloid solutions (usually lactated Ringer’s solution), colloids (albumin), or a combination of the two. Paramedics generally administer IV saline until the patient’s arrival at the hospital. The Parkland (Baxter) formula for fluid replacement is the formula most commonly used to estimate fluid replacement (Table 27.12; see also the Parkland Formula for Burns calculator in the Resources for this chapter). It is important to remember that all formulas yield estimates, which must be titrated on the basis of the patient’s physiological response. For example, in patients with an electrical injury or inhalation injury, fluid requirements may be greater than normal and include an osmotic diuretic (mannitol) and sodium bicarbonate to alkalize the urine. Too much fluid and overestimation of TBSA contribute to the development of fluid over-­ resuscitation or “fluid creep” (Greenhalgh, 2019). Colloidal solutions (e.g., albumin) may be given. However, administration is recommended in the first 12 to 24 hours after the burn injury, when capillary permeability returns to normal or near normal. After this time, the plasma remains in the vascular space and expands the circulating volume. The replacement volume is calculated on the basis of the patient’s body

TABLE 27.12    FLUID RESUSCITATION WITH THE

PARKLAND (BAXTER) FORMULA*

Formula 4 mL of lactated Ringer’s solution per kilogram of body weight per percentage of TBSA burned = Total fluid requirements for first 24 hr after burn

Application

50% of total in first 8 hr 25% of total in second 8 hr 25% of total in third 8 hr

Example For a 70-­kg patient with a burn on 50% of TBSA: 4 mL × 70 kg × 50% of TBSA burned 50% of total in first 8 hr 25% of total in second 8 hr 25% of total in third 8 hr

= = = =

14 000 mL, or 14 L, in 24 hr 7 000 mL (875 mL/hr) 3 500 mL (438 mL/hr) 3 500 mL (438 mL/hr)

TBSA, total body surface area. *Formulas are guidelines. Fluid is administered at a rate to produce 0.5–1.0 mL/kg/hr of urine output.

weight and TBSA burned (e.g., 0.3 to 0.5 mL/kg per percentage of TBSA burned). The adequacy of fluid replacement is best assessed according to clinical parameters. Urine output, the most commonly used parameter, and cardiac parameters are defined as follows: 1. Urine output: The goal is generally 0.5 to 1 mL/kg/hour for most patients with burn injuries but increases to 75 to 100 mL/hour for patients with an electrical burn and evidence of hemoglobinuria or myoglobinuria. 2. Cardiac factors: Mean arterial pressure is greater than 65 mm Hg, systolic BP is greater than 90 mm Hg, and heart rate is less than 120 beats/minute. Mean arterial pressure and BP are most appropriately measured by means of an arterial line. Peripheral measurement is often invalid because of vasoconstriction and edema.  WOUND CARE Once a patent airway, adequate circulation, and adequate fluid replacement have been established, the priority is care of the burn wound. Full-­thickness burn wounds are dry and waxy white to dark brown or black and have only minor, localized sensation because nerve endings have largely been destroyed. Partial-­thickness burn wounds appear pink to cherry red and are wet and shiny with serous exudate. These wounds may or may not have intact blisters and are painful when touched or open to air because of exposed nerve endings. Cleansing and gentle debridement, with the use of scissors and forceps, can occur on a cart shower (Figure 27.9), a regular shower, or the patient’s bed or stretcher. Extensive, surgical debridement (Figure 27.10) is performed in the operating room. During debridement, necrotic skin is removed from the wound to prevent infection and promote healing. Releasing escharotomies and fasciotomies can be carried out in the emergent phase, usually in burn units by burn physicians. Patients find the initial wound care to be both physically and psychologically demanding. Patients are showered with tap water not exceeding 40°C. A once-­daily shower and dressing change in the morning, followed by a dressing change in the patient’s room in the evening, are part of a common routine

CHAPTER 27  Nursing Management: Burns

FIG. 27.9  Cart shower. Showering presents an opportunity for wound care

and physiotherapy. Source: Courtesy Judy A. Knighton, RN, MScN, Toronto.

FIG. 27.10  Surgical debridement of full-­thickness burns is necessary to prepare the wound for grafting. Source: Courtesy Judy Knighton, Toronto, Canada.

in many burn units. Some of the newer antimicrobial dressings can be left in place from 3 to 14 days, thereby decreasing the frequency of dressing changes. The source of infection in burn wounds can be the patient’s own flora, predominantly from the skin (burned and unburned), respiratory tract, and gastrointestinal tract. Increased opportunity for infection occurs following invasive hospital procedures such as central line placement (Manning, 2018). The prevention of cross-­contamination between one patient and another is a priority for all members of the interprofessional health care team. Two approaches to burn wound treatment are the open method and the closed method, using multiple dressing changes. In the open method, the patient’s burn is covered with a topical antimicrobial and has no dressing over the wound. In the multiple–dressing change or closed method, sterile gauze dressings are impregnated with or laid over a topical antimicrobial. These dressings are changed at various intervals, from every 12 to 24 hours to once every 14 days, depending on the product. Most burn units support the concept of moist wound

531

healing and use dressings to cover the burned areas, except for the burned face. When the patient’s open burn wounds are exposed, staff must wear personal protective equipment (PPE) (e.g., disposable hats, masks, gowns, gloves). Increased levels of PPE are required when caring for burn patients with suspected SARS-­ CoV-2 infection. When removing contaminated dressings and washing the dirty wound, the nurse may use nonsterile, disposable gloves. Sterile gloves, however, are used when applying ointments and sterile dressings. In addition, the room must be kept warm (approximately 30°C) to prevent the patient from using up valuable calories through shivering. When finished treating one patient, the nurse removes all PPE and dons new PPE before treating another patient to avoid transmitting organisms from one patient to another. Careful hand hygiene and the use of alcohol-­based hand rub, both inside and outside each patient room, is also necessary to prevent cross-­contamination. After the dressing change is completed, the equipment and immediate environment are thoroughly cleaned and disinfected. The use of plastic liners on equipment is helpful in reducing the potential contamination of the equipment and facilitates cleaning. Coverage is the primary goal for burn wounds. In the major burn wound (>50% TBSA), there is rarely enough unburned skin for immediate grafting. This necessitates the use of other temporary wound closure methods. Allograft (homograft) skin (from a cadaver skin bank) is used, along with newer biosynthetic options, with varying frequency among burn units (Table 27.13).  OTHER CARE MEASURES For certain parts of the body (e.g., face, eyes, hands, arms, ears, perineum), nursing care must be particularly meticulous. The face is highly vascular and subject to a great amount of edema. It is often covered with ointments and gauze but not wrapped, to limit pressure on delicate facial structures. Eye care for corneal burns or edema includes antibiotic ointments. All patients with facial burns should undergo an ophthalmological examination soon after admission. Periorbital edema can prevent opening of the eyes and be frightening to the patient. The nurse should provide assurance that the swelling is not permanent. Instillation of methyl cellulose drops or artificial tears into the eyes for moisture provides additional comfort for patients. Burned hands and arms should be extended and elevated on pillows to minimize edema. Splints may need to be applied to maintain them in positions of function. Ears should be kept free of pressure because of their poor vascularization and predisposition to infection. A patient with ear burns should not rest their head on pillows because pressure on the cartilage may cause chondritis and the ear may stick to the pillowcase, causing pain and bleeding. The patient’s head can be elevated with a rolled towel placed under the shoulders, with care to avoid pressure necrosis. The same holds true for a patient with neck burns. Pillows are removed and a rolled towel is placed under the shoulders to hyperextend the neck and prevent neck wound contracture. The perineum must be kept as clean and dry as possible. In addition to providing hourly urine outputs, an in-­dwelling catheter prevents urine contamination of the perineal area. Routine laboratory tests are performed to monitor fluid and electrolyte balance. ABGs are measured to determine adequacy

532

SECTION 4  Conditions Related to Altered Sensory Input

TABLE 27.13    SOURCES OF GRAFTS Source

Graft Name

Coverage

Porcine skin

Heterograft or xenograft (different species) Homograft or allograft (same species) Autograft Cultured epithelial autograft (CEA) Biobrane

Temporary (3 days to 2 wk)

Cadaveric skin Patient’s own skin Patient’s own skin and cell cultures Porcine collagen bonded to silicone membrane Bovine collagen and glycosaminoglycan bonded to silicone membrane Acellular dermal matrix derived from donated human skin Donated neonatal foreskin fibroblasts and keratinocytes in bovine collagen sponge Donated neonatal foreskin fibroblasts and keratinocytes in bovine collagen gel Bovine collagen and elastin matrix

TABLE 27.14    MEDICATION THERAPY Medications Commonly Used in Burn Treatment Types and Names of Medications

Temporary (3 days to 2 wk) Permanent Permanent

Nutritional Support

Analgesia

Integra

Temporary (10–21 days) Permanent

AlloDerm

Permanent

OrCel

Permanent

Apligraf

Permanent

MatriDerm

Permanent

of ventilation and perfusion in all patients with suspected or confirmed inhalation or electrical injury. Physiotherapy is begun immediately, sometimes during showering and dressing changes and before new dressings are applied. Early range-­of-­motion exercises are necessary to facilitate mobilization of the extravasated fluid back into the vascular bed. Exercise also maintains function, prevents contracture, and reassures the patient that movement is still possible. 

Vitamins A, C, E, and multivitamins Minerals: zinc, iron (ferrous sulphate)

Morphine (Statex) Sustained-­release morphine (MS Contin) Hydromorphone (Dilaudid) Sustained-­release hydromorphone (Dilaudid) Fentanyl Acetaminophen (Tylenol) Ibuprofen (Advil) Adjuvant analgesics (e.g., gabapentin [Neurontin], pregabalin [Lyrica])

Purpose Promote wound healing Promote cell integrity and hemoglobin formation Promote pain control

Sedation–Hypnosis Quetiapine (Seroquel) Haloperidol (Haldol) Lorazepam (Ativan) Midazolam Ketamine (Ketalar)

Produce antipsychotic and sedative effects Diminish anxiety Provide short-­acting amnestic effects

Antidepressant Therapy Venlafaxine (Effexor XR) Citalopram (Celexa)

Reduce depression; improve mood

Anticoagulation Therapy Enoxaparin (Lovenox) Heparin

Prevent venous thromboembolism

Gastrointestinal Support Ranitidine (Zantac) Esomeprazole (Nexium) Aluminum/magnesium hydroxide (Diovol)

Decrease stomach acid and risk for Curling’s ulcer Neutralize stomach acid

MEDICATION THERAPY

ANALGESICS AND SEDATIVES.  Analgesics are ordered to promote patient comfort. Early in the postburn period, pain medications should be given intravenously because (a) onset of action is fastest with this route; (b) gastrointestinal function is slowed or impaired as a result of shock or paralytic ileus; and (c) medications injected intramuscularly are not absorbed adequately in burned or edematous areas, and so medications pool in the tissues. When fluid mobilization begins, interstitial accumulation of previous intramuscular medications could cause inadvertent overdose. Opioids commonly used for pain control are listed in Table 27.14. The need for analgesia must be re-­evaluated frequently because patients’ needs may change and tolerance to medications may develop over time. Initially, opioids are the drugs of choice for pain control. Sedative–hypnotics and antidepressant drugs can also be given with analgesics to control the anxiety, insomnia, or depression that patients may experience (see Table 27.14). Analgesic requirements can vary tremendously from one patient to another. The extent and depth of burn may not be correlated with pain intensity. Hospital pharmacists, psychiatrists, and multidisciplinary pain services are valuable resources for the more complex patient situations. Effective pain control depends on assessment, prompt analgesia with dosages titrated to achieve effect, and regular evaluation. 

TETANUS IMMUNIZATION.  Tetanus toxoid is given routinely to all patients with burn injuries because of the likelihood of anaerobic contamination of the burn wound. If the patient has not received an active immunization in the 10 years before the burn injury, tetanus immunoglobulin should be considered.  ANTIMICROBIAL AGENTS.  After the wound is cleansed, topical agents are applied and covered with a light dressing. Systemic antibiotics are not routinely used to control burn wound flora because there is little or no blood supply to the burn eschar and, consequently, little delivery of the antibiotic to the wound. In addition, the routine use of systemic antibiotics increases the chance of developing multidrug-­ resistant organisms. Some topical burn agents penetrate the eschar, thereby inhibiting bacterial invasion of the wound. Silver-­impregnated dressings (e.g., Acticoat Flex, Aquacel Ag Burn, Exsalt T7) can be left in place anywhere from 3 to 14 days and are effective against many organisms. Silver sulphadiazine (Flamazine) and mafenide acetate (Sulfamylon) creams are also used (Cartotto, 2017). Sepsis remains a leading cause of death in patients with major burns because it may lead to multiple organ dysfunction syndrome (see Chapter 69). Systemic antibiotic therapy is initiated when invasive burn wound sepsis is clinically diagnosed or when some other source of infection (e.g., pneumonia) is identified.

CHAPTER 27  Nursing Management: Burns Fungal infections may develop in the patient’s mucous membranes (mouth and genitalia) as a result of systemic antibiotic therapy and low resistance in the host. The offending organism is usually Candida albicans. Oral infection is treated with nystatin mouthwash. When a normal diet is resumed, yogourt or Lactobacillus may be given by mouth to reintroduce the normal intestinal flora that have been destroyed by antibiotic therapy.  VENOUS THROMBOEMBOLISM PROPHYLAXIS.  For burn-­injured patients at risk for venous thromboembolism (e.g., those with lower extremity burns, patients with obesity), if there are no contraindications, it is recommended that low-­ molecular-­ weight heparin (enoxaparin [Lovenox]) or low-­dose unfractionated heparin be started as soon as it is considered safe to do so (see Table 27.14). For any patients who are at high risk for bleeding, it is recommended that mechanical prophylaxis against venous thromboembolism, with sequential compression devices or graduated compression stockings, or both, be used until the bleeding risk decreases and heparin can be started (Weinberger & Cipolle, 2016) (see Table 27.14).  NUTRITIONAL THERAPY The metabolic rate of burn patients can exceed twice the normal rate, and without early and aggressive nutritional support within several hours of the burn injury, impaired wound healing, organ dysfunction, and susceptibility to infection can occur (Clark et  al., 2017). Nonintubated patients with a burn over less than 20% TBSA are generally able to eat enough to meet their nutritional requirements. Intubated patients and those with larger burns require additional support. Enteral feedings (gastric or intestinal) have almost entirely replaced parenteral feeding. Early enteral feeding, usually with smaller-­bore tubes, preserves gastrointestinal function, increases intestinal blood flow, promotes optimal conditions for wound healing, and prevents complications (e.g., Curling’s ulcer). The patient with a large burn (greater than 20% TBSA) can develop paralytic ileus within a few hours as a result of the body’s response to major trauma. If a large nasogastric tube is inserted on admission, gastric residuals should be checked frequently to detect delayed gastric emptying. Bowel sounds should be assessed every 8 hours. In general, feedings can begin slowly at 20 to 40 mL/hour and be increased to the goal rate within 24 to 48 hours. A hypermetabolic state proportional to the size of the wound occurs after a major burn injury. Resting metabolic expenditure may increase by 50 to 100% above normal in patients with major burns. Core temperature is elevated. Catecholamines, which stimulate catabolism and heat production, increase. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delayed healing. Calorie-­containing nutritional supplements and milkshakes are often administered because of the great need for calories. Protein powder can also be added to food and liquids. Decreased levels of vitamins A, C, and D and iron, copper, selenium, and zinc have been found to negatively affect wound healing and skeletal and immune function. Supplemental vitamins should ideally be initiated within 24 hours of injury (Clark et al., 2017; see Table 27.14). 

ACUTE PHASE The acute phase begins with mobilization of extracellular fluid and subsequent diuresis. This phase concludes when the burned

533

area is completely covered by skin grafts or when the wounds are healed. This may take weeks or many months.

Pathophysiological Changes Burn injury involves pathophysiological changes in many body systems. Diuresis from fluid mobilization occurs, and the patient becomes less edematous. Areas that are full-­or partial-­ thickness burns are more evident than in the emergent phase. Bowel sounds return. The patient may now become aware of the enormity of the situation and benefit from additional psychosocial support. Some healing begins as WBCs surround the burn wound and phagocytosis occurs. Necrotic tissue begins to slough. Fibroblasts lay down matrices of the collagen precursors that eventually form granulation tissue. A partial-­ thickness burn wound heals from the edges and the dermal bed below if kept free from infection and desiccation (dryness). However, full-­thickness burn wounds, unless extremely small, must be covered by skin grafts. In some cases, healing time and length of hospitalization are decreased by early excision and grafting.  Clinical Manifestations Partial-­thickness wounds form eschar, which begins separating fairly soon after injury. Once the eschar is removed, re-­ epithelialization begins at the wound margins and appears as red or pink scar tissue. Epithelial buds from the dermal bed eventually close in the wound, which then heals spontaneously without surgical intervention, usually within 10 to 21 days. Margins of full-­thickness eschar take longer to separate. As a result, full-­thickness wounds necessitate surgical debridement and skin grafting for healing.  Laboratory Values Because the body is attempting to re-­establish fluid and electrolyte homeostasis in the initial acute phase, it is important to monitor serum electrolyte levels closely. Sodium.  Hyponatremia can develop from excessive gastrointestinal suction, diarrhea, and excessive water intake. Manifestations of hyponatremia include weakness, dizziness, muscle cramps, fatigue, headache, tachycardia, and confusion. The patient with burn injuries may also develop water intoxication, a dilutional form of hyponatremia. To avoid this condition, the patient should drink fluids other than water, such as juice or nutritional supplements. Hypernatremia may occur after successful fluid replacement if copious amounts of hypertonic solutions were required. Other causes may be related to tube-­feeding therapy or inappropriate fluid administration. Manifestations of hypernatremia include thirst; dry, coated tongue; lethargy; confusion; and possibly seizures.  Potassium.  Hyperkalemia is noted if the patient has renal failure, adrenocortical insufficiency, or massive deep muscle injury (e.g., electrical burn) and if large amounts of potassium are being released from damaged cells. Cardiac dysrhythmias and ventricular failure can occur with elevated potassium levels. Muscle weakness and electrocardiographic changes are observed clinically (see Chapter 19). Hypokalemia occurs with vomiting, diarrhea, prolonged gastrointestinal suction, and prolonged IV therapy without potassium supplementation. Constant potassium loss occurs through the burn wound. Manifestations of hypokalemia include fatigue,

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SECTION 4  Conditions Related to Altered Sensory Input

muscle weakness, leg cramps, paresthesias, and decreased reflexes (see Chapter 19). 

Complications Infection.  The body’s first line of defence, the skin, is destroyed by burn injury. Pathogens often proliferate before phagocytosis has adequately begun. The burn wound becomes colonized with organisms. If the bacterial density at the junction of the eschar with underlying viable tissue rises to greater than 105 bacteria/g of tissue, the burn wound is considered infected. In the presence of an infection, localized inflammation, induration, and sometimes suppuration can occur at the burn wound margins. Partial-­thickness burns can convert to full-­thickness wounds when the infecting organisms invade viable, adjacent, unburned tissue. Invasive wound infections may be treated with systemic antibiotics on the basis of culture results. Burn wound infection may progress to transient bacteremia and sepsis as a result of burn wound manipulation (e.g., after showering and debridement). Manifestations of sepsis include hypothermia or hyperthermia, increased heart and respiratory rates, decreased BP, and decreased urine output. Patients may exhibit mild confusion, chills, malaise, and loss of appetite. The WBC count is usually between 10 and 20 × 109/L. There are functional deficits in the WBCs, and the patient remains immunosuppressed for a time after the burn injury. The causative organisms of sepsis are usually Gram-­negative bacteria (e.g., Pseudomonas, Proteus organisms), which increase the risk for septic shock. When sepsis is suspected, cultures are immediately obtained from all possible sources, including the burn wound, blood, urine, sputum, oropharynx, perineal regions, and any invasive line or tube sites. However, treatment should not be delayed pending results of the culture and sensitivity studies. Therapy begins with antibiotics appropriate for the usual residual flora of the particular burn unit. The topical antibiotic in use may be continued or changed to another medication. At this stage, the patient’s condition is critical, and vital signs must be monitored closely. Collaboration with infectious disease specialists is important to ensure appropriate antibiotic coverage.  Cardiovascular and Respiratory Systems.  The same cardiovascular and respiratory system complications present in the emergent phase may continue into the acute phase of care. In addition, new complications might arise, necessitating timely intervention.  Neurological System.  Neurologically, the patient usually has no physical symptoms, unless severe hypoxia from respiratory injuries or complications from electrical injuries occur. However, some patients may demonstrate certain behaviours that are not completely understood. A patient can become extremely disoriented, become withdrawn or combative, or have hallucinations and nightmare-­like episodes. Delirium is more acute at night and occurs more often in older patients. Consultation with psychiatric or geriatric services is helpful in quickly diagnosing and treating delirium or similar behaviours. The nurse can then focus on strategies to orient and reassure a confused or agitated patient. Delirium is a transient state, lasting from a day or two to several weeks. Various causes have been considered, including electrolyte imbalance, stress, cerebral edema, sepsis, sleep disturbances, and the use of analgesics and antianxiety drugs. 

Musculoskeletal System.  The musculoskeletal system is prone to complications during the acute phase. As the burns begin to heal and scar tissue forms, the skin is less supple and pliant. Range of motion may be limited, and contractures can occur. The muscles in the body tend to shorten in a flexed position. The patient should be encouraged to stretch and move the burned body parts as much as possible. Splinting can be beneficial in preventing or reducing contracture formation. Attention to repositioning and the use of devices such as pressure-­redistribution mattresses may also be necessary to decrease the potential for tissue ischemia and skin breakdown.  Gastrointestinal System.  The gastrointestinal system may also exhibit complications during this phase. Paralytic ileus results from sepsis. Diarrhea may be caused by the use of enteral feedings or antibiotics. Constipation can occur as an adverse effect of opioid analgesics, decreased mobility, and a low-­fibre diet. Curling’s ulcer is a type of gastroduodenal ulcer characterized by diffuse superficial lesions (including mucosal erosion). It is caused by a generalized stress response to decreased blood flow to the gastrointestinal tract during the emergent phase; this response results in decreased production of mucus and increased secretion of gastric acid. The best measure for preventing Curling’s ulcer is feeding the patient soon after the injury. Antacids, H2-­histamine blockers (e.g., ranitidine [Zantac]), and proton pump inhibitors (e.g., esomeprazole [Nexium]) are used prophylactically to neutralize stomach acids and inhibit the secretion of histamine and hydrochloric acid (see Table 27.14).  Endocrine System.  A transient increase in blood glucose levels may occur because of stress-­mediated cortisol and catecholamine release, which results in increased mobilization of glycogen stores, gluconeogenesis, and subsequent production of glucose. Insulin production and release also increase. However, insulin’s effectiveness decreases because of relative insulin insensitivity; consequently, the blood glucose level becomes elevated. Later, hyperglycemia can be caused by the increased caloric intake necessary to meet metabolic requirements. When hyperglycemia occurs, the treatment is supplemental IV insulin, not decreased feeding. Serum glucose levels are checked frequently, and an appropriate amount of insulin is given if hyperglycemia is present. Glucometers may be used to assess blood glucose at the patient’s bedside; however, serum glucose samples yield more accurate results. As the patient’s metabolic demands are met and less stress is placed on the entire system, this stress-­induced condition may be reversed before or at time of discharge. 

NURSING AND INTERPROFESSIONAL MANAGEMENT ACUTE PHASE The predominant therapeutic interventions in the acute phase are (a) wound care, (b) excision and grafting, (c) pain management, (d) physiotherapy and occupational therapy, (e) nutritional therapy, and (f) psychosocial care. WOUND CARE The goals of wound care are to (a) prevent infection by cleansing and debriding the area of necrotic tissue that would promote bacterial growth and (b) promote wound re-­epithelialization, successful skin grafting, or both. Wound care consists of daily observation, assessment, cleansing, debridement, and dressing reapplication. Nonsurgical debridement, dressing changes, topical antimicrobial

CHAPTER 27  Nursing Management: Burns therapy, graft care, and donor site care are performed as necessary, depending on the topical cream or dressing ordered. Wounds are cleansed with soap and water or with normal saline–moistened gauze to gently remove the old antimicrobial agent and any loose necrotic tissue, scabs, or dried blood. During the debridement phase, the wound is covered with topical antimicrobial agents (e.g., silver sulphadiazine, silver-­impregnated dressings). When partial-­thickness burn wounds have been fully debrided, a protective greasy (paraffin or petroleum) gauze dressing is applied to protect the re-­epithelializing cells as they resurface and close the open wound bed. If grafting is necessary, the meshed, split-­ thickness skin graft may be protected with the same greasy gauze dressings, followed by middle and outer dressings. With facial grafts, the unmeshed sheet graft is left open, so it is possible for blebs (serosanguinous exudate) to form between the graft and the recipient bed. Blebs prevent the graft from permanently attaching to the wound itself. The evacuation of blebs is best performed by aspiration with a tuberculin syringe and only by professionals who have received instruction in this specialized skill. (Dressings are discussed in Chapter 14 and Table 14.11.)  EXCISION AND GRAFTING Current management of full-­thickness burn wounds involves early removal of the necrotic tissue, followed by application of split-­thickness autograft skin. In the past, patients with major burns had low rates of survival, hypertrophic scars, contractures, and poor functional outcomes and developed sepsis because healing and wound coverage took so long (Douglas et al., 2017). Currently, as a result of earlier intervention, mortality and morbidity rates have been greatly reduced. Many patients, especially those with major burns, are taken to the operating room for wound excision on day 1 or 2 (resuscitation phase). The wounds are covered with a biological dressing or allograft for temporary coverage until permanent grafting can be accomplished (see Table 27.13). During the procedure of excision and grafting, devitalized tissue (eschar) is removed down to the subcutaneous tissue or

A

535

the fascia, depending on the degree of injury. Surgical excision can result in massive blood loss. Topical application of epinephrine or thrombin, application of extremity tourniquets, or application of a fibrin sealant (ARTISS) all work to decrease surgical blood loss. Once hemostasis has been achieved, a graft is then placed on clean, viable tissue to achieve good adherence. Whenever possible, the freshly excised wound is covered with autograft (the person’s own) skin (see Table 27.13). Fibrin sealant has been used to attach skin grafts to the wound bed. Grafts can also be stapled or sutured into place (Figure 27.11, A). Negative-­pressure wound therapy dressings are often placed on top of skin grafts to optimize adherence to the excised bed (Mohsin et al., 2017). A temporary allograft (from a cadaver skin bank) can be used to test how the recipient site will accept a graft. The allograft is then removed several days later in the operating room and an autograft applied. With early excision, function is restored and scar tissue formation is minimized. Frequent observation for bleeding and circulation problems and appropriate nursing interventions can help identify and manage complications that would interfere with graft survival. Facial, neck, and hand burns require skillful nursing care to identify and manage clots quickly for the best functional and aesthetic outcomes. Donor skin from another area of the patient’s body is harvested for grafting by means of a dermatome, which removes a thin (14/1000 to 16/1000) split-­thickness layer of skin from an unburned site (see Figure 27.11, B). This sample of skin can be meshed (usually a ratio of 1.5:1) to allow for greater wound coverage, or it may be applied as an unmeshed sheet graft for a better cosmetic result when grafting the face, neck, and hands. The site from which this skin was taken now becomes a new open wound. The goals of donor site care are to promote rapid moist wound healing, decrease pain at the site, and prevent infection. The choices of dressings vary among burn centres and include greasy gauze dressings, silver-­impregnated dressings,

B

FIG. 27.11  Split-­thickness skin grafting. A,

C

D

Freshly applied split-­thickness sheet skin graft to the hand. B, Split-­thickness skin graft is harvested from a patient’s thigh using a dermatome. C, Donor site is covered with a hydrophilic foam dressing after harvesting. D, Healed donor site. Source: Courtesy Judy A. Knighton, RN, MScN, Toronto.

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SECTION 4  Conditions Related to Altered Sensory Input

and hydrophilic foam dressings (see Figure 27.11, C). Nursing care of the donor site is specific to the dressing selected. Several of the newer dressing materials offer decreased healing time, which facilitates earlier reharvesting of skin at the same site. The average healing time for a donor site is 10 to 14 days (see Figure 27.11, D). CULTURED EPITHELIAL AUTOGRAFTS.  In the patient with large body surface area burns, only a limited amount of unburned skin may be available as donor sites for grafting, and some of that available skin may be unsuitable for harvesting. Cultured epithelial autograft (CEA) is a method of obtaining permanent skin from a person with limited available skin for harvesting. CEA is grown from biopsy specimens obtained from the patient’s own unburned skin. The specimens are sent to a commercial laboratory, where the keratinocytes from the biopsy sample are grown in a culture medium containing epidermal growth factor. After approximately 18 to 25 days, the keratinocytes have expanded up to 10 000 times and form confluent sheets that can be used as skin grafts. The cultured skin is returned to the burn unit, where it is placed on the patient’s excised burn wounds. Because CEA tissue is made only of epidermal cells, meticulous care is required to prevent shearing injury or infection (Figure 27.12). Problems related to CEA include infection, contracture development, and poor graft take as a result of loss of thin epidermal skin during healing.  ARTIFICIAL SKIN.  Skin substitutes are an alternative to conventional skin grafting techniques for reconstruction of partial-­ thickness and full-­thickness burn wounds (Sando & Chung, 2017). The Integra dermal regeneration template is an example of a successful skin replacement system available in burn care today. As with CEA, it is indicated for use in the treatment of life-­threatening full-­thickness or deep partial-­thickness burn wounds when conventional autograft is not available or advisable, as in older patients or those at high risk for complications from anaesthesia. It has also been successfully used in surgical burn reconstructive procedures. As with CEA, it needs to be applied within a few days of admission for greatest success. Integra artificial skin has a bilayer membrane composed of acellular dermis and silicone. The wound is debrided, the bilayer membrane is placed dermal layer down, and the wound is wrapped with dressings in the operating room. The dermal layer functions as a biodegradable template that induces organized regeneration of new dermis by the body. The silicone layer remains intact for 3 weeks as the dermal layer degrades and epidermal autografts become available. At this point, the silicone

is removed during a second surgical procedure and replaced by the patient’s own epidermal autografts. In some situations, burn units use CEA as the source of epidermis. Another currently available dermal replacement is AlloDerm, a cryopreserved allogenic dermis. Human allograft dermis, harvested from cadavers, is decellularized to render it immunogenic, and then it is freeze-­dried. Once thawed, AlloDerm is rehydrated with ultrathin epidermal autografts immediately before placement on a newly excised wound.  PAIN MANAGEMENT One of the most critical functions a nurse performs on behalf of a patient with burn injuries is individualized and ongoing pain assessment and management. Many aspects of burn care cause pain. However, patients experience moments of relative comfort if they receive adequate analgesia. A coordinated understanding of both physiological and psychological aspects of pain is essential if the nurse is to intervene with actions that are beneficial. (General pain management is discussed in Chapter 10.) Patients with burn injuries experience two kinds of pain: (1) continuous, background pain that might be present throughout the day and night and (2) treatment-­induced pain associated with dressing changes, ambulation, and rehabilitation activities. Initial treatment is pharmacological (see Table 27.14). With background pain, a continuous IV infusion of an opioid allows for a steady, therapeutic level of medication. If an IV infusion is not present, slow-­release twice-­a-­day opioid medications (e.g., MS Contin, sustained-­release hydromorphone [Dilaudid]) are indicated. Around-­the-­clock oral analgesics can also be used (ibuprofen, acetaminophen). Breakthrough doses of pain medication need to be available regardless of the regimen selected. Anxiolytics (e.g., lorazepam [Ativan]), which frequently potentiate analgesics, are also indicated. For treatment-­induced pain, premedication with an analgesic and perhaps an anxiolytic via the IV or oral route, is required. For patients with an IV infusion, a potent, short-­acting analgesic, such as fentanyl, is useful. During treatment or activity, doses should be low but high enough to keep the patient as comfortable as possible. Elimination of all pain is difficult to achieve, and most patients indicate satisfaction with “tolerable” levels of discomfort. Pain can also be managed through nonpharmacological strategies. Mind–body interventions such as relaxation, hypnosis, guided imagery, biofeedback, and music therapy are considered adjuncts to traditional pharmacological treatment of pain.

FIG. 27.12  Cultured epithelial autograft (CEA). A, Intraoperative application of CEA. B, Appearance of healed CEA. Source: Courtesy of Epicel.

A

B

CHAPTER 27  Nursing Management: Burns They are not meant to be used exclusively to control pain but may help some patients cope with the painful aspects of care, both in the hospital and after discharge (see Chapter 8). An important point to remember is that the more control the patient has in managing the pain, the more successful the chosen strategies are. Patient-­controlled analgesia (PCA) is used in some burn units, with varying degrees of success. (PCA is discussed in Chapters 10 and 22.) Active patient participation has been found to be effective also for some patients in anticipating and coping with treatment-­induced pain.  PHYSIOTHERAPY AND OCCUPATIONAL THERAPY Rigorous physiotherapy throughout burn recovery is imperative to maintain muscle strength and optimal joint function. A good time for exercise is during and after wound cleansing, when the skin is softer and bulky dressings are removed. Passive and active range-­of-­motion exercises should be performed on all joints. The patient with neck burns must sleep without pillows or with the head hanging slightly over the top of the mattress to encourage hyperextension. Custom-­fitted splints are designed to keep joints in a functional position. These must be re-­examined frequently to ensure an optimal fit with no undue pressure that might lead to skin breakdown or nerve damage.  NUTRITIONAL THERAPY The goal of nutritional therapy during the acute burn phase is to provide adequate calories and protein to promote healing. The patient with burn injury is in a hypermetabolic and highly catabolic state. Decreasing catecholamine release by minimizing pain, fear, anxiety, and cold can maximize the patient’s comfort and conserve energy. Infection also increases the metabolic rate. Meeting daily caloric requirements is crucial and should begin within the first 1 to 2 days after the burn injury. The daily estimated caloric needs must be regularly calculated by a dietitian and readjusted as the patient’s condition changes (e.g., wound healing, sepsis). If the patient is on a mechanical ventilator or unable to consume adequate calories by mouth, a small-­bore feeding tube is inserted and enteral feedings are initiated. When the patient is extubated, a swallowing assessment should be performed by a speech–language pathologist before oral feeding is commenced. The alert patient should be encouraged to eat high-­protein, high-­carbohydrate foods to meet increased caloric needs. Family members should be encouraged to bring in favourite foods from home. Ideally, weight loss should not be more than 10% of preburn weight. Daily calorie counts and weekly weights are monitored by the dietitian to evaluate progress.  PSYCHOSOCIAL CARE The patient and family have many needs for psychosocial support during the often lengthy, unpredictable, and complex course of care. The social worker and nursing staff have important support and counselling roles to play. (Patient and family emotional needs are discussed later in this chapter and in Chapter 6.) 

REHABILITATION PHASE The formal rehabilitation phase begins when the patient’s burn wounds have healed and the patient is able to resume a level of self-­care activity. This can occur as early as 2 weeks or as long as 7 to 8 months after the burn injury. The goal for this period is to assist the patient to regain and maintain function and

537

EVIDENCE-­INFORMED PRACTICE Research Highlight Does Cooling Burns With Water as a First Aid Treatment Affect Outcomes in Burn Patients? Clinical Question In patients with burns (P), what is the effect of holding a burn under cool, running water (I) versus alternate treatment (C) in reducing skin surface temperature, admission to the critical care unit (CCU), and depth of the wound and pain (O)? 

Best Available Evidence Systematic review of randomized controlled trial (RCT), cohort study, expert opinion, and clinical practice guidelines 

Critical Appraisal and Synthesis of Evidence • O  ne RCT (n = 96) with burn patients in the emergency department and a large cohort study (n = 2 897) using burn registry data • The RCT found that cooling with water as an initial first aid treatment was associated with a significant reduction in skin temperature as compared to hydrogel tea tree burn dressings. • The cohort study reported an association between 20 to 25 minutes of water cooling as a standard first aid measure and a reduction in surgery and admission to CCU. Expert opinions reported a decrease in burn depth, faster healing, and less scarring with the use of 20 minutes of running, cool water. Clinical guidelines suggested that cooling significantly reduced pain and wound edema if started within 3 hours of the burn injury. 

Conclusion • It is recommended that a burned wound should be held under running cool tap water for 20 minutes within 3 hours following burn injuries, unless contraindicated (e.g., large burn causing rapid heat loss, hypothermia, multiple trauma). 

Implications for Nursing Practice • N  urses can promote the use of this simple, easy-­to-­implement first aid measure when educating patients, families, and community groups. • It is important to stress that the water should be running and cool; ice is contraindicated as it can cause vasoconstriction, hypothermia, and burning if placed directly on the skin.

Reference for Evidence Gyi, A. A. (2018). Management of burn injuries: Cooling burns with water. JBI Evidence Summary. AN, JBI20528. P, patient population of interest; I, intervention or area of interest; C, comparison of interest or comparison group; O, outcomes of interest (see Chapter 1).

independence (Knighton, 2020). Rehabilitation-­focused activities that were taking place during the earlier emergent and acute phases begin in earnest once the patient’s wounds have healed.

Pathophysiological Changes and Clinical Manifestations Burn wounds can heal on their own or through skin grafting. Through epithelialization, the tissue structure destroyed by the burn injury begins to rebuild. Collagen fibres, present in the new scar tissue, assist with healing and add strength to weakened areas. The new skin appears flat and pink. In approximately 4 to 6 weeks, the area may become raised and hyperemic. If adequate range of motion is not instituted, the new tissue shortens, which causes a contracture. Mature healing is reached in about 12 months, by which time suppleness has returned and, in lighter-­skinned people, the pink or red colour has faded to a slightly lighter hue than the surrounding unburned tissue. More heavily pigmented skin takes longer to regain its dark colour because many of the melanocytes have been destroyed. In many cases, the skin does not regain its original colour. Paramedical

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SECTION 4  Conditions Related to Altered Sensory Input

cosmetic camouflage—the topical application of pigment onto the skin—can help even out unequal skin tones and improve the patient’s overall appearance and self-­image. Scarring has two components: discoloration and contour. The discoloration of scars fades somewhat with time. However, scar tissue tends to develop altered contours; that is, it is no longer flat or slightly raised but becomes elevated and enlarged above the original burned area. It is believed that pressure can help keep a scar flat. Gentle pressure can be maintained on the healed burn with custom-­fitted pressure garments, worn up to 24 hours a day for as long as 12 to 18 months. They should never be worn over unhealed wounds and are removed for bathing. Patients typically experience discomfort from itching where healing is occurring. Application of water-­based moisturizers and use of oral antihistamines (e.g., diphenhydramine [Benadryl]) help reduce the itching. Massage, transcutaneous electrical nerve stimulation (TENS), silicone gel sheeting (e.g., Cica-­ Care), gabapentin (Neurontin)/pregabalin (Lyrica), beeswax and herbal oil, antipruritic hydrogel, and injectable steroids may also be helpful (Nedelec & LaSalle, 2018). As “old” epithelium is replaced by new cells, flaking occurs. Newly formed skin is extremely sensitive to trauma. Blisters and skin tears are likely to develop from slight pressure or friction. In addition, newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch. Grafted areas are more likely to be hyposensitive until peripheral nerve regeneration occurs. Healed burn areas must be protected from direct sunlight for 3 to 6 months to prevent hyperpigmentation and sunburn. 

Complications The most common complication during the rehabilitative phase are contractures due to the healing process and scaring and the loss of soft tissue length and extensibility (Godleski & Umraw, 2020). A contracture (an abnormal, usually permanent condition of a joint, characterized by flexion and fixation) develops as a result of the shortening of scar tissue in the flexor tissues of a joint. Areas most susceptible to contracture formation include anterior and lateral neck areas, axillae, antecubital fossae, fingers, groin areas, popliteal fossae, knees, and ankles (Figure 27.13). Not only does the skin over these areas develop contractures, but also the underlying tissues, such as the ligaments and tendons, have a tendency to shorten in the healing process. Because of pain, patients with burn injuries prefer to assume a flexed position for comfort. This position predisposes wounds to contracture formation. Proper positioning,

splinting, and exercise should be instituted to minimize this complication while the skin matures. Burned legs may be wrapped with elastic (e.g., tensor [ACE]) bandages to assist with circulation to leg graft and donor sites before ambulation. This additional pressure prevents blister formation, promotes venous return, and decreases pain and itchiness. Once the skin is completely healed and less fragile, interim tubular gauze (Tubigrip, Coban) and then custom-­fitted pressure garments can replace the elastic bandages. 

NURSING AND INTERPROFESSIONAL MANAGEMENT REHABILITATION PHASE During the rehabilitation phase, both the patient and the family are actively encouraged to participate in care. Because the patient may go home with small, unhealed wounds, education and “hands-­on” instruction in dressing changes and wound care are needed. If necessary, home care nursing services may be arranged to assist with wound care for the first few weeks after discharge. An emollient, water-­based cream (e.g., Vaseline Intensive Care Extra Strength) that penetrates into the dermis should be used routinely on healed areas to keep the skin supple and well moisturized, thereby decreasing itching and flaking. Reconstructive surgery is frequently required after a major burn. It is important for the patient to understand the need for or possibility of further surgery before leaving the hospital. The continuous role of exercise and physiotherapy or occupational therapy cannot be overemphasized. Computerized gaming devices such as tablets can provide patients with a break from exercise routines and allow access to interactive games, movies, books and puzzles (Burns-­Nader et  al., 2017). Constant encouragement and reassurance are necessary to maintain morale, particularly once the patient realizes that recovery can be slow and rehabilitation may need to be a primary focus for at least the next 12 months. Because of the tremendous psychological effect of burn injury, health care providers should be particularly sensitive and attuned to the patient’s emotions and concerns. It is essential that patients be encouraged to discuss their fears regarding loss of their lifestyle as they once knew it, loss of function, temporary or permanent deformity and disfigurement, return to work and home life, and financial burdens resulting from a long and potentially costly hospitalization and rehabilitation. Patients may benefit from being assisted toward a realistic and positive

FIG. 27.13 Contractures. A, Foot. B, Neck. Source: Courtesy Judy A. Knighton, RN, MScN, Toronto, and Linda Bucher, RN, PhD.

A

B

CHAPTER 27  Nursing Management: Burns appraisal of their particular situation, emphasizing what they can do instead of what they cannot do. A person’s self-­esteem may be affected by a burn injury. In some individuals, an overwhelming fear may be the loss of relationships because of perceived or actual physical disfigurement. In a society in which physical beauty is valued, alterations in body image may result in psychological distress. Encouraging appropriate independence, an eventual return to preburn activities, and interactions with other burn survivors will involve the patient in familiar activities that may bring comfort and help restore self-­esteem. Counselling, which may have started in the acute phase of care, can be offered after discharge. Patients appreciate reassurance that their emotions during this period of adjustment are normal and that frustration is to be expected as they attempt to resume a normal lifestyle. 

AGE-­RELATED CONSIDERATIONS BURNS Older patients with burns present many challenges for the burn team. The normal aging process puts such patients at risk for injury because of the possibility of an unsteady gait, limited eyesight, and diminished hearing. As people age, skin becomes drier, more wrinkled, and looser. The dermal layer thins, there is a loss of elastic fibres, the amount of subcutaneous adipose tissue lessens, and vascularity decreases. As a result, the thinner dermis, with reduced blood flow, sustains deeper burns with poorer rates of healing. Once injured, older persons have more complications in the emergent and acute phases of burn resuscitation because of pre-­ existing medical conditions. For example, among older patients with diabetes, heart failure, or chronic obstructive pulmonary disease, morbidity and mortality rates exceed those of healthy, younger patients. Pneumonia is a frequent complication, burn wounds and donor sites take longer to heal, and surgical procedures are not as well tolerated. Weaning from a ventilator can be a challenge, and delirium from medication and anaesthesia may be a distressing, although usually self-­limiting, outcome. It usually takes longer for older patients to become rehabilitated to the point at which they can safely return home. For some, a return home to independent living may not be possible. As the population ages, developing strategies to prevent burn injuries in this age group is a priority. 

EMOTIONAL NEEDS OF THE PATIENT AND CAREGIVERS Treatment of the burn injury often takes priority over psychological assessments and interventions. Close relatives, especially caregivers, may have to cope with many concerns, such as childcare financial issues and changes in family roles and the patient’s appearance (Bond et  al., 2017). It is important to ensure that correct interventions addressing a patient’s coping ability and mental health occur appropriately in each of the stages of the recovery process (Cleary et al., 2018). At any time, emotions of fear, anxiety, anger, guilt, and depression may be experienced (Table 27.15). A common emotional response is regression. The patient may revert to behaviour that helped with stressful situations in the past. This response can be healthy and is usually short-­lived. As more independence is expected from the patient, new fears must be confronted: “Can I do it?” “Am I a desirable partner

539

TABLE 27.15    EMOTIONAL RESPONSES OF

PATIENTS WITH BURN INJURY*

Emotion

Possible Verbal Expression

Fear

“Will I die?” “What will happen next?” “Will I be disfigured?” “Will my family and friends still love me?” “I feel out of control.” “What’s going to happen to me?” “When will I look normal again?” “Why did this happen to me?” “The nurses enjoy hurting me.” “I hope the person who did this to me dies.” “If only I’d been more careful.” “I’m being punished because I did something wrong.” “It’s no use going on like this.” “I don’t care what happens to me.” “I wish people would leave me alone.”

Anxiety

Anger

Guilt Depression

*List is not all-­inclusive.

or parent?” Open and frequent communication among the patient, family members, close friends, and burn team members is essential. Burn survivors frequently experience thoughts and feelings that are frightening and disturbing, such as guilt about the burn accident, reliving the experience, fear of death, concern about future therapy and surgery, frustrations with ongoing discomfort and wound breakdown, and, perhaps, hopelessness about the future. Families may share some or all of these feelings. At times, family members may feel helpless to assist their loved one. Continued support from trusted and familiar burn team members is essential. Assisting with aspects of care helps family members reconnect with their loved one and assists with the transition home. Many burn survivors and their families eventually adapt quite well and resume a productive and satisfying life; however, this process of adaptation can continue for several years (Rosenberg et al., 2018). Acknowledgement of a range of possible feelings (e.g., hopelessness, despair, rage, joy, and hope) can provide support for patients and their families. The stress of the burn injury occasionally precipitates a time-­limited psychiatric or psychological crisis. Many patients realize that coping with this experience is beyond their ability. Assessment by a psychiatrist who can prescribe appropriate medication, if needed, and begin short-­term counselling is frequently helpful. Early psychiatric intervention is essential if the patient has been previously treated for a psychiatric illness or if the injury resulted from a suicide attempt. The diagnosis of post-­traumatic stress disorder is made in a number of patients with burn injuries. However, it has been noted that distress and trauma symptoms can act as a catalyst for positive post-­traumatic growth. Social support is a strong predictor of psychological recovery following a burn injury (Bond et  al., 2017). Treatment typically begins in the hospital, but links to community resources must be made before discharge to ensure continuity of psychological care. Once the patient is discharged, referral to a psychiatrist, psychologist, mental health counsellor, social worker, or psychiatric clinical nurse specialist may be helpful if concerns are raised at burn clinic follow-­up. Patients with burn injuries benefit from information about sexuality and intimacy (Rosenberg et  al., 2018)). Physical appearance is altered in patients who have sustained a major burn, and acceptance of any changes can be difficult at first for both the patient and their significant other. The nature of skin

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SECTION 4  Conditions Related to Altered Sensory Input

injury causes modifications in processing sexual stimuli. Touch is an important part of sexuality, and immature scar tissue may make the sensation of touch unpleasant or may dull it. This effect is usually transient, but the patient and partner need to know that it is normal, so they will benefit from anticipatory guidance from the health care team to avoid undue emotional strain. Patient and family support groups may assist patients and families with their emotional needs at any phase of the recovery process. Speaking with other people who have experienced burn trauma can be beneficial, both in terms of reaffirming that their feelings are normal and allowing for sharing of helpful advice (Rosenberg et  al., 2018)). The Phoenix Society (see the Resources at the end of this chapter) is an international and highly respected burn survivors’ support group that has been offering invaluable support and resources to burn survivors, family members, and burn team personnel for many years. 

SPECIAL NEEDS OF THE NURSING STAFF Warm, trusting, mutually satisfying relationships frequently develop between patients with burn injuries and nursing staff, not only during hospitalization but also during the long-­term rehabilitation period. The frequency and intensity of family contact can also be rewarding, as well as draining, for the

nurse. Those new to burn nursing often find it difficult at first to cope with not only the deformities caused by burn injury but also the odours, the unpleasant sight of wounds, and the reality of the pain that accompanies the burn and its treatment. With time and positive experiences, those reactions diminish. Many nurses come to know that the care they provide makes a critical difference in helping patients not only to survive but also to cope with and triumph over a challenging and multifaceted injury. It is this belief that allows and inspires nurses to provide meaningful care to patients with burn injury and their families. Ongoing support services for the burn nurse or critical incident stress debriefings led by a psychiatrist, psychologist, psychiatric clinical nurse specialist, or social worker may be helpful. Professional burn nursing groups (e.g., American Burn Association, Canadian Association of Burn Nurses, International Society for Burn Injuries) can serve a similar purpose by helping nursing staff cope with difficult feelings they may experience when caring for patients with burn injuries. Burn nursing is physically, psychologically, and intellectually demanding and immensely rewarding. Attention to self-­care helps to maintain a positive attitude and healthy work–life balance. Time with family and friends and rest and relaxation at home are essential parts of self-­care and living a life with purpose and fulfillment.

CASE STUDY Burn Injury Patient Profile

Discussion Questions

E. C. (pronouns he/him), 65 years old, is brought to the emergency department with burns to his face, neck, torso, right arm and hand, and right foot from a kitchen grease fire. Upon arrival, the nurse notes an 18-­gauge IV line with lactated Ringer’s solution infusing at 100 mL/hour, and 100% humidified oxygen by mask is being administered. 

1. Priority decision: What are the priorities of care in the prehospital setting and emergency department? How should E. C.’s airway, breathing, and circulation be managed? 2. Priority decision: What signs and symptoms indicate that he likely has an inhalation injury? What priority interventions can be anticipated? 3. What pain medications might be considered to relieve the pain? 4. Which of the criteria for admission to the hospital burn unit does E. C. meet? 5. What metabolic disturbances would be expected soon after his admission? Explain the physiological basis for these changes. 6. How might E. C.’s comorbidities affect burn care and rehabilitation? 7. What measures should be taken to support E. C.’s family? 8. Priority decision: What three priority nursing diagnoses and any interprofessional issues can be identified, based on the assessment data presented? 9. Evidence-­informed practice: What are the most effective wound care strategies to manage E. C.’s burn wounds?

Subjective Data •  Reports impaired vision and swallowing difficulties • States burns are painful and is scared • States has “diabetes and high blood pressure” 

Objective Data Physical Examination  atient is awake, alert, and oriented but in some distress P Eyes are red and irritated Voice is hoarse; nasal hair is singed Face is reddened, with blisters noted on the nose and forehead Right arm, right hand, anterior torso, neck, and right foot have shiny, bright red, wet wounds • Patient is shivering  • • • • •

Answers are available at http://evolve.elsevier.com/Canada/Lewis/medsurg.

 REVIEW QUESTIONS The number of the question corresponds to the same-­numbered objective at the beginning of the chapter. 1. Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety? a. Set hot water temperature at 60°C. b. Use only hard-­wired smoke detectors. c. Encourage regular home fire exit drills. d. Never permit older persons to cook unattended.

2. Which of the following injuries is least likely to result in a full-­ thickness burn? a. Sunburn b. Scald injury c. Chemical burn d. Electrical injury

CHAPTER 27  Nursing Management: Burns

REFERENCES American Burn Association (ABA). (2016). Burn incidence and treatment in the United States: 2016. https://www.ameriburn.org/resour ces_factsheet.php Arno, A., Knighten, J., & F. (2020). Prevention of burn injuries. In F. Sjöberg, et al. (Series Ed.), & M. Jeschke, & L. P. Kamolz (Vol. Eds.) Handbook of burns: Vol. 1. (2nd ed.). Springer. Billette, J.-­M., & Janz, T. (2015). Injuries in Canada: Insights from the Canadian community health Survey. Statistics Canada. http://www.statcan.gc.ca/pub/82-624-­x/2011001/article/11506-­ eng.htm Bond, S., Gourlay, C., Desjardins, A., et al. (2017). Anxiety, depression and PTSD-­related symptoms in spouses and close relatives of burn survivors: When the supporter needs to be supported. Burns, 43(3), 592–601.

8. Which of the following is most effective in terms of pain management for the client with burn injuries? (Select all that apply.) a. A pain rating tool is used to monitor the client’s level of pain. b. Painful dressing changes are delayed until the client’s pain is completely relieved. c. The client is educated about pain management and has some control over its management. d. A multimodal approach is used (e.g., sustained-­release and short-­acting opioids, nonsteroidal anti-­inflammatory drugs, adjuvant analgesics). e. Nonpharmacological therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury. 9. Which of the following therapeutic measures is used to prevent hypertrophic scarring during the rehabilitative phase of burn recovery? a. Applying pressure garments b. Repositioning the patient every 2 hours c. Performing active range of motion at least every 4 hours d. Massaging the new tissue with water-­based moisturizers 10. A client is recovering from second-­and third-­degree burns over 30% of his body and is now ready for discharge. What is the first action that the nurse should take when meeting with the client? a. Arrange a return-­to-­clinic appointment and prescription for pain medications. b. Teach the client and the caregiver proper wound care to be performed at home. c. Review the client’s current health care status and readiness for discharge to home. d. Give the client written discharge information and websites for additional information for burn survivors. 1. c; 2. a; 3. a, d, e; 4. d; 5. c; 6. a; 7. b; 8. a, c, d; 9. a; 10. c.

3. When assessing a client with a partial-­thickness burn, what would the nurse expect to find? (Select all that apply.) a. Blisters b. Exposed fascia c. Exposed muscles d. Intact nerve endings e. Red, shiny, wet appearance 4. A client is admitted to the burn centre with burns on his head and neck, chest, and back after an explosion in his garage. On assessment, the nurse auscultates the lung fields and hears wheezes throughout. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a. Obtain vital signs and an immediate arterial blood gas. b. Encourage the client to cough and auscultate the lungs again. c. Document the findings and continue to monitor the client’s breathing. d. Anticipate the need for endotracheal intubation and notify the physician. 5. Which of the following fluid and electrolyte shifts occurs during the early emergent phase? a. Adherence of albumin to vascular walls b. Movement of potassium into the vascular space c. Sequestering of sodium and water in interstitial fluid d. Hemolysis of RBCs from large volumes of rapidly administered fluid 6. Which of the following must the client with a major burn do in order to maintain a positive nitrogen balance? a. Eat a high-­protein, low-­fat, high-­carbohydrate diet. b. Increase normal adult caloric intake by about three times. c. Eat at least 1 500 calories per day in small, frequent meals. d. Eat rice and whole wheat for their chemical effect on nitrogen balance. 7. A client has 25% of TBSA burned in a car fire. His wounds have been debrided and covered with a silver-­impregnated dressing. What should the nurse’s priority intervention for wound care be? a. To reapply a new dressing without disturbing the wound bed b. To observe the wound for signs of infection during dressing changes c. To apply cool compresses for pain relief in between dressing changes d. To wash the wound aggressively with soap and water three times a day

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For even more review questions, visit http://evolve.elsevier.com/Cana da/Lewis/medsurg.

Burns-­Nader, S., Joe, L., & Pinion, K. (2017). Computer tablet distraction reduces pain and anxiety in pediatric burn patients undergoing hydrotherapy: A randomized trial. Burns, 43(6), 1203–1211. Cartotto, R. (2017). Topical antimicrobial agents for pediatric burns. Burns Trauma, 5, 33. https://doi.org/10.1186/s41038-017-0096-6 Clark, A., Imran, J., Madni, T., et al. (2017). Nutrition and metabolism in burn patients. Burns & Trauma, 5(1), 1–12. Cleary, M., Visentin, D. C., West, S., et al. (2018). Bringing research to the bedside: Knowledge translation in the mental health care of burns patients. International Journal of Mental Health Nursing, 27(6), 1869–1876. Douglas, H., Dunne, J., & Rawlins, J. (2017). Management of burns. Surgery, 35(9), 511–518. Dyamenahalli, K., Garg, G., Shupp, J., et al. (2019). Inhalation injury: Unmet clinical needs and future research. Journal of Burn Care and Research, 40(5), 570–584.

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Fahlstrom, K., Boyle, C., & Makic, M. B. F. (2013). Implementation of a nurse-­driven burn resuscitation protocol: A quality improvement project. Critical Care Nurse, 33(1), 25–35. https://doi.org/10.4037/ ccn2013385 Foncerrada, G., Capek, K., Wurzer, P., et al. (2017). Functional exercise capacity in children with electrical burns. Journal of Burn Care and Research, 38(3), E647–E652. Godleski, M., & Umraw, N. C. (2020). Rehabilitation management during the acute phase. In M. Jeschke, L. P. Kamolz, F. Sjöberg, et al. (Eds.), Handbook of burns (2nd ed., Vol. 1). Springer. Grant, E. (2017). Burn injuries: Prevention, advocacy, and legislation. Clinics in Plastic Surgery, 44(3), 451–466. Greenhalgh, D. G. (2019). Management of burns. New England Journal of Medicine, 380(24), 2349–2359. https://doi.org/10.1056/ nejmra1807442 Hampson, N. B., Piantadosi, C. A., Thom, S. R., et al. (2012). Practice recommendations in the diagnosis, management, and prevention of carbon monoxide poisoning. American Journal of Respiratory and Critical Care Medicine, 186(11), 1095–1101. https://doi. org/10.1164/rccm.201207-1284CI Knighton, J. (2020). Nursing management of the burn patient. In M. Jeschke, L. P. Kamolz, F. Sjöberg, et al. (Eds.), Handbook of burns (2nd ed., Vol. 1). Springer. Manning, J. (2018). Sepsis in the burn patient. Critical Care Nursing Clinics of North America, 30(3), 423–430. https://doi.org/10.1016/j. cnc.2018.05.010 Mohsin, M., Zarger, H., Wani, A., et al. (2017). Role of customized negative-­pressure wound therapy in the integration of split-­ thickness skin grafts: A randomized control trial. Indian Journal of Plastic Surgery, 50(1), 43–49. https://doi.org/10.4103/ijps. IJPS_196_16 NB Trauma Program. (2019). Consensus statement. Clinical practice guidelines for burn injuries. https://nbtrauma.ca/wp-­ content/uploads/2020/10/Consensus-­Statement-­Emergency-­Burn-­ Care-­March-2019-­Final.pdf Nedelec, B., & LaSalle, L. (2018). Postburn itch: A review of the literature. Wounds, 30(1), 10–16. Okonkwo, U., & DiPietro, L. (2017). Diabetes and wound angiogenesis. International Journal of Molecular Science, 18(7), 1419. https:// doi.org/10.3390/ijms18071419 Peck, M. D., & Toppi, J. T. (2020). Epidemiology and prevention of burns throughout the world. In M. Jeschke, L. P. Kamolz, F. Sjöberg, et al. (Eds.), Handbook of burns (2nd ed., Vol. 1). Springer. Ramponi, D. R. (2017). Chemical burns of the eye. Advanced Emergency Nursing Journal, 39(3), 193–198.

Rosenberg, L., Rosenberg, M., Rimmer, R., et al. (2018). Psychosocial recovery and reintegration of patients with burn injuries. In D. Herndon (Ed.), Total burn care (5th ed., pp. 709–720). Elsevier. Sando, I., & Chung, K. (2017). The use of dermal skin substitutes for the treatment of the burned hand. Hand Clinics, 33(2), 269–276. Waldmann, V., Narayanan, K., Combes, N., et al. (2018). Electrical cardiac injuries: Current concepts and management. European Heart Journal, 39(16), 1459–1465. https://doi.org/10.1093/eurheartj/ehx142 Weinberger, J., & Cipolle, M. (2016). Mechanical prophylaxis for post-­ traumatic VTE: Stockings and pumps. Current Trauma Reports, 2, 35–41. https://doi.org/10.1007/s40719-016-0039-­x World Health Organization. (2018). Burns. https://www.who.int/news-­room/fact-­sheets/detail/burns Yang, L., Cui, C., Ding, H., et al. (2018). Delayed cerebellar infarction after a slight electric injury. The American Journal of Emergency Medicine, 36(12), 2337.e3–2337.e5. https://doi.org/10.1016/j. ajem.2018.08.064

RESOURCES Canadian Burn Survivors Community https://canadianburnsurvivors.ca/ Canadian Skin Patient Alliance https://canadianskin.ca/burns American Burn Association https://www.ameriburn.org Burn Foundation https://www.burnfoundation.org Burn Survivors Throughout the World http://www.burnsurvivorsttw.org Changing Faces https://www.changingfaces.org.uk International Society for Burn Injuries http://www.worldburn.org Parkland Formula for Burns Calculator https://www.mdcalc.com/parkland-­formula-­for-­burns Phoenix Society for Burn Injuries https://www.phoenix-­society.org Sage Burn Diagram https://www.sagediagram.com For additional Internet resources, see the website for this book at http://evolve.elsevier.com/Canada/Lewis/medsurg.

S E C T I O N

5

Conditions of Oxygenation: Ventilation

Source: © CanStock Photo/Elenathewise

Chapter 28: Nursing Assessment: Respiratory System Chapter 29: Nursing Management: Upper Respiratory Conditions Chapter 30: Nursing Management: Lower Respiratory Conditions Chapter 31: Nursing Management: Obstructive Pulmonary Diseases

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CHAPTER

28

Nursing Assessment

Respiratory System Lesley MacMaster Originating US chapter by Eugene Mondor

WEBSITE http://evolve.elsevier.com/Canada/Lewis/medsurg • • • • • •

 eview Questions (Online Only) R Key Points Answer Guidelines for Case Study Conceptual Care Map Creator Audio Glossary Supporting Media—Animations • Patterns of Respiration

•

• Percussion Tones Throughout the Chest • Pulmonary Circulation Supporting Media—Audio • Bronchial Breath Sounds • Bronchovesicular Breath Sounds • High-­Pitched Crackles • High-­Pitched Wheeze

•

• Low-­Pitched Crackles • Low-­Pitched Wheeze • Pleural Friction Rub • Stridor • Vesicular Breath Sounds Content Updates

LEARNING OBJECTIVES 1. Describe the structures and functions of the upper respiratory tract, the lower respiratory tract, and the chest wall. 2. Describe the process that initiates and controls inspiration and expiration. 3. Describe the process of gas diffusion within the lungs. 4. Identify the respiratory defence mechanisms. 5. Describe the significance of arterial blood gas values and the oxygen– hemoglobin dissociation curve in relation to respiratory function. 6. Identify the signs and symptoms of inadequate oxygenation and the implications of these findings.

7. Describe age-­related changes in the respiratory system and differences in assessment findings. 8. Identify the significant subjective and objective data related to the respiratory system that should be obtained from a patient. 9. Describe the techniques used in physical assessment of the respiratory system. 10. Differentiate normal from common abnormal findings in a physical assessment of the respiratory system. 11. Describe the purpose, significance of results, and nursing responsibilities related to diagnostic studies of the respiratory system.

KEY TERMS adventitious sounds chemoreceptor compliance crackles dyspnea

  

elastic recoil mechanical receptors pleural friction rub surfactant tactile fremitus

STRUCTURES AND FUNCTIONS OF THE RESPIRATORY SYSTEM The primary purpose of the respiratory system is gas exchange, which involves the transfer of oxygen and carbon dioxide from the atmosphere to the blood. The respiratory system is divided into two parts: the upper respiratory tract and the lower respiratory tract (Figure 28.1). The upper respiratory tract includes the nasal cavity, the pharynx, the adenoids, the tonsils, the epiglottis, the larynx, and the trachea. The major structures of the lower respiratory tract are the bronchi, the bronchioles,

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tidal volume ventilation wheezes

the alveolar ducts, and the alveoli. With the exception of the right and left mainstem bronchi, all lower airway structures are contained within the lungs. The right lung is divided into three lobes (upper, middle, and lower) and the left lung into two lobes (upper and lower; Figure 28.2). The structures of the chest wall (ribs, pleura, muscles of respiration) are also essential for respiration.

Upper Respiratory Tract The nose, made of bone and cartilage, is divided into two nares by the nasal septum. The interior of the nose is shaped into

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CHAPTER 28  Nursing Assessment: Respiratory System Right midclavicular line

Pharynx

Nasal cavity

Epiglottis

Thyroid cartilage

Larynx Right mainstem bronchus Segmental bronchi

Suprasternal notch

Trachea Carina

First rib Angle of Louis Left upper lobe

Right upper lobe Right middle lobe

Cilia

Terminal bronchiole

Dust particle Mucus

Larynx Trachea

Right lower lobe

Respiratory bronchiole

Left lower lobe

Right anterior axillary line

A

Midsternal line Vertebral line

Alveolar duct

B

Alveoli

Septa

A

Spinal processes

Goblet cell Left upper lobe

Pores of Kohn

Left lower lobe

FIG. 28.1  Structures of the respiratory tract. A, Pulmonary functional unit.

B, Ciliated mucous membrane. Source: Redrawn from Price, S. A., & Wilson, L. M. (2003). Pathophysiology: Clinical concepts of disease processes (6th ed.). Mosby.

rolling projections called turbinates that increase the surface area for warming and moistening air. The internal portion of the nose opens directly into the sinuses. The nasal cavity is connected to the pharynx, a tubular passageway that is subdivided into three parts: In descending order, they are the nasopharynx, the oropharynx, and the laryngopharynx. Breathing through the narrow nasal passages (rather than mouth breathing) provides protection for the lower airway. The nose is lined with mucous membrane and small hairs. Air entering the nose is warmed to near body temperature, humidified to nearly 100% water saturation, and filtered to remove particles larger than 10 mcm (e.g., dust, bacteria). The olfactory nerve endings (receptors for the sense of smell) are located in the roof of the nose. The adenoids and the tonsils, which are small masses of lymphatic tissue, are found in the nasopharynx and the oropharynx, respectively. The epiglottis is a small flap of tissue at the base of the tongue. During swallowing, the epiglottis covers the larynx, preventing solids and liquids from entering the lungs. After passing through the oropharynx, air moves through the laryngopharynx and the larynx, where the vocal cords are located, and then down into the trachea. The trachea is a

Right upper lobe

Right lower lobe

B

Scapular line FIG. 28.2  Landmarks and structures of the chest wall. A, Anterior view. B, Posterior view. Source: Thompson, J. M., McFarland, G., & Tucker, S. (2002). Mosby’s clinical nursing (5th ed.). Mosby.

cylindrical tube about 10 to 12 cm long and 1.5 to 2.5 cm in diameter. The support of U-­shaped cartilages keeps the trachea open but allows the adjacent esophagus to expand for swallowing. The trachea bifurcates into the right and left mainstem bronchi at a point called the carina, located at the level of the manubriosternal junction, also called the angle of Louis. The carina is highly sensitive, and touching it during suctioning causes vigorous coughing (Patton, 2019). 

Lower Respiratory Tract Once air passes the carina, it is in the lower respiratory tract. The mainstem bronchi, the pulmonary vessels, and nerves enter the lungs through a slit called the hilum. The right mainstem

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SECTION 5  Conditions of Oxygenation: Ventilation Conducting airways

Trachea

Respiratory unit

Bronchi, Subsegmental segmental bronchi bronchi

Bronchioles NonRespiratory respiratory

Alveolar ducts, alveoli

A A

A

20 mcm

B

20 mcm

FIG. 28.4  Scanning electron micrograph of lung parenchyma. A, Alveoli (A)

Generations

8

15

21–22

24

28

FIG. 28.3  Structures of lower airways. “Generations” refers to the number

of subdivisions of the mainstem bronchus. Source: Thompson, J. M., McFarland, G., & Tucker, S. (2002). Mosby’s clinical nursing (5th ed.). Mosby.

and alveolar capillary (arrow). B, Effects of atelectasis. Alveoli (A) are partially or totally collapsed. A, From Bone, R. C., Dantzker, D. R., George, R. B., et al. (Eds.). (1993). Pulmonary and critical care medicine (Vol. 1). Mosby. B, From Albertine, K. H., Williams, M. C., & Hyde, D. M. (2005). Anatomy of the lungs. In Mason, R. J., Broaddus, V. C., Murray, J. F., et al. (Eds.), Murray and Nadel’s textbook of respiratory medicine (4th ed.). W. B. Saunders.

ALVEOLUS

Alveolar epithelial cell

Respiratory membrane

Surfactant layer

bronchus is shorter, wider, and straighter than the left mainstem bronchus. For this reason, aspiration is more likely to occur in the right lung than in the left lung. The mainstem bronchi subdivide several times to form the lobar, segmental, and subsegmental bronchi. In further divisions, the bronchioles are formed. The most distant bronchioles are called the respiratory bronchioles. Beyond these lie the alveolar ducts and the alveolar sacs (Figure 28.3). The bronchioles are encircled by smooth muscles that constrict and dilate in response to various stimuli. Smooth muscle contraction causes bronchoconstriction (i.e., decrease in the diameter of the bronchioles) while smooth muscle relaxation causes bronchodilation (i.e., increase in the diameter of the bronchioles). The area of the respiratory tract from the nose to the respiratory bronchioles serves only as a conducting pathway and is therefore termed the anatomical dead space (VD). This space must be filled with every breath, but the air that fills it is not available for gas exchange. In adults, a normal tidal volume, or volume of air exchanged with each breath, is about 500 mL. Of each 500 mL inhaled, about 150 mL is VD. After moving through the conducting zone, air reaches the respiratory bronchioles and the alveoli (Figure 28.4). Alveoli are small sacs that form the functional unit of the lungs. The alveoli are interconnected by pores of Kohn, which allow movement of air from alveolus to alveolus (see Figure 28.1). Bacteria can also move through these pores; as a result, a respiratory infection can extend to previously noninfected areas. The alveolar–capillary membrane (Figure 28.5) is very thin—less than 5 mcm thick—and is the site of gas exchange. In conditions such as pulmonary edema, excess fluid fills the interstitial space and the alveoli, markedly impairing gas exchange (Patton, 2019). Surfactant.  The alveolar surface is composed of cells that provide structure and cells that secrete surfactant (see Figure 28.5). Surfactant, a lipoprotein that lowers the surface tension in the alveoli, reduces the amount of pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. Normally, each person takes a slightly larger breath, termed a sigh, after every five to six breaths. This sigh stretches the alveoli and promotes surfactant secretion. When the amount of surfactant is insufficient, the alveoli collapse. The term atelectasis refers to collapsed, airless alveoli

Interstitial layer

Endothelial cell of capillary CO2

Basement membrane O2

Capillary lumen CO2 RED BLOOD CELL O2

Diffusion of CO2

Diffusion of O2

FIG. 28.5  Illustration of a small portion of the respiratory membrane, greatly

magnified. An extremely thin interstitial layer of tissue separates the endothelial cell and basement membrane on the capillary side from the epithelial cell and surfactant layer on the alveolar side of the respiratory membrane. The total thickness of the respiratory membrane is less than 5 mcm.

(see Figure 28.4). The patient who has just undergone surgery is at risk for postoperative atelectasis because of the effects of anaesthesia and restricted breathing with pain (see Chapter 22). In acute respiratory distress syndrome, lack of surfactant contributes to widespread atelectasis (McCance & Huether, 2019). Acute respiratory distress syndrome is discussed further in Chapter 70).  Blood Supply.  The lungs have two different types of circulation: pulmonary and bronchial. The pulmonary circulation provides the lungs with blood for gas exchange. Deoxygenated blood enters the right atria via the vena cava, flows into the right ventricle and then into the pulmonary artery trunk, which branches into the right and left pulmonary arteries. Further subdivisions form a vast capillary network, where oxygen–carbon dioxide exchange occurs at the alveolar–capillary membrane. The pulmonary veins return the oxygenated blood to the left atrium of the heart, where it enters the systemic circulation via the aorta.

CHAPTER 28  Nursing Assessment: Respiratory System The bronchial circulation perfuses the tracheobronchial tree and other pulmonary tissues. The bronchial arteries branch off the aorta and perfuse structures in the left side of the thorax, while branches from the intercostal, subclavian, or internal mammary artery perfuse structures on the right side. Most deoxygenated venous blood returns to the right side of the heart; however, some venous blood from the bronchial circulation returns into the pulmonary veins and the left atrium. 

Chest Wall The chest wall is shaped, supported, and protected by 24 ribs (12 on each side). The ribs and the sternum protect the lungs and the heart from injury and, collectively, are sometimes called the thoracic cage. The structures of the chest wall include the thoracic cage, the pleura, and the respiratory muscles. During exertion or certain diseases, accessory muscles may provide support during inspiration (i.e., sternocleidomastoid, scalene, and trapezius) and expiration (i.e., abdominal and internal intercostals). The chest cavity is lined with a membrane called the parietal pleura, and the lungs are lined with a membrane called the visceral pleura. The parietal and visceral pleurae are joined and form a closed, double-­walled sac. The visceral pleura does not have any afferent pain fibres or nerve endings. The parietal pleura, however, does have afferent pain fibres. Therefore, irritation of the parietal pleura causes severe pain with each breath. The space between the pleural layers is termed the intrapleural space. In a normal adult, this space is filled with a thin film of 20 to 25 mL of fluid, which serves two purposes: It provides lubrication, allowing the layers of pleura to slide over each other during breathing, and it increases cohesion between the pleural layers, thereby facilitating expansion of the pleura and lung during inspiration. Fluid is normally drained from the pleural space by the lymphatic circulation. Several pathological conditions may cause the accumulation of greater amounts of fluid; such accumulations are termed pleural effusions. Pleural fluid may accumulate because malignant cells block lymphatic drainage or because there is an imbalance between intravascular and oncotic fluid pressures, as occurs in heart failure. The presence of purulent pleural fluid with bacterial infection is called empyema. Air in the pleural space (pneumothorax) or blood in the pleural space (hemothorax) can result in partial or complete collapse of the lung (see Chapter 30 for a full discussion of lower respiratory conditions). The diaphragm is the major muscle of respiration. During inspiration, the diaphragm contracts, pushing the abdominal contents downward. At the same time, the external intercostal muscles and scalene muscles contract, increasing the lateral and anteroposterior dimension of the chest. This causes the size of the thoracic cavity to increase and intrathoracic pressure to decrease, so that air can enter the lungs. The diaphragm is made up of two hemidiaphragms, each innervated by the right and left phrenic nerves. The phrenic nerves arise from the spinal cord between the third and fifth cervical vertebrae (C3 and C5). Injury to the phrenic nerve results in hemidiaphragmatic paralysis on the side of the injury. Complete spinal cord injuries above the level of C3 result in total diaphragmatic paralysis, and affected patients are dependent on mechanical ventilation (Herlihy, 2021). 

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Physiology of Respiration Ventilation.  Ventilation involves inspiration (movement of air into the lungs) and expiration (movement of air out of the lungs). Air moves in and out of the lungs because intrathoracic pressure changes in relation to pressure at the airway opening. Contraction of the diaphragm and of the intercostal and scalene muscles increases chest dimensions, thereby decreasing intrathoracic pressure. Gas flows from an area of higher pressure (atmospheric) to one of lower pressure (intrathoracic). In forced inspiration, such as during heavy exercise or conditions associated with respiratory distress, accessory muscles (i.e., sternomastoid, scalene, trapezius) assist to heave up the sternum and rib cage (Jarvis et al., 2019). In some conditions such as phrenic nerve paralysis, rib fractures, or neuromuscular disease, diaphragm or chest wall movement may be limited and cause the patient to breathe with smaller tidal volumes. As a result, the lungs do not fully inflate, and gas exchange is impaired. In contrast to inspiration, expiration is passive. The elastic recoil of the chest wall and lungs allows the chest to passively return to its normal position. Intrathoracic pressure rises, causing air to move out of the lungs. Exacerbations of asthma or emphysema cause expiration to become an active, laboured process (see Chapter 31). When there is persistent airflow limitation, such as in chronic obstructive pulmonary disease (COPD), accessory muscles (i.e., the rectus abdominus, internal intercostals) contract to push the abdominal viscera in and up against the diaphragm, causing it to expand and squeeze against the lungs, augmenting the force of expiration (Jarvis et al., 2019). Elastic Recoil and Compliance.  Elastic recoil is the tendency for the lungs to recoil after being stretched or expanded. The elasticity of lung tissue is attributable to the elastin fibres that are found in the alveolar walls and that surround the bronchioles and capillaries. Compliance (distensibility) is a measure of the elasticity of the lungs and the thorax. When compliance is decreased, inflation of the lungs is more difficult. Examples of conditions in which compliance is decreased include those that increase fluid in the lungs (e.g., pulmonary edema, acute respiratory distress syndrome), diseases that make lung tissue less elastic (e.g., pulmonary fibrosis, sarcoidosis), and conditions that restrict lung movement (e.g., pleural effusion). Compliance is decreased as a result of aging and when there is destruction of alveolar walls and loss of tissue elasticity, as in emphysema.  Diffusion.  Oxygen and carbon dioxide move across the alveolar capillary membrane by diffusion. The overall direction of movement is from the area of higher concentration to the area of lower concentration. Thus oxygen moves from alveolar gas (atmospheric air) into the arterial blood, and carbon dioxide from the arterial blood into the alveolar gas. Diffusion continues until equilibrium is reached (see Figure 28.5). The ability of the lungs to oxygenate arterial blood adequately is determined by examination of the arterial oxygen tension (PaO2; also referred to as the partial pressure of oxygen in arterial blood) and arterial oxygen saturation (SaO2). Oxygen is carried in the blood in two forms: dissolved oxygen and hemoglobin-­bound oxygen. The PaO2 represents the amount of oxygen dissolved in the plasma and is expressed in millimetres of mercury (mm Hg). The SaO2 is the amount of oxygen actually bound to hemoglobin, as opposed to the amount of oxygen that the hemoglobin can carry. The SaO2 is expressed as a percentage. For example, if the SaO2 is 90%, this means that 90% of the hemoglobin attachments for oxygen have oxygen bound to them.

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SECTION 5  Conditions of Oxygenation: Ventilation

Oxygen–Hemoglobin Dissociation Curve.  The affinity of hemoglobin for oxygen is described by the oxygen–hemoglobin (oxyhemoglobin) dissociation curve (Figure 28.6). Oxygen delivery to the tissues depends on the amount of oxygen transported to the tissues and the ease with which hemoglobin gives up oxygen once it reaches the tissues. In the upper flat portion of the curve, fairly large changes in the PaO2 cause small changes in hemoglobin saturation. For this reason, if the PaO2 drops from 100 to 60 mm Hg, the saturation of hemoglobin changes only 7% (from the normal 97% to 90%). In other words, the hemoglobin remains 90% saturated despite a 40–mm Hg drop in the PaO2. This portion of the curve also explains why a patient is considered adequately oxygenated when the PaO2 is higher than 60 mm Hg. Increasing the PaO2 above this level does little to improve hemoglobin saturation. The lower portion of the oxygen–hemoglobin dissociation curve indicates a different type of phenomenon. As hemoglobin is desaturated, larger amounts of oxygen are released for tissue use. This is an important method of maintaining the pressure

Oxyhemoglobin (% saturation)

90 80

Caused by: pH Temperature PCO2

70 Normal

60 50

Caused by: pH Temperature PCO2 2,3-DPG

40 30 20 10

10

20

30

40

50

60

70

80

90 100

PaO2 (mm Hg) Normal Shift to left Shift to right FIG. 28.6  Oxygen–hemoglobin dissociation curve. A shift to the left in-

dicates the hemoglobin’s increased affinity for oxygen. A shift to the right indicates the hemoglobin’s decreased affinity for oxygen. 2,3-­DPG, 2,3-­diphosphoglycerate; PaO2, partial pressure of oxygen in arterial blood; PCO2, partial pressure of carbon dioxide.

gradient between the blood and the tissues. It also ensures an adequate oxygen supply to peripheral tissues, even if oxygen delivery is compromised. Many factors alter the affinity of hemoglobin for oxygen. A shift to the left in the oxygen–hemoglobin dissociation curve indicates that blood picks up oxygen more readily in the lungs but delivers oxygen less readily to the tissues. This occurs in alkalosis, in hypothermia, and with a decrease in arterial carbon dioxide tension (PaCO2; also referred to as the partial pressure of carbon dioxide in the arterial blood; see Figure 28.6). A patient with a condition that causes a leftward shift of the curve, such as hypothermia that follows open heart surgery, may be given higher concentrations of oxygen until the body temperature normalizes. This helps compensate for decreased oxygen unloading in the tissues. A shift in the curve to the right indicates the opposite: Blood picks up oxygen less rapidly in the lungs but delivers oxygen more readily to the tissues. This occurs in acidosis, in hyperthermia, and when the PaCO2 is increased. Two methods are used to assess the efficiency of gas transfer in the lung: analysis of arterial blood gas (ABG) values and oximetry. These measures are usually adequate if the patient is stable and not critically ill. Many critically ill patients have a condition that impairs tissue oxygen delivery. In such patients, cardiac output, tissue oxygen consumption, mixed venous oxygen tension (PvO2), and venous oxygen saturation (SvO2) may also be assessed (Urden et al. 2018; see Chapter 68).  Arterial Blood Gases.  ABGs are measured to determine oxygenation status and acid–base balance. ABG analysis includes measurement of the PaO2, the PaCO2, the pH, and the amount of bicarbonate (HCO3−) in arterial blood. The SaO2 is either calculated or measured during this analysis. Blood for ABG analysis can be obtained by arterial puncture or from an arterial catheter in the radial or the femoral artery. Both techniques are invasive and allow only intermittent analysis. Continuous intra-­ arterial blood gas monitoring is also possible via a fibre-­optic sensor or an oxygen electrode inserted into an arterial catheter. An arterial catheter enables ABG sampling without repeated arterial punctures. Normal ABG values are given in Table 28.1, and ABG analysis and interpretation are further discussed in Chapter 19. The normal PaO2 decreases with advancing age. The normal PaO2 also varies in relation to the distance above sea level. At higher altitudes, the barometric pressure is lower, and thus the amount of inspired oxygen pressure and the PaO2 are lower (see Table 28.1). Most airplanes are pressurized to approximate an altitude of 2 400 m above sea level. A normal person can expect a 16– to

TABLE 28.1    NORMAL ARTERIAL AND VENOUS BLOOD GAS VALUES* Arterial Blood Gases Laboratory Value

BP at Sea Level: 760 mm Hg

BP at 1609 m Above Sea Level: 629 mm Hg Mixed Venous Blood Gases

pH Partial pressure of oxygen Oxygen saturation Partial pressure of carbon dioxide

7.35–7.45 80–100 mm Hg ≥95%† 35–45 mm Hg

7.35–7.45 65–75 mm Hg ≥95%† 35–45 mm Hg

HCO3−

21–28 mmol/L

21–28 mmol/L

−,

7.31–7.41 40–50 mm Hg 60%–80%† SvO2 is a better indicator for change in acid–base balance 21–28 mmol/L

BP, barometric pressure; HCO3 bicarbonate; SvO2, venous oxygen saturation. *Assumes patient is 60 years of age or younger and breathing room air. †The same normal values apply to both the venous oxygen saturation value (obtained through mixed venous blood gas sampling or oximetry via catheter) and the oxygen saturation value (obtained through pulse oximetry).

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CHAPTER 28  Nursing Assessment: Respiratory System TABLE 28.2    SIGNS AND SYMPTOMS OF

INADEQUATE OXYGENATION

Signs and Symptoms

Onset

Central Nervous System Unexplained apprehension Unexplained restlessness or irritability Unexplained confusion or lethargy Combativeness Coma

Early Early Early or late Late Late

Respiratory System Tachypnea Dyspnea on exertion Dyspnea at rest Use of accessory muscles Retraction of interspaces on inspiration Pause for breath between sentences, words

A

Early Early Late Late Late Late

Cardiovascular System Tachycardia Mild hypertension Dysrhythmias (e.g., premature ventricular contractions) Hypotension Cyanosis Cool, clammy skin

Early Early Early or late Late Late Late

Other Body Systems Diaphoresis Decreased urinary output Unexplained fatigue

B FIG. 28.7  A, Portable pulse oximeter displays oxygen saturation (SpO2) and pulse rate. B, A pulse oximeter displays the oxygen saturation and pulse rate as a digital reading. Sources: A, © Can Stock Photo/praisaeng. B, © Can Stock Photo/masuti.

32–mm Hg fall in PaO2 at this altitude (McCance & Huether, 2019). A patient who is already receiving oxygen therapy or whose PaO2 is lower than 72 mm Hg while they are breathing room air needs a careful evaluation before air travel. Supplemental oxygen or a change in litre flow may be required during the flight.  Mixed Venous Blood Gases.  For patients with normal or near-­normal cardiac status, an assessment of PaO2 or SaO2 is usually sufficient to determine adequate oxygenation. Patients with impaired cardiac output or hemodynamic instability may have inadequate tissue oxygen delivery or abnormal oxygen consumption. The amount of oxygen delivered to the tissues or consumed can be calculated. A catheter positioned in the pulmonary artery, termed a pulmonary artery catheter, is used for mixed venous sampling (see Chapter 68). Blood drawn from a pulmonary artery catheter is termed a mixed venous blood gas sample because it consists of venous blood that has returned to the heart from all tissue beds and “mixed” in the right ventricle. Normal mixed venous values are listed in Table 28.1. When tissue oxygen delivery is inadequate or when the amount of oxygen transported to the tissues by the hemoglobin is inadequate, the PvO2 and SvO2 fall.  Oximetry.  Arterial oxygen saturation can be monitored continuously by means of a pulse oximetry probe on a finger, a toe, an ear, the forehead, or the bridge of the nose (Figure 28.7).

Early or late Early or late Early or late

A pulse oximeter emits two wavelengths of light, one red and one infrared, which pass from a light-­emitting diode (positioned on one side of the probe) to a photodetector (positioned on the opposite side). Well-­oxygenated blood absorbs light differently from deoxygenated blood. The oximeter determines the amount of light absorbed by the vascular bed and calculates the saturation. The oxygen saturation value obtained by pulse oximetry (SpO2) and heart rate are displayed on the monitor as digital readings (see Figure 28.7, B). The normal SpO2 is higher than 95%. Pulse oximetry is particularly valuable in critical care and perioperative areas, in which sedation or decreased consciousness might mask hypoxia (Table 28.2). SpO2 is assessed during each routine check of vital signs in many inpatient areas. Changes in SpO2 can be detected quickly and treated (Table 28.3). Oximetry is also used during exercise testing and when flow rates are adjusted during long-­term oxygen therapy. Values obtained by pulse oximetry are less reliable if the SpO2 is lower than 70%. At this level, the oximeter tends to underestimate saturation and may display an artificially low value. Pulse oximetry is also inaccurate if hemoglobin variants (e.g., carboxyhemoglobin, methemoglobin) are present. Other factors that can alter the accuracy of pulse oximetry include motion, low perfusion, anemia, bright fluorescent lights, intravascular dyes, thick acrylic nails, and dark skin colour. If there is doubt about the accuracy of the SpO2 reading, ABGs should be measured to verify accuracy. Oximetry can also be used to monitor SvO2 via a pulmonary artery catheter. A decrease in SvO2 suggests that less oxygen is being delivered to the tissues or that more oxygen is being consumed. Changes in SvO2 provide an early warning of a change in cardiac output or tissue oxygen delivery. Normal SvO2 is 60 to 80%. 

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SECTION 5  Conditions of Oxygenation: Ventilation

TABLE 28.3    CRITICAL VALUES FOR PaO2 AND SpO2* PaO2

SpO2

Considerations

≥70%

≥95%

60%

90%

55%

88%

40%

75%

25 breaths/min in older persons

Hyperventilation

Increase in rate and depth

Kussmaul’s respirations

Regular, rapid, and deep respirations

Inspection Pursed-­lip breathing Tripod position; inability to lie flat Accessory muscle use; intercostal retractions Splinting ↑ Anteroposterior diameter

COPD, asthma, cystic fibrosis; lung hyperinflation; advanced age Drug-­induced depression of the respiratory centre in the medulla, increased intracranial pressure, and diabetic coma Narcotic or anaesthetic overdose; can occur with effort to avoid pain (e.g., rib fracture, chest trauma, thoracic or abdominal surgery) Fever, anxiety, hypoxemia, restrictive lung disease; ↑ above normal respiratory rate reflects increased work of breathing Extreme exertion, fear or anxiety; diabetic ketoacidosis, hepatic coma, salicylate overdose, midbrain lesions; compensation for metabolic acidosis Metabolic acidosis; ↑ in rate aids body in ↑ CO2 excretion

CHAPTER 28  Nursing Assessment: Respiratory System

559

TABLE 28.9    ASSESSMENT ABNORMALITIES Respiratory System—cont’d Finding

Description

Possible Etiology and Significance*

Cheyne-­Stokes respirations

Regular breathing pattern (30–45 sec) with increasing then decreasing rate and depth, followed by periods of apnea (20 sec) Bluish coloration of skin, best seen in earlobes, under the eyelids, or in nail beds ↑ Depth, bulk, sponginess of distal digit of finger; angle between nail base and nail ≥180° Inward (rather than normal outward) movement of abdomen during inspiration

Older persons in sleep; severe heart failure, renal failure, meningitis, drug overdose and increased intracranial pressure ↓ Oxygen transfer in lungs, ↓ cardiac output; nonspecific, unreliable indicator Chronic hypoxemia; COPD, cystic fibrosis, lung cancer, bronchiectasis Inefficient and ineffective breathing pattern; nonspecific indicator of severe respiratory distress

Tracheal deviation

Leftward or rightward movement of trachea from normal midline position

Altered tactile fremitus

Increase or decrease in vibrations

Altered chest movement

Diminished movement (can be asymmetrical or symmetrical) of two sides of chest with inspiration

Nonspecific indicator of change in position of mediastinal structures; medical emergency if caused by tension pneumothorax ↑ In pneumonia, pulmonary edema; ↓ in pleural effusion, lung hyperinflation; absent in pneumothorax, atelectasis Asymmetrical movement caused by atelectasis, pneumothorax, pleural effusion, splinting; symmetrical but diminished movement caused by barrel shape of chest, restrictive disease, neuromuscular disease

Cyanosis Clubbing of fingers Abdominal paradox

Palpation

Percussion Hyper-­resonance Dullness

Loud, lower-­pitched sound over areas that normally produce a resonant sound Medium-­pitched sound over areas that normally produce a resonant sound

Lung hyperinflation (COPD), lung collapse (pneumothorax), air trapping (asthma) ↑ Density (pneumonia, widespread atelectasis), ↑ fluid pleural space (pleural effusion)

Series of short, explosive, high-­pitched sounds heard just before the end of inspiration; rapid equalization of gas pressure when collapsed alveoli or terminal bronchioles suddenly snap open; sounds similar to rolling hair between fingers just behind ear Series of short, low-­pitched sounds on inspiration and sometimes expiration; air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa; sounds similar to blowing through straw under water (increase in bubbling quality with more fluid) Continuous high-­pitched squeaking sound caused by rapid vibration of bronchial walls; first evident on expiration; possibly evident on inspiration as obstruction of airway increases; possibly audible without stethoscope Continuous musical sound of constant pitch; result of partial obstruction of larynx or trachea No sound evident over entire lung or area of lung

Interstitial fibrosis (asbestosis), interstitial edema (early pulmonary edema), alveolar filling (pneumonia), loss of lung volume (atelectasis), early phase of heart failure

Auscultation Fine crackles

Coarse crackles

Wheezes

Stridor Absence of breath sounds

Pleural friction rub

Creaking or grating sound occurs when roughened, inflamed surfaces of pleura rub together; evident on inspiration, expiration, or both; no change with coughing; usually painful, especially on deep inspiration

Heart failure, pulmonary edema, pneumonia with severe congestion, COPD

Bronchospasm (caused by asthma), airway obstruction (caused by foreign body; tumour; viscous, thick increased secretions), COPD, pneumonia, bronchiectasis Croup, epiglottitis, vocal cord edema after extubation, foreign body Pleural effusion, mainstem bronchi obstruction, widespread atelectasis, pneumonectomy, lobectomy, severe acute asthma (i.e., silent chest) Pleurisy, pneumonia, pulmonary infarct

*Only common causes are listed. (These conditions are discussed further in Chapters 29 through 31.) COPD, chronic obstructive pulmonary disease.

Tuberculin Skin Testing.  When reading tuberculin skin test (TST) results, the nurse should use a good light and the reading should be performed within 48 to 72 hours after the purified protein derivative is administered (PHAC, The Lung Association, & Canadian Thoracic Society, 2014). If an area of induration (i.e., hardness) is present, the widest diameter of the induration is measured in millimetres. Areas of erythema (i.e., redness) without induration are not considered significant. Situations associated with positive reactions are described in Table 28.12. Canadian health care settings use tuberculin purified protein (Tubersol) for skin tests. If any patient has had

a previous bacille Calmette-­Guérin vaccination, it will affect results. This is significant especially for people from Quebec, Newfoundland, and Indigenous populations, who regularly received this vaccine from 1940 through the 1970s (PHAC, 2020). 

Radiological Studies Chest Radiography.  Chest radiographic examination is the most common method of assessing the respiratory system. It is also used to assess progression of disease and response to treatment. The views most commonly used are posteroanterior and

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SECTION 5  Conditions of Oxygenation: Ventilation

lateral. (See Table 28.11 for nursing responsibilities related to chest radiographic examinations.)  Computed Tomography.  Computed tomography (CT) may be used to examine cross-­sections of the entire body. CT is used to evaluate areas that are difficult to assess by conventional radiographic study, such as the mediastinum, the hilum, and the pleura. With enhancement by a contrast medium, with a high-­ resolution technique, or with newer spiral CT, even pulmonary arteries can be inspected for emboli.  Magnetic Resonance Imaging.  While in a strong magnetic field, the alignment of spinning nuclei can be changed with a superimposed radiofrequency, and the rate at which they return to alignment with the field can be measured. Magnetic resonance imaging (MRI) is used to produce images of body structures. MRI has limited indications. It is most useful for evaluating images near the lung apex or the spine and for distinguishing vascular from nonvascular structures. 

CASE STUDY Diagnostic Studies The health care provider orders the following diagnostic studies for F. T.: • Complete blood cell count, basic metabolic panel (electrolytes, blood urea nitrogen, creatinine) • ABGs • Chest radiograph • Sputum for culture and sensitivity The ABGs demonstrate a compensated respiratory acidosis (pH, 7.37; PaCO2, 58 mm Hg; HC03−, 29 mEq/L) with hypoxemia (PaO2, 58 mm Hg; SaO2, 87%). The white blood cell count is 14.3 × 109/L, and the chest radiograph shows lower lobe pneumonia. F. T. is admitted to the cardiopulmonary medical-­surgical nursing unit. See Case Study: Patient Introduction, Case Study: Subjective Data, and Case Study: Objective Data: Physical Examination for more information on F. T.

Ventilation–Perfusion Scan.  A ventilation–perfusion scan is used primarily to check for the presence of a pulmonary embolus. There is no specific preparation or aftercare. A radioisotope is administered intravenously for the perfusion portion of the test; it outlines the pulmonary vasculature, which is then photographed. For the ventilation portion, the patient inhales a radioactive gas, which outlines the alveoli, and another photograph is taken. Normal scans show homogeneous radioactivity. Diminished appearance or absence of radioactivity is suggestive of lack of perfusion or airflow.  Pulmonary Angiography.  Pulmonary angiography is used to confirm the diagnosis of an embolus if findings of the lung scan are inconclusive. A series of radiographs is taken after radiopaque dye is injected into the pulmonary artery. This test can also detect congenital and acquired lesions of the pulmonary vessels.  Positron Emission Tomography.  Positron emission tomography (PET) scans involve the use of radionuclides with short half-­lives. PET scans are used to distinguish benign from malignant solitary pulmonary nodules. Because uptake of glucose is increased in malignant lung cells, the PET scan, in which an intravenous glucose preparation is used, can demonstrate the presence of malignant lung cells. 

Endoscopic Examinations Bronchoscopy.  Bronchoscopy is a procedure in which the bronchi are visualized through a fibre-­optic tube. Bronchoscopy may be used to obtain biopsy specimens, assess changes resulting from treatment, and remove mucous plugs or foreign bodies. Small amounts (30 mL) of sterile saline may be injected through the bronchoscope, then withdrawn, and examined for cells. This technique, termed bronchoalveolar lavage, is used to diagnose Pneumocystis jiroveci pneumonia (PCP; see Figure 28.13).

TABLE 28.10    CHEST EXAMINATION FINDINGS IN COMMON PULMONARY CONDITIONS Condition

Inspection

Palpation

Percussion

Auscultation

Chronic bronchitis

Barrel shape of chest; cyanosis; possible clubbing of fingers Barrel shape of chest; tripod position; use of accessory muscles Prolonged expiration; tripod position; pursed lips

—

Resonant

↓ Chest expansion

Hyper-­resonant or dull if consolidation is present

Crackles over deflated areas; wheeze may be present Crackles diminished if no exacerbation is present

↓ Chest expansion ↓ Fremitus if hyperinflation is present

Hyper-­resonance

Unequal movement with lobar involvement; ↑ fremitus over affected area If area affected is small, no change If area affected is large, ↓ movement on affected side; ↑ fremitus ↓ Chest expansion or normal movement ↓ Chest expansion ↑ Fremitus above effusion; absence of fremitus over effusion ↓ Chest expansion

Dull over affected areas

Emphysema

Asthma (during an exacerbation)

Pneumonia

Tachypnea; use of accessory muscles; cyanosis

Atelectasis

No change unless entire segment or lobe is involved

Pulmonary edema

Tachypnea; laboured respirations; cyanosis Tachypnea; use of accessory muscles

Pleural effusion

Pulmonary fibrosis

Tachypnea

Wheezes; ↓ breath sounds are ominous sign if no improvement occurs (represent severely diminished air movement) Early: bronchial sounds Later: crackles; wheezes

Dull over affected areas

Crackles (may disappear with deep breaths); absence of sounds if large area is affected

Dull or normal, depending on amount of fluid Dull

Fine or coarse crackles

Normal

Diminished or absent over effusion; egophony over effusion Crackles

CHAPTER 28  Nursing Assessment: Respiratory System

561

TABLE 28.11    DIAGNOSTIC STUDIES Respiratory System Study

Description and Purpose

Nursing Responsibility

Value reflects amount of hemoglobin available for combination with oxygen. Venous blood is sampled. Normal level for men is 140–180 mmol/L; normal level for women is 120–160 mmol/L. Value reflects ratio of red blood cells to plasma cells. Hematocrit is increased (polycythemia) in chronic hypoxemia. Venous blood is sampled. Normal value for men is 0.42–0.52; normal value for women is 0.37–0.47. Values reflect acid–base balance, ventilation status, need for oxygen therapy, change in oxygen therapy, or change in ventilator settings.* Arterial blood is obtained through puncture of radial or femoral artery or through arterial catheter. Continuous ABG monitoring is also possible via a sensor or electrode inserted into the arterial catheter.

Explain procedure and its purpose.

Blood Studies Hemoglobin (Hb) measurement

Hematocrit (Hct) measurement

ABG measurements

Oximetry

Test monitors arterial or venous oxygen saturation. Oximetry is used for intermittent or continuous monitoring and exercise testing.†,‡ Device attaches to finger, forehead, earlobe, or nose for SpO2 monitoring or is contained in a pulmonary artery catheter for SvO2 monitoring.

Explain procedure and its purpose.

Indicate whether patient is using supplemental oxygen (percentage, amount per minute). Avoid change in oxygen therapy or interventions (e.g., suctioning, position change) for 20 min before obtaining sample. Assist with positioning (e.g., palm up, wrist slightly hyperextended if radial artery is used). Collect blood into heparinized syringe. To ensure accurate results, expel all air bubbles, and place sample on ice, unless it will be analyzed in 80% of predicted >80% of predicted ≈170 L/min ≤600 L/min ≤80 cm H2O

*Normal values vary with height, weight, age, and sex of patient.

Pulmonary Function Tests Pulmonary function tests (PFTs) are conducted to measure lung volumes and airflow. The results of PFTs are used to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators. In PFTs, a spirometer is used. The patient’s age, sex, height, and weight are entered into the PFT computer to calculate predicted values. The patient inserts a mouthpiece, takes as deep a breath as possible, and exhales as hard, fast, and long as possible. Verbal coaching is given to ensure that the patient continues blowing out until exhalation is complete. The computer determines the actual value achieved, predicted (normal) value, and percentage of the predicted value for each test. A normal actual value is 80 to 120% of the predicted value. Normal values for PFTs are shown in Tables 28.13 and 28.14, and the relationships between lung volumes and capacities are described in Figure 28.16. Home spirometry may be used to monitor lung function in persons with asthma or cystic fibrosis, as well as before and after lung transplantation. Changes in spirometry values at home can warn of early lung transplant rejection or infection. Feedback from a peak expiratory flowmeter can increase the sense

Maximal inhalation

IRV (3 000 mL)

IC (3 500 mL) VC (4 500 mL)

TLC (6 000 mL)

VT (500 mL) ERV (1 000 mL) FRC (2 500 mL)

Maximal exhalation

RV (1 500 mL)

FIG. 28.16  Relationship of lung volumes and capacities. ERV, expiratory

reserve volume; FRC, functional residual capacity; IC, inspiratory capacity; IRV, inspiratory reserve volume; RV, residual volume; TLC, total lung capacity; VC, vital capacity; VT, tidal volume.

CHAPTER 28  Nursing Assessment: Respiratory System of control achieved when persons with asthma learn to modify activities and medications in response to changes in rates of peak expiratory flow. Pulmonary function parameters can also be used to determine the need for mechanical ventilation or the readiness to be weaned from ventilatory support. Vital capacity, maximum inspiratory pressure, and minute volume are measured to make this determination (see Tables 28.13 and 28.14). 

Exercise Testing Exercise testing is used in diagnosis, in determining exercise capacity, and for disability evaluation. A complete exercise test involves walking on a treadmill while expired oxygen and

565

carbon dioxide, respiratory rate, heart rate, and rhythm are monitored. A modified test (desaturation test) may also be used. In that case, only SpO2 is monitored. A desaturation test can also be used to determine the oxygen flow needed to maintain the SpO2 at a safe level during activity or exercise in patients who use home oxygen therapy. A timed walk can also be used to measure exercise capacity. The patient is instructed to walk as far as possible during a timed period (6 or 12 minutes), to stop when short of breath, and to continue when able. The distance walked is measured, and the data are used to monitor progression of disease or improvement after rehabilitation.

 REVIEW QUESTIONS 7. During the respiratory assessment of an older adult, the nurse would expect to find which of the following? (Select all that apply.) a. A vigorous cough b. Increased chest expansion c. Increased residual volume d. Increased breath sounds in the lung apices e. Increased anteroposterior (AP) chest diameter 8. Which of the following should the nurse inquire about when assessing activity and exercise related to respiratory health? a. Dyspnea during rest or exercise b. Recent weight loss or weight gain c. Ability to sleep through the entire night d. Willingness to wear oxygen equipment in public 9. Which of the following is the best tool to assess for the vibration of tactile fremitus? a. Palms b. Fingertips c. Stethoscope d. Index fingers 10. Which of the following is an abnormal finding in the assessment of the respiratory system? a. Presence of tactile fremitus b. Inspiratory chest expansion of 2.5 cm c. Percussion resonance over the lung bases d. Symmetrical chest expansion and contraction 11. Which of the following is performed to remove pleural fluid for analysis? a. Thoracentesis b. Bronchoscopy c. Pulmonary angiography d. Sputum culture and sensitivity 1. c; 2. d; 3. a; 4. a; 5. c; 6. b; 7. c, e; 8. a; 9. a; 10. a; 11. a.

The number of the question corresponds to the same-­numbered objective at the beginning of the chapter. 1. Which of the following is the mechanism that stimulates the release of surfactant? a. Fluid accumulation in the alveoli b. Alveolar collapse from atelectasis c. Alveolar stretch from deep breathing d. Air movement through the alveolar pores of Kohn 2. Which of the following causes air to enter the thoracic cavity during inspiration? a. Contraction of the accessory abdominal muscles b. Increased carbon dioxide and decreased oxygen in the blood c. Stimulation of the respiratory muscles by the chemoreceptors d. Decreased intrathoracic pressure relative to pressure at the airway 3. Which of the following measures the lungs’ ability to adequately oxygenate the arterial blood? a. Arterial oxygen tension b. Carboxyhemoglobin level c. Arterial carbon dioxide tension d. Venous carbon dioxide tension 4. Which of the following is the most important respiratory defence mechanism distal to the respiratory bronchioles? a. Alveolar macrophage b. Impaction of particles c. Reflex bronchoconstriction d. Mucociliary clearance mechanism 5. Which of the following is caused by a rightward shift of the oxygen–hemoglobin dissociation curve? a. Metabolic alkalosis b. Postoperative hypothermia c. Release of oxygen at the tissue level d. Greater affinity of oxygen for hemoglobin 6. Which of the following are very early signs or symptoms of inadequate oxygenation? a. Dyspnea and hypotension b. Apprehension and restlessness c. Cyanosis and cool, clammy skin d. Increased urine output and diaphoresis

For even more review questions, visit http://evolve.elsevier.com/Canada/ Lewis/medsurg.

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REFERENCES Cobb, N. K., & Solanki, J. N. (2020). E-­cigarettes, vaping devices, and acute lung injury. Respiratory Care, 65(5), 713–718. https://doi-­ org.eztest.ocls.ca/10.4187/respcare.07733 Health Canada. (2018). Health Canada statement on use of vaping products by youth. https://www.canada.ca/en/health-­canada/news/ 2018/11/health-­canada-­statement-­on-­use-­of-­vaping-­products-­by-­ youth.html Herlihy, B. (2021). The human body in health and illness (7th ed.). Elsevier Saunders. Jarvis, C., Browne, A., MacDonald-­Jenkins, J., et al. (2019). Physical examination & health assessment (3rd Canadian ed.). Elsevier. McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Mosby. Patton, K. T. (2019). Anatomy and physiology (10th ed.). Mosby. Public Health Agency of Canada (PHAC). (2019). An Advisory Committee Statement (ACS) National Advisory Committee on Immunization (NACI): Canadian immunization guide chapter on influenza and statement on seasonal influenza vaccine for 2019–2020, (pp. 6 12–13). https://www.canada.ca/conte nt/dam/phac-­aspc/documents/services/publications/healt hy-­living/canadian-­immunization-­guide-­statement-­seasonal-­ influenza-­vaccine-­2019-­2020/NACI_Stmt_on_Seasonal_Influenz a_Vaccine_2019-­2020_v12.3_EN.pdf Public Health Agency of Canada (PHAC). (2020). Canadian immunization guide: Bacille Calmette-­Guérin (BCG) vaccine. https://www.canada.ca/en/public-­health/services/publications/heal thy-­living/canadian-­immunization-­guide-­part-­4-­active-­vaccines/ page-­2-­bacille-­calmette-­guerin-­vaccine.html Public Health Agency of Canada (PHAC). (2021a). About vaping. https://www.canada.ca/en/health-­canada/services/smoking-­ tobacco/vaping.html Public Health Agency of Canada (PHAC). (2021b). Canadian immunization guide: Part 4—Active vaccines. https://www.canada.ca/en/public-­health/services/publica tions/healthy-­living/canadian-­immunization-­guide-­part-­4-­active-­vaccines.html

Public Health Agency of Canada (PHAC). (2021c). Coronavirus disease (COVID-­19): Symptoms and treatment. https://www.canada.ca/en/public-­health/services/diseases/2019-­ novel-­coronavirus-­infection/symptoms.html Public Health Agency of Canada (PHAC), The Lung As­sociation, & Ca­nadian Thoracic Society. (2014). Canadian tuberculosis standards (7th ed.). https://www.canada.ca/en/public-­health/services/infectious-­ diseases/canadian-­tuberculosis-­standards-­7th-­edition.html Public Health Ontario. (2021). Technical brief: IPAC recommendations of use of personal protective equipment for care of individuals with suspect or confirmed COVID-­19. https://www.publichealthontar io.ca/-­/media/documents/ncov/updated-­ipac-­measures-­covid-­ 19.pdf?la=en Registered Nurses Association of Ontario (RNAO) (2005). Nursing care of dyspnea: the 6th vital sign in individuals with chronic obstructive pulmonary disease (COPD). https://rnao.ca/sites/rnao-­ ca/files/Nursing_Care_of_Dyspnea_-The_6th_Vital_Sign_in_Indi viduals_with_Chronic_Obstructive_Pulmonary_Disease.pdf Registered Nurses’ Association of Ontario (RNAO). (2013). Best practice guidelines: Developing and sustaining interprofessional health care. Optimizing patient, organizational and system outcomes. https://rnao.ca/sites/rnao-­ca/files/DevelopingAndSustainingBPG .pdf Registered Nurses’ Association of Ontario (RNAO). (2016). System and healthy work environment best practice guidelines. Intra-professional collaborative practice among nurses (2nd ed.). https://rnao.ca/sites/rnao-­ca/files/bpg/Intra-­professional_Collabor ative_Practice_042017.pdf Urden, L. D., Stacy, K. M., & Lough, M. E. (2018). Critical care nursing: Diagnosis and management (8th ed.). Elsevier Mosby.

RESOURCES Resources for this chapter are listed in Chapters 30 and 31. For additional Internet resources, see the website for this book at http://evolve.elsevier.com/Canada/Lewis/medsurg.

CHAPTER

29

Nursing Management

Upper Respiratory Conditions Mary Kate Garrity Originating US chapter by Eugene Mondor

WEBSITE http://evolve.elsevier.com/Canada/lewis/medsurg • • • •

 eview Questions (Online Only) R Key Points Answer Guidelines for Case Study Student Case Study • Head and Neck Cancer: Laryngectomy With Tracheostomy

• Customizable Nursing Care Plans • Tracheostomy • Total Laryngectomy and/or Radical Neck Surgery • Conceptual Care Map Creator • Audio Glossary

• S  upporting Media—Animation • Anatomical Location of Sinuses • Content Updates

LEARNING OBJECTIVES 1. Describe the clinical manifestations and nursing management of conditions of the nose. 2. Describe the clinical manifestations and nursing management of conditions of the paranasal sinuses. 3. Describe the clinical manifestations and nursing management of conditions of the pharynx and the larynx. 4. Discuss the nursing management of the patient who requires a tracheostomy.

5. Identify the steps involved in performing tracheostomy care and suctioning an airway. 6. Describe the risk factors and warning symptoms associated with head and neck cancer. 7. Discuss the nursing management of the patient with a laryngectomy. 8. Describe the methods used in voice restoration for the patient with temporary or permanent loss of speech.

KEY TERMS allergic rhinitis deviated septum epistaxis esophageal speech

  

nasal fracture nasal polyps rhinoplasty septoplasty

Disorders of the upper respiratory system, including the nose, sinuses, pharynx, and larynx, and the care of patients undergoing surgery for head and neck cancers are the focus of this chapter. The primary concern with these conditions is the impact on ventilation and oxygen (O2) availability. These disorders can also negatively affect sleep, impair the ability to maintain adequate nutrition, change the senses of both smell and taste, and may lead to depression and changes in body image and sexuality.

  STRUCTURAL AND TRAUMATIC DISORDERS OF THE NOSE

tracheostomy tracheotomy

normal childhood growth, or a congenital defect. On inspection, the septum is bent to one side, significantly altering air flow and nasal drainage. The patient may experience obstruction to nasal breathing, nasal edema, or dryness of the nasal mucosa with crusting and bleeding (epistaxis). A severely deviated septum may block drainage of mucus from the sinus cavities, resulting in infection (sinusitis) (Patton & Thibodeau, 2016). For patients with severe symptoms, a nasal septoplasty (surgical realignment of the septum) is performed to reconstruct and properly align the deviated septum. Medical management of deviated septum also includes nasal allergy control, as in allergic rhinitis (discussed later in this chapter). 

DEVIATED SEPTUM

NASAL FRACTURE

Deviated septum is a misalignment of a normally straight nasal septum. Causes of a deviated septum include trauma to the nose,

Nasal fracture is most often caused by trauma of substantial force to the middle of the face. Facial fractures occur four to

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five times more often in Indigenous people in Canada than in the non-­Indigenous population (Brennan-­Olsen et  al., 2017). Some cases of facial trauma can be prevented by using protective sports equipment and protecting against falls. Complications of a nasal fracture include airway obstruction, epistaxis, meningeal tears, and cosmetic deformity. Nasal fractures are classified as unilateral, bilateral, or complex. A unilateral fracture typically produces little or no displacement. Bilateral fractures, the most common type, give the nose a flattened look. Powerful frontal blows cause complex fractures, which may also shatter the frontal bones. Injury of enough force to fracture nasal bones results in considerable swelling of soft tissues, which can make it difficult to verify the extent of deformity or to repair the fracture until several days later, when the edema subsides. Diagnosis is based on the health history, direct observation, and radiographic findings. The patient’s ability to breathe through each side of the nose needs to be assessed. The nurse should note the presence of edema, bleeding, or hematoma. The nose is inspected internally for evidence of deviated septum, hemorrhage, or clear drainage. Periorbital bruising (ecchymosis) involving both eyes is called raccoon eyes and often suggests a basilar skull fracture. If the nurse notes periorbital bruising, the patient should be assessed for a cerebrospinal (CSF) leak. Clear, pink-­tinged, or persistent drainage from the nose (rhinorrhea) or ear (otorrhea) suggests a CSF leak. If needed, a specimen should be sent to the laboratory to determine the fluid type. The goals of nursing management are to reduce edema, prevent complications, and provide emotional support. Ice may be applied to the face and nose to reduce edema and bleeding. When a fracture is confirmed, the goal of management is to realign the fracture using closed or open reduction (septoplasty, rhinoplasty). These procedures are used to re-­establish cosmetic appearance and proper function of the nose and to provide an adequate airway. After the patient undergoes nasal surgery, the patient should be assessed for the ability to mouth-­breathe. Nasal intubation or use of a nasogastric tube should be avoided in any patient suspected of having a nasal fracture (Rothrock, 2019).

Surgical Procedures Rhinoplasty refers to surgery performed on the nose to remodel or reconstruct the external nose. Septoplasty refers to rhinoplasty in addition to reconstruction and remodelling of the nasal septum, the internal wall which separates the two sides of the nose. Assessment of the patient’s expectations is a critical aspect in preparation for surgery. Expected results of surgery should be explained frankly and truthfully to prepare the patient for any psychosocial or body image changes (Rothrock, 2019). Interprofessional Care.  Rhinoplasty and septoplasty surgeries are performed as an outpatient procedure, using regional anaesthesia. Nasal tissue may be added or removed, and the nose may be lengthened or shortened. Plastic implants are sometimes used to reshape the nose. If the nasal bones are crooked and pushing the septum off to one side, it may be necessary to make cuts in the bones of the nose to reposition them. Small, reinforcing strips of cartilage can be used to help straighten a deviated septum. After surgery, nasal packing may be inserted to apply pressure and prevent bleeding or septal hematoma formation. Nasal septal splints may be inserted to help prevent formation of

scar tissue between the surgical site and the lateral nasal wall. Adhesive-­strip skin closures are placed to hold the skin against the septal cartilage. Typically, nasal packing is removed the day after surgery, and the splint is removed in 3 to 5 days. A small dressing under the nostrils is changed as often as every 2 hours during the first 24 hours. The patient is instructed to prevent pressure on the surgical site by sneezing through the mouth (Rothrock, 2019). 

NURSING MANAGEMENT NASAL SURGERY Before surgery, the patient should be instructed to not take medications containing acetylsalicylic acid (i.e., Aspirin) or nonsteroidal anti-­inflammatory drugs (NSAIDs) for 2 weeks to reduce the risk for bleeding. Nursing interventions during the immediate postoperative period include assessment of respiratory status, pain management, and observation of the surgical site for hemorrhage and edema. Discharge teaching is important because the patient must be able to detect complications, such as bright red bleeding lasting more than 10 minutes, heavy bleeding, vision problems, including black eyes, and a fever over 38°C (Rothrock, 2019). There is an interim period while edema and ecchymosis resolve before the final cosmetic effect can be achieved. 

EPISTAXIS Epistaxis (nosebleed) occurs in all age groups, especially in children and older patients. Epistaxis may be caused by trauma, foreign bodies, dry air, nasal spray misuse, alcohol misuse, street drug use, anatomical malformation, allergic rhinitis, or tumours. Any condition that prolongs bleeding time or alters platelet counts will predispose the patient to epistaxis. Bleeding time may also be prolonged if the patient takes NSAIDs or anticoagulants, such as Aspirin. Chronic conditions, such as hypertension, are associated with an increased risk and severity of epistaxis (Byun et  al., 2020). Elevated blood pressure, however, makes bleeding more difficult to control. About 90% of epistaxis cases occur in the anterior portion of the nasal cavity and are easily visualized. Anterior bleeding can be self-­treated and usually stops spontaneously. Posterior bleeding occurs more often in older persons, secondary to other health conditions (e.g., hypertension). Since posterior nosebleeds are closer to the throat, it is often hard to determine how much blood loss has occurred. Posterior bleeding may need medical treatment. 

NURSING AND INTERPROFESSIONAL MANAGEMENT EPISTAXIS Simple first-­aid measures should be attempted to control epistaxis. The nurse should (1) keep the patient quiet; (2) place the patient in a sitting position, leaning forward or, if not possible, in a reclining position with head and shoulders elevated; (3) apply direct nasal compression, pinching the soft lower portion of the nose for 10 to 15 minutes; (4) apply ice compresses to the forehead and have the patient suck on ice; (5) apply digital pressure if bleeding continues; and (6) obtain medical assistance if bleeding does not stop.

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blowing, strenuous activity, lifting, and straining for 4 to 6 weeks. The patient should be taught to sneeze with the mouth open and to avoid the use of ASA (Aspirin)–containing products or NSAIDs (Rothrock, 2019). 

  INFLAMMATION AND INFECTION OF THE NOSE AND PARANASAL SINUSES ALLERGIC RHINITIS

A

B

FIG. 29.1  Method for placing posterior nasal pack. A, Catheter is passed

through the bleeding side of the nose and pulled out through the mouth with a hemostat. Strings are tied to the catheter, and the pack is pulled up behind the soft palate and into the nasopharynx. B, Nasal pack in position in the posterior nasopharynx. Dental roll at the nose helps maintain correct position.

Medical management involves localization of the bleeding site and application of a vasoconstrictive agent, cauterization, or anterior packing by a health care provider. Anterior packing may consist of ribbon gauze infused with anaesthetic solution (lidocaine), a vasoconstrictive agent (epinephrine), or both, that is wedged firmly in the desired location and remains in place for 48 to 72 hours. If posterior packing is required, the patient should be hospitalized. Inflatable balloons may be used as a nasal pack, or gauze rolls may be inserted (Figure 29.1). Strings attached to the packing are brought to the outside and taped to the cheek for ease of removal. A nasal sling (a folded 2 × 2–inch gauze pad) should be taped over the nares to absorb drainage. Thermal cauterization is reserved for more severe bleeding and may require the use of local or general anaesthesia (Byun et al., 2020). Nasal sponges, packing, and balloons can impair respiratory status. The nurse needs to closely monitor level of consciousness, heart rate and rhythm, respiratory rate, and O2 saturation (SpO2) using pulse oximetry. The nurse should also observe for any signs of difficulty breathing or swallowing. Because of the increased risk for complications due to location of the injury, all patients with posterior packing should be admitted to a monitored unit for close observation. Packing is painful because much pressure needs to be applied to stop the bleeding. Nasal packing predisposes to infection from bacteria (e.g., Staphylococcus aureus) present in the nasal cavity. The patient should receive a mild opioid analgesic for pain (e.g., acetaminophen with codeine) and an antibiotic effective against staphylococci to protect against infection. Posterior packs are left in place for no longer than 48 hours because of the incidence of toxic shock syndrome and are usually removed by the surgeon. Before removal, the patient should be medicated for pain because this procedure is extremely uncomfortable. After removal, the nares may be gently cleaned and then lubricated with a petroleum or water-­based jelly. The patient can be discharged after being taught about home care. The patient should be instructed to avoid vigorous nose

Allergic rhinitis is inflammation of the nasal mucosa due to a specific allergen. Attacks of seasonal rhinitis usually occur in the spring and fall and are caused by an allergy to tree, flower, or grass pollens. A typical attack lasts for several weeks during times when pollen counts are high, then disappears, and recurs at the same time the following year. Perennial rhinitis is present intermittently or constantly. Symptoms are usually caused by specific environmental triggers such as pet dander, dust mites, moulds, or cockroaches. Because symptoms of perennial rhinitis resemble the common cold, the patient may believe the condition is a continuous or repeated cold.

Clinical Manifestations Manifestations of allergic rhinitis are nasal congestion; sneezing; watery, itchy eyes and nose; altered sense of smell; and thin, watery nasal discharge. The nasal turbinates appear pale, boggy, and swollen. With chronic exposure to allergens, the patient’s responses include headache, congestion, pressure, postnasal drip, and nasal polyps. The patient may experience cough, hoarseness, snoring, or the recurrent need to clear the throat. 

NURSING AND INTERPROFESSIONAL MANAGEMENT ALLERGIC RHINITIS Several steps are used in managing allergic rhinitis. The most important step involves identifying and avoiding triggers of allergic reactions (Table 29.1). The patient should be instructed to keep a diary of times when the allergic reaction occurs and the activities that precipitate the reaction. Steps can then be taken to avoid these triggers. Medication therapy involves using nasal sprays, leukotriene receptor antagonists, antihistamines, and decongestants to manage symptoms (Table 29.2). Intranasal corticosteroid and cromolyn sprays are effective for seasonal and perennial rhinitis. Nasal corticosteroid sprays are used to decrease inflammation locally; there is little absorption in the systemic circulation and, therefore, systemic adverse events are rare. Relief may require combining a nasal corticosteroid spray and an antihistamine. The patient using nasal inhalers needs careful instructions about proper use. Nasal decongestant sprays can be used only for up to 5 days because they can cause a rebound effect from prolonged use. Immunotherapy (“allergy injections”) may be used when a specific, unavoidable allergen is identified and medications are not tolerated or ineffective. Immunotherapy involves controlled exposure to small amounts of a known allergen through frequent (at least weekly) injections, with the goal of decreasing sensitivity. (The mechanisms involved in the allergic response and immunotherapy are discussed in Chapter 16.)

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SECTION 5  Conditions of Oxygenation: Ventilation

TABLE 29.1    PATIENT & CAREGIVER TEACHING GUIDE How to Reduce Symptoms of Allergic Rhinitis Include the following information when teaching the patient and caregiver how to reduce symptoms of allergic rhinitis.









1. Avoidance of allergens is the best treatment. 2. Avoid house dust. Use the approach, “less is best.” Focus on the bedroom. Remove carpeting. Limit furniture. Enclose pillows, mattress, and springs in airtight, vinyl encasements. Limit clothing in the bedroom to items used frequently. Place clothing in airtight, zipper-­sealed, vinyl clothes bags. Install an air filter. Close the air-­conditioning vent into the room. Limit stuffed toys. 3. Avoid house dust mites. Wash bedding in hot water (55°C), weekly. Wear a mask when vacuuming. Double-­bag the vacuum cleaner. Install a filter on the outlet port of the vacuum cleaner. Avoid sleeping or lying on upholstered furniture. Remove carpets that are laid on concrete. If possible, have someone else clean the house. 4. Avoid mould spores. The three Ds that promote growth of mould spores are darkness, dampness, and drafts. Avoid places where humidity is high (e.g., basements, camps on the lake, clothes hampers, greenhouses, stables, barns). Dehumidifiers may be helpful in humid weather and in damp spaces. Ventilate closed rooms, open doors, and install fans. HEPA (high-­efficiency particulate air) filters may be beneficial. Consider adding windows to dark rooms. Consider keeping a small light on in closets. A basement light with a timer that provides light several hours a day may decrease mould growth. 5. Avoid pollens. Stay inside, with doors and windows closed, during high-­pollen season. Avoid the use of fans. Install an air conditioner with a good air filter. Wash filters weekly during high pollen season. Put the car air conditioner on “recirculate” when driving. Get someone else to tend to your yard. 6. Avoid pet allergens. Remove pets from the interior of the home. Clean the living area thoroughly. Do not expect instant relief. Symptoms usually do not improve significantly for 2 months following pet removal. 7. Avoid exposure to smoke. The presence of a smoker will sabotage the best of all possible symptom-­reduction programs.

TABLE 29.2    MEDICATION THERAPY Allergic Rhinitis and Sinusitis Preparation

Mechanism of Action

Adverse Effects

Nursing Actions

Inhibits inflammatory response. At recommended dosage, systemic adverse effects are unlikely because of low systemic absorption. Systemic effects may occur with greater-­than-­recommended dosages.

Mild transient nasal burning and stinging; in rare instances, localized fungal infection with Candida albicans

• Teach patient correct use. • Instruct patient to use on regular basis and not PRN. • Explain to patient that the spray acts to decrease inflammation over time and does not have an immediate effect. • Discontinue use if nasal infection develops.

Inhibits degranulation of sensitized mast cells that occurs after exposure to specific antigens

Minimal adverse effects; occasional burning or nasal irritation

• Teach patient correct use. • Reinforce that spray prevents symptoms. • Begin 2 wk before pollen season starts and use throughout pollen season. • If isolated allergy, such as to cats, use prophylactically (i.e., 10–15 min before exposure to allergen).

Headaches, dizziness, rash, altered liver function tests, abdominal pain Zafirlukast: Monitor PT levels and theophylline levels if patient is taking coumadin or theophylline.

• Monitor liver function tests periodically while on therapy; discontinue if values elevate. • Administer on empty stomach. • Do not discontinue therapy without consulting health care provider. • Not to be used for acute attacks

Corticosteroids Nasal Spray Beclomethasone (Apo Beclomethasone) Budesonide (Rhinocort) Flunisolide (Apo-­Flunisolide) Fluticasone (Flonase) Triamcinolone (Nasacort) Ciclesonide (Omnaris)

Mast Cell Stabilizer Nasal Spray Cromolyn spray (Apo-­Cromolyn)

Leukotriene Receptor Antagonists (LTRAs) Antagonists Zafirlukast (Accolate) Montelukast (Singulair)

Antagonize or inhibit leukotriene activity, thereby inhibiting airway edema and bronchoconstriction through decreasing inflammatory process

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TABLE 29.2    MEDICATION THERAPY—cont’d Allergic Rhinitis and Sinusitis Preparation

Mechanism of Action

Adverse Effects

Nursing Actions

Blocks hypersecretory effects by competing for binding sites on the cell Reduces rhinorrhea in the common cold and allergic and nonallergic rhinitis

Dryness of the mouth and nose may occur Does not cause systemic adverse effects

• Teach patient correct use. • Reinforce that spray prevents symptoms, with onset of action within 1 hr of use. • May reduce need for other rhinitis medications

Bind with H1 receptors on target cells, blocking histamine binding Relieve acute symptoms of allergic response (itching, sneezing, excessive secretions, mild congestion)

First-­generation agents cross blood– brain barrier, bind to H1 receptors in brain, and cause sedation (diminished alertness, slow reaction time, somnolence) and stimulation (restlessness, nervousness, insomnia). Some medications (e.g., ethanolamines) are more likely to cause sedation. Patients vary in their sensitivity to these adverse effects. The next most common adverse effects involve the GI system and include loss of appetite, epigastric distress, constipation, or diarrhea. They may cause palpitations, tachycardia, or urinary retention or frequency.

• Warn patient that operating machinery and driving may be dangerous because of sedative effect. Drowsiness usually passes after 2 wk of treatment. • Teach patient to report palpitations, change in heart rate, change in bowel, bladder habits. • Instruct patient not to use alcohol with antihistamines because of additive depressant effect. • Rapid onset of action, no medication tolerance with prolonged use • Limited use with sinusitis

—

Second-­generation agents have limited affinity for brain H1 receptors; they cause minimal sedation; few effects on psychomotor activities, bladder function.

• Teach patient to expect few, if any, adverse effects. • More expensive than classical antihistamines • Rapid onset of action, no medication tolerance with prolonged use General interactions: • Do not take with alcohol or any form of tranquilizer or sedative. • Do not take with any monoamine oxidase inhibitor.

Stimulate adrenergic receptors on blood vessels, promote vasoconstriction, and reduce nasal edema and rhinorrhea

CNS stimulation, causing insomnia, excitation, headache, irritability, increased blood and ocular pressure, dysuria, palpitations, tachycardia

• Advise patient of adverse reactions. • Advise that use of some preparations is contraindicated for patients with cardiovascular disease, hypertension, diabetes, glaucoma, prostate hyperplasia, and hepatic and renal disease. • Teach patient that these medications should not be used for more than 3 days or more than three or four times a day; longer use increases risk for rebound vasodilation, which can increase congestion.

Same as above Blocks action of histamine

Same as above, plus rhinitis medicamentosa (rebound nasal congestion), headache, bitter taste, somnolence, nasal irritation

—

Anticholinergic Nasal Spray Ipratropium bromide (Atrovent)

Antihistamines First-­Generation Agents Ethanolamines Diphenhydramine (Benadryl) Ethylenediamines Tripelennamine (Vagin-­X) Alkylamines Brompheniramine (Dimetane) Chlorpheniramine (Chlor-­Tripolon)

Second-­Generation Agents Loratadine (Claritin) Cetirizine (Reactine) Fexofenadine (Allegra) Desloratadine (Aerius)

Decongestants Oral Pseudoephedrine (Sudafed)

Topical (Nasal Spray) Oxymetazoline (Dristan) Phenylephrine (Dimetapp)

CNS, central nervous system; GI, gastrointestinal; H1, histamine 1; PRN, as needed; PT, prothrombin time.

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MEDICATION ALERT—Antihistamines

• First-­generation antihistamines (e.g., diphenhydramine) can cause drowsiness and sedation. • Warn patients that operating machinery and driving may be dangerous because of the sedative effect.

MEDICATION ALERT—Pseudoephedrine

• Large doses may produce tachycardia and palpitations, especially in patients with cardiac disease. • Overdose in people over 60 years of age may result in central nervous system depression, seizures, and hallucinations. 

ACUTE VIRAL RHINITIS Acute viral rhinitis (common cold or acute coryza) is caused by viruses that invade the upper respiratory tract. It is the most prevalent infectious disease and is spread by airborne droplet sprays emitted by the infected person while breathing, talking, sneezing, or coughing or by direct hand contact. Frequency increases in the winter months, when people stay indoors, and overcrowding is more common. Other factors such as fatigue, physical and emotional stress, and compromised immune status may increase susceptibility. The patient with acute viral rhinitis typically first experiences tickling, irritation, sneezing, or dryness of the nose or nasopharynx, followed by copious nasal secretions, some nasal obstruction, watery eyes, elevated temperature, general malaise, and headache. After the early profuse secretions, the nose becomes more obstructed and the discharge is thicker. Within a few days, the general symptoms improve, nasal passages reopen, and normal breathing is re-­established. 

NURSING AND INTERPROFESSIONAL MANAGEMENT ACUTE VIRAL RHINITIS Supportive therapy such as rest, fluids, proper diet, antipyretics, and analgesics is the recommended treatment. Complications of acute viral rhinitis include pharyngitis, sinusitis, otitis media, tonsillitis, and lung infections. Antibiotics do not have a role in the treatment of viral rhinitis during the cold season; the patient with a chronic illness or a compromised immune status should be advised to avoid crowded, close situations and other persons who have obvious cold symptoms. Frequent hand hygiene and avoiding hand-­to-­face contact may help prevent direct spread. Interventions are directed toward relieving annoying and uncomfortable symptoms. The patient should be encouraged to drink increased amounts of fluids to liquefy secretions. Antihistamine or decongestant therapy reduces postnasal drip and significantly decreases severity of cough, nasal obstruction, and nasal discharge. The patient should be taught to recognize the symptoms of secondary bacterial infection, such as a temperature higher than 38°C; purulent nasal exudate; tender, swollen glands; and a sore, red throat. In the patient with pulmonary disease, signs of infection include a change in consistency, colour, or volume of the sputum. 

INFLUENZA Approximately 10 to 20% of Canadians become infected with seasonal influenza each year, which runs from October to April. The 2019–2020 influenza season ended in March 2020, which coincided with the start of the COVID-­19 pandemic. As of November 10, 2021, a total of 1 740 005 confirmed cases caused by the novel Coronavirus SARS-­CoV-­2 and 29 249 deaths were reported in Canada (Public Health Agency of Canada, 2021).

COMPLEMENTARY & ALTERNATIVE THERAPIES Echinacea Clinical Uses Common cold, upper respiratory tract infection, wound healing, urinary tract infections. 

Effects Can reduce cold episodes, pain-­killer medicated episodes, recurrent infections and complications of the common cold; anti-­inflammatory (Rondanelli et al., 2018) 

Nursing Implications • E  chinacea is considered safe when used on a short-­term basis in recommended doses. • Caution patients with autoimmune disorders or a tendency toward allergic reactions about using this herb. • May be used in conjunction with antibiotics. • Should not be taken for more than 8 weeks.

COMPLEMENTARY & ALTERNATIVE THERAPIES Zinc Clinical Uses Common cold, diarrhea, zinc deficiency 

Effects Antiviral effects; if taken within 24 hours of symptom onset may shorten the duration of colds by approximately 33% (Rondanelli et al., 2018) 

Nursing Implications • Intranasal zinc can cause an irreversible loss of the sense of smell. • Long-­term zinc use, especially in high doses, can cause copper deficiency and may increase the risk for urinary tract disorders and reduce immune function. • Zinc may interact with medications, including antibiotics and penicillamine.

Although the majority recover completely from influenza, an estimated 500 to 1 500 people die from influenza each year (IPAC Canada, 2021). Pneumonia, a common complication of influenza, combined with influenza kills more than 8 000 people a year (IPAC Canada, 2021). Much of the influenza-­related morbidity and mortality could be prevented by vaccination of high-­ risk groups (Table 29.3). Indigenous populations account for less than 5% of Canada’s population; however, they are amongst the hardest hit by influenza, including the 2009 H1N1 influenza epidemic, which saw hospitalization rates nearly triple that of non-­Indigenous populations (Boggild et  al., 2011). Therefore, nurses working with Indigenous populations need to take into account how the social determinants of health affect influenza prevention and management. There are three groups of influenza viruses—A, B, and C; note that influenza C has little pathogenic potential. Influenza viruses have a remarkable ability to change over time. This ability accounts for widespread disease and the need for annual vaccination against new strains. Fewer cases of influenza result when a minor change in the virus occurs and individuals have partial pre-­existing immunity (Public Health Agency of Canada [PHAC], 2018). Birds are natural carriers of influenza A viruses. Avian influenza H5N1 is circulating in some countries, especially in Asia and northeast Africa, and infecting many poultry populations and some humans (Fasanmi et  al., 2017). There is

CHAPTER 29  Nursing Management: Upper Respiratory Conditions no evidence that this virus is transmitted from person to person. Although seasonal influenza immunization will not prevent avian influenza infection, immunization is recommended for those in direct contact with poultry infected with avian influenza during the culling operation. The rationale is that preventing infection with human influenza strains may reduce the theoretical potential for human–avian reassortment of genes should workers become co-­infected with both influenza viruses (PHAC, 2015). The Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector document, updated in 2018, provides strategic guidance and a framework for pan-­Canadian preparedness and response. It is not a response plan (PHAC, 2018).

Clinical Manifestations The onset of the flu is typically abrupt, with systemic symptoms of cough, fever, and myalgia often accompanied by a headache and sore throat. Milder symptoms, similar to those of the common cold, may also occur. Physical findings are usually minimal, with normal assessment on chest auscultation. Dyspnea and diffuse crackles are signs of pulmonary complications. In uncomplicated cases, symptoms subside within 7 days. Some patients, particularly older adults, experience weakness or lassitude that persists for weeks. The convalescent phase may be marked by hyperactive airways and a chronic cough. Important diagnostic factors include the patient’s health history and clinical findings and the presence of other cases of influenza in the community. The most common complication of influenza is pneumonia. The patient who develops secondary bacterial pneumonia experiences gradual improvement of influenza symptoms and then worsening cough and purulent sputum. Treatment with antibiotics is usually effective if started early. 

NURSING AND INTERPROFESSIONAL MANAGEMENT INFLUENZA Regular handwashing and annual influenza vaccination are the most effective strategies to reduce the risk for influenza. The nurse should also advocate influenza vaccination for patients at high risk, during routine office visits or, if hospitalized, at the time of discharge (see Table 29.3). The vaccine is 70% to 90% effective in preventing influenza in adults. To be effective, the vaccine must be given in the fall (mid-­October), before exposure occurs. Although all healthy people 6 months and older should be encouraged to receive the vaccination, high priority should be given to pregnant women, people who are immunosuppressed, residents of long-­term care facilities and retirement settings, and groups that can transmit influenza to high-­risk persons, such as health care workers. Vaccination can decrease the risk of transmitting influenza to those who have less ability to cope with the effects of this illness. Despite obvious benefits, many persons are reluctant to be vaccinated. Current vaccines are highly purified, and reactions are extremely uncommon. Soreness at the injection site is usually the only adverse effect. Contraindications to the flu vaccine include children younger than 6 months and people with severe, life-­threatening allergies to an ingredient in the flu vaccine. People with a previous history of Guillain-­Barré syndrome following a vaccination should avoid future vaccinations. The primary goals in nursing management are supportive measures directed toward relief of symptoms and prevention of secondary infection. The patient should drink plenty of fluids and get plenty of rest. Older adults and those with a chronic

573

TABLE 29.3    TARGET GROUPS FOR INFLUENZA

IMMUNIZATION

Groups at High Risk • Indigenous people • Healthy children between age 6 and 59 months • Pregnant females, in the third trimester, if their delivery date is in influenza season • Residents of nursing homes or long-­term care facilities • People with chronic conditions such as diabetes, anemia, cancer, immunodeficiency, immunosuppression, neurological conditions, renal disease, or conditions that compromise management of respiratory secretions • Health care workers, those who provide essential community services, and other caregivers and household contacts capable of transmitting influenza to the above at-­risk groups Source: Public Health Agency of Canada. (2021). Canadian immunization guide chapter on influenza and statement on seasonal influenza vaccine for 2020– 2021. https://www.canada.ca/en/public-­health/services/publications/vaccines-­ immunization/canadian-­immunization-­guide-­statement-­seasonal-­influenza-­vaccine-­2020-­ 2021.html

illness may require hospitalization. Medication therapy with oral oseltamivir (Tamiflu) and inhaled zanamivir (Relenza) may be given to prevent or decrease symptoms of influenza in high-­ risk patients. These medications prevent the virus from budding and spreading to other cells. For maximum benefit, they should be initiated as soon as possible and ideally within 2 days of the onset of symptoms. They shorten the duration and severity of influenza and can be used prophylactically for control of outbreaks.  COMPLEMENTARY & ALTERNATIVE THERAPIES Goldenseal Clinical Uses Common cold, respiratory and gastrointestinal infections, wound healing, cirrhosis of the liver, gallbladder inflammation, peptic ulcers 

Effects Has a wide variety of effects, such as anti-­inflammatory properties, antimicrobial effects, and immunostimulating actions. Goldenseal can stimulate the flow of bile. 

Nursing Implications Because of the anticoagulant effects, goldenseal should not be used for longer than 2 weeks. Large doses may cause gastrointestinal distress (e.g., diarrhea, vomiting) and possible nervous system effects. Commonly combined with Echinacea in preparations. May be used in conjunction with antibiotics. Should not be used concurrently with anticoagulants, antihypertensives, β-­adrenergic blockers, or calcium channel blockers. Should not be used if the person has heart or vascular disease, especially hypertension, heart failure, or dysrhythmias. Source: Rothrock, J. (2019). Alexander’s care of the patient in surgery (16th ed.). Mosby.

SINUSITIS Sinusitis affects one in every seven adults. It develops when inflammation or swelling of the mucosa blocks the openings (ostia) in the sinuses, through which mucus drains into the nose (Figure 29.2). The secretions that accumulate behind the obstruction provide a rich medium for growth of bacteria, viruses, and fungi, all of which may cause infection (Tung

574

SECTION 5  Conditions of Oxygenation: Ventilation TABLE 29.4    PATIENT & CAREGIVER TEACHING

GUIDE

Frontal sinuses

Ethmoidal sinuses Maxillary sinuses Sphenoidal sinus

FIG. 29.2  Location of the sinuses.

et al., 2016). Bacterial sinusitis is most caused by Staphylococcus aureus, Haemophilus influenzae, or pneumococci (Cash et  al., 2020). Viral sinusitis follows an upper respiratory infection in which the virus penetrates the mucous membrane and decreases ciliary transport. Viral infections usually resolve without treatment in less than 14 days. If symptoms worsen after 3 to 5 days or last for longer than 10 days, a secondary bacterial infection may be present. Only 5 to 10% of patients with viral sinusitis develop a bacterial infection and need antibiotic therapy. Acute sinusitis usually results from an upper respiratory infection, allergic rhinitis, swimming, or dental manipulation, all of which can cause inflammatory changes and retention of secretions. When acute sinusitis follows viral rhinitis, symptoms worsen after 5 to 7 days and are worse than the original rhinitis. Chronic sinusitis is a persistent infection usually associated with allergies and nasal polyps. Chronic sinusitis generally results from repeated episodes of acute sinusitis that result in irreversible loss of the normal ciliated epithelium lining the sinus cavity.

Clinical Manifestations Acute sinusitis causes significant pain over the affected sinus(es), purulent nasal drainage, nasal obstruction, congestion, fever, and malaise. The patient looks and feels sick. Assessment involves inspection of the nasal mucosa and palpation of the sinus points for pain. Findings that indicate acute sinusitis include a hyperemic and edematous mucosa, enlarged turbinates, and tenderness over the involved sinus(es). The patient may have recurrent headaches that change in intensity with position changes or when secretions drain (Cash et al., 2020). Chronic sinusitis is difficult to diagnose because symptoms may be nonspecific. The patient is rarely febrile. Although there may be facial pain, nasal congestion, and increased drainage, often severe pain and purulent drainage are absent. Symptoms may mimic those seen with allergies. Radiographic studies of the sinuses or a sinus computed tomographic (CT) scan may be performed to confirm the diagnosis. CT scans may show the sinuses to be filled with fluid or the mucous membrane to be thickened. Nasal endoscopy with a flexible scope may be used to examine the sinuses, obtain drainage for culture, and restore normal drainage. Many patients with asthma have sinusitis. The link between these conditions is unclear. Postnasal drip associated with sinusitis may trigger asthma by stimulating reflex bronchospasm.

Acute or Chronic Sinusitis The following information should be included when teaching the patient and caregiver about sinusitis. 1. Keep well hydrated by drinking six to eight glasses of water daily to liquefy secretions. 2. Take hot showers twice daily; use a steam inhaler (15-­min vaporization of boiled water), bedside humidifier, or nasal saline spray to promote secretion drainage. 3. Report temperature of ≥38°C, which may indicate infection. 4. Follow prescribed medication regimen: • Take analgesics to relieve pain. • Take decongestants or expectorants, or both, to relieve swelling and to thin mucus. • Take antibiotics, as prescribed, for infection. Be sure to take entire prescription and report continued symptoms or a change in symptoms. • Administer nasal sprays correctly. 5. Do not smoke, and avoid exposure to smoke—smoke is an irritant and may worsen symptoms. 6. If allergies predispose to sinusitis, follow instructions regarding environmental control, medication therapy, and immunotherapy to reduce the inflammation and prevent sinus infection. 7. Avoid use of nasogastric tube inserted via the nares.

Appropriate treatment of sinusitis often causes a reduction in asthma symptoms (Calhoun et al., 2016). 

NURSING AND INTERPROFESSIONAL MANAGEMENT SINUSITIS If allergies are the precipitating cause of sinusitis, the patient needs to be instructed in ways to reduce sinus inflammation and infection, including environmental control of allergies and appropriate medication therapy (see section on allergic rhinitis earlier in this chapter). Treatment of acute sinusitis includes antibiotics to treat the infection, decongestants to promote drainage, nasal corticosteroids to decrease inflammation, and mucolytics to promote mucus flow (Table 29.4). Classical (first-­ generation) antihistamines increase the viscosity of mucus and promote continued symptoms, so they should be avoided. Nonsedating (second-­generation) antihistamines do not cause this problem. For acute sinusitis, antibiotic therapy is usually continued for 10 to 14 days. If symptoms do not resolve, the antibiotic should be changed to a broader-­spectrum agent. With chronic sinusitis, mixed bacterial florae are often present and infections are difficult to eliminate. Broad-­spectrum antibiotics may be used for 4 to 6 weeks. The patient should be encouraged to increase fluid intake (six to eight glasses daily) and use nasal cleaning techniques. This may include taking a hot shower in the morning and the evening, followed by blowing the nose thoroughly each time. Other interventions to cleanse the nasal passages and promote drainage include irrigating the nose with saltwater (Cooper & Gosnell, 2019). The patient with persistent or recurrent sinus conditions that are not alleviated by medical therapy may require nasal endoscopic surgery to relieve blockage caused by hypertrophy or deviated septum. This is an outpatient procedure usually performed under local anaesthesia (Cooper & Gosnell, 2019). 

CHAPTER 29  Nursing Management: Upper Respiratory Conditions

  OBSTRUCTION OF THE NOSE AND PARANASAL SINUSES POLYPS Nasal polyps are benign mucous membrane masses that form slowly in response to repeated inflammation of the sinus or the nasal mucosa. Polyps, which appear as bluish, glossy projections in the naris (nostril), can exceed the size of a grape. The patient may be anxious, fearing the polyps are malignant. Clinical manifestations include nasal obstruction, nasal discharge (usually clear mucus), and speech distortion. Nasal polyps can be removed with endoscopic or laser surgery, but recurrence is common. Topical or systemic corticosteroids may slow polyp growth (Cooper & Gosnell, 2019). 

FOREIGN BODIES A variety of foreign bodies may lodge in the upper respiratory tract. Inorganic foreign bodies such as buttons and beads may cause no symptoms, lie undetected, and be accidentally discovered on routine examination. Organic foreign bodies such as wood, cotton, beans, peas, and paper produce a local inflammatory reaction and nasal discharge, which may become purulent and foul smelling. Foreign bodies should be removed from the nose through the route of entry. Sneezing with the opposite nostril closed may be effective in assisting the removal of foreign bodies. Irrigation of the nose or pushing the object backward should not be done because either could cause aspiration and airway obstruction. If sneezing or blowing the nose does not remove the object, the patient should see a health care provider. 

  CONDITIONS RELATED TO THE PHARYNX ACUTE PHARYNGITIS Acute pharyngitis is an acute inflammation of the pharyngeal walls. It may include the tonsils, palate, and uvula. It can be caused by a viral, bacterial, or fungal infection. Viral pharyngitis accounts for approximately 90% of cases. Acute follicular pharyngitis (“strep throat”) results from β-­hemolytic streptococcal invasion and accounts for an additional 5 to 15% of episodes (Cooper & Gosnell, 2019). Fungal pharyngitis, especially candidiasis, can develop with prolonged use of antibiotics or inhaled corticosteroids or in immunosuppressed patients, especially those with human immunodeficiency virus (HIV). Other causes of pharyngitis include dry air, smoking, gastroesophageal reflux disease (GERD), allergy and postnasal drip, endotracheal intubation, chemical fumes, and cancer.

Clinical Manifestations Symptoms of acute pharyngitis range in severity from reports of a “scratchy throat” to pain so severe that swallowing is difficult. Both viral and strep infections appear as a red and edematous pharynx, with or without patchy yellow exudates. Four classic manifestations present in bacterial pharyngitis include (1) fever greater than 38°C (100.4°F), (2) anterior cervical lymph node enlargement, (3) tonsillar or pharyngeal exudate, and (4) absence of cough. However, appearance is not always diagnostic. When two or three of these criteria are present, a rapid antigen detection test, throat culture, or both can help establish the

575

cause and direct treatment. White, irregular patches on the oropharynx suggest fungal infection with Candida albicans. 

NURSING AND INTERPROFESSIONAL MANAGEMENT ACUTE PHARYNGITIS The goals of nursing management are infection control, symptomatic relief, and prevention of secondary complications. There is a high incidence of pharyngitis in Indigenous communities, which may lead to rheumatic fever (Gordon et al., 2015). Nurses must consider Indigenous communities’ access to necessary medications and treatment. For viral pharyngitis, antibiotics are not recommended because they do not alter the course of viral infections. For bacterial pharyngitis caused by group A β-­hemolytic streptococci, penicillin is the medication of choice. Other antibiotics include azithromycin (Zithromax) or a first-­generation cephalosporin. The patient with documented strep throat is treated with antibiotics. Most people with streptococcal infections are contagious until they have been on antibiotics for 24 to 48 hours. Repeat throat cultures after antibiotic therapy are not required. Candida infections are treated with nystatin, an antifungal antibiotic. The preparation should be swished in the mouth for as long as possible before it is swallowed, and treatment should continue until symptoms are gone. The patient should be encouraged to increase fluid intake. Cool, bland liquids and gelatin will not irritate the pharynx; the patient should avoid drinking citrus juices, which can be irritating to the throat. 

PERITONSILLAR ABSCESS Peritonsillar abscess is a complication of acute pharyngitis or acute tonsillitis, when bacterial infection invades one or both tonsils. The tonsils may enlarge sufficiently to threaten airway patency. The patient experiences a high fever, leukocytosis, and chills. Intravenous antibiotic therapy is given along with needle aspiration or incision and drainage of the abscess. An emergency tonsillectomy may be performed, or an elective tonsillectomy may be scheduled after the infection has subsided. 

  CONDITIONS RELATED TO THE TRACHEA AND LARYNX AIRWAY OBSTRUCTION Airway obstruction may be complete or partial. Complete airway obstruction is a medical emergency. Partial airway obstruction may occur as a result of aspiration of food or a foreign body. In addition, partial airway obstruction may result from laryngeal edema following extubation, laryngeal or tracheal stenosis, central nervous system (CNS) depression, and allergic reactions. Symptoms include stridor, use of accessory muscles, suprasternal and intercostal retractions, wheezing, restlessness, tachycardia, and cyanosis. Prompt assessment and treatment are essential because partial obstruction may quickly progress to complete obstruction. Interventions to re-­establish a patent airway include the obstructed airway (Heimlich) manoeuvre, cricothyroidotomy, endotracheal intubation, and tracheostomy. Unexplained or recurrent symptoms indicate the need for additional tests, such as a chest radiography, pulmonary function tests, and bronchoscopy. 

576

SECTION 5  Conditions of Oxygenation: Ventilation

TRACHEOSTOMY A tracheotomy is a surgical incision into the trachea for the purpose of establishing an airway. A tracheostomy is the stoma (opening) that results from the tracheotomy. A tracheostomy tube is an artificial airway that is inserted into the trachea during a tracheotomy. Indications for a tracheostomy are to (1) bypass an upper airway obstruction, (2) facilitate removal of secretions, (3) enable long-­term mechanical ventilation, and (4) facilitate oral intake and speech in the patient who requires long-­term mechanical ventilation. Most patients who require mechanical ventilation are initially managed with an endotracheal tube (ETT), which can be quickly inserted in an emergency (see Chapter 68). A tracheotomy may be performed for patients requiring intubation longer than 7 to 10 days or when an airway is obstructed due to trauma, tumours, or swelling. A tracheostomy may also be required to facilitate airway clearance when spinal cord injury, neuromuscular disease, or severe debilitation is present (Stacy, 2018). A tracheostomy tube is usually inserted by an open procedure in the operating room but can also be inserted emergently in a percutaneous procedure at the bedside (Stacy, 2018). Several advantages make a tracheostomy a better option than an ETT for long-­term nursing management and weaning from the ventilator. Without a tube in the mouth, patient comfort and mobility can be increased, and risk for long-­term damage to the vocal cords is decreased. The patient can eat with a tracheostomy and, depending on the type of tracheostomy, can also talk (Stacy, 2018). 

NURSING MANAGEMENT TRACHEOSTOMY PROVIDING TRACHEOSTOMY CARE Before the tracheotomy procedure, the nurse should explain to the patient and caregivers the purpose of the procedure and inform them that the patient will not be able to speak while an inflated cuff is used. Several complications can occur with tracheostomies (Table 29.5). A variety of tubes are available to meet individual patient needs (Table 29.6). All tracheostomy tubes contain a faceplate or flange, which rests on the neck between the clavicle and an outer cannula. In addition, all tubes have an obturator, which is used when inserting the tube (Figure 29.3, A). In the event of accidental decannulation, a spare tracheostomy set, obturator, and tracheal dilator should be kept at the bedside, preferably taped at the head of the bed. Some tracheostomy tubes also have an inner cannula, which can be removed for cleaning (see Figure 29.3, C). If an inner cannula is used, whether disposable or nondisposable, tracheostomy care also involves inner cannula care (Stacy, 2018; see Table 29.8). The cleaning procedure involves removal of mucus from the inside of the tube. Acute care settings predominantly use disposable inner cannulas for safety and hygienic purposes. There is also less risk for mucus plugging when using a disposable, inner cannula. If humidification is adequate, mucus may not accumulate and a tube without an inner cannula can be used. Care of the patient with a tracheostomy involves suctioning the airway to remove secretions (Figure 29.4 and Table 29.7) and cleaning around the stoma. In addition, tracheostomy care includes changing tracheostomy ties (Figure 29.5 and Table 29.8). Novice nurses should have another nurse present for safety.

TABLE 29.5    COMPLICATIONS OF

TRACHEOSTOMIES

Complication Causes

Nursing Management

Abnormal bleeding

Surgical intervention Erosion or rupture of blood vessel, or both

• Monitor bleeding. • Notify physician if it continues or is excessive.

Tube dislodgement

Excessive manipulation or suctioning

• Ensure ties are secure. • Keep obturator, hemostat, and new tracheostomy tube at bedside.

Obstructed tube

Dried or excessive secretions

• Assess patient’s respiratory status. • Suction as necessary. • Maintain humidification. • Perform tracheostomy care. • Ensure adequate hydration.

Subcutaneous emphysema

Air escapes from the incision to the subcutaneous tissue

• Monitor subcutaneous emphysema. • Reassure patient and family.

Tracheoesophageal fistula

Tracheal wall necrosis, leading to fistula formation

• Monitor cuff pressure. • Monitor patient for coughing and choking while eating or drinking.

Tracheal stenosis

Narrowing of tracheal lumen owing to scarring caused by tracheal irritation

• Monitor cuff pressure. • Ensure prompt treatment of infections. • Ensure ties are secure.

Both cuffed and uncuffed tracheostomy tubes are available. A tracheostomy tube with an inflated cuff is used if the patient is at risk for aspiration or needs mechanical ventilation. Because an inflated cuff exerts pressure on tracheal mucosa, it is important to inflate the cuff with the minimum volume of air required to obtain an airway seal. Cuff inflation pressure should not exceed 20 mm Hg or 25 cm H2O because higher pressures may compress tracheal capillaries, limit blood flow, and predispose to tracheal necrosis. An alternative approach, termed the minimal leak technique (MLT), involves inflating the cuff with the minimum amount of air to obtain a seal and then withdrawing 0.1 mL of air. Disadvantages of MLT are risk for aspiration from secretions leaking around the cuff and difficulty maintaining positive end-­expiratory pressure (Stacy, 2018). In some patients, cuff deflation is performed to remove secretions that accumulate above the cuff. Before deflation, the patient should cough up secretions, if possible, and the tracheostomy tube and mouth should be suctioned (see Figure 29.4 and Table 29.7). This step is important to prevent secretions from being aspirated during deflation. The cuff is deflated during exhalation because the exhaled gas helps propel secretions into the mouth. The patient should also cough or be suctioned after cuff deflation. The cuff should be reinflated during inspiration. The volume of air required to inflate the cuff should be monitored daily because this volume may increase if there is tracheal dilation from cuff pressure. The nurse should assess the patient’s ability to protect the airway from aspiration and remain with the patient when the cuff is initially deflated, unless the patient can protect the airway from aspiration and breathe without respiratory distress. Respiratory therapists should also be involved with patients who have a tracheostomy.

CHAPTER 29  Nursing Management: Upper Respiratory Conditions

577

TABLE 29.6    CHARACTERISTICS AND NURSING MANAGEMENT OF TRACHEOSTOMIES Tube

Characteristics

Nursing Management

Tracheostomy tube with cuff and pilot balloon (see Figure 29.3, A and B)

When properly inflated, low-­pressure, high-­ volume cuff distributes cuff pressure over large area, minimizing pressure on tracheal wall.

Procedure for Cuff Inflation • S  pontaneously breathing patient: Inflate cuff to minimal occlusion pressure by slowly injecting air into the cuff until no sound is heard after deep breath or during inhalation with manual resuscitation bag. If using MLT, remove 0.1 mL of air while maintaining seal. MLT should not be used if there is risk for aspiration. • Immediately after cuff inflation: Verify that pressure is within accepted range (≤20 mm Hg or ≤25 cm H2O) with a manometer. Record cuff pressure and volume of air used for cuff inflation in chart.

Care of Patients With an Inflated Cuff • Monitor and record cuff pressure q8h. Cuff pressure should be ≤20 mm Hg or ≤25 cm H2O to allow adequate tracheal capillary perfusion. If necessary, remove or add air to the pilot tubing using a syringe and stopcock. Afterward, verify that cuff pressure is within accepted range with manometer. • Report inability to keep the cuff inflated or need to use progressively larger volumes of air to keep cuff inflated. Potential causes of these problems include tracheal dilation at the cuff site or a crack or slow leak in the housing of the one-­way inflation valve. If the leak is caused by tracheal dilation, the physician may intubate the patient with a larger tube. Cracks in the inflation valve may be temporarily managed by clamping the small-­bore tubing with a hemostat. The tube should be changed within 24 hr. Fenestrated tracheostomy tube (Shiley, Portex) with cuff, inner cannula, and decannulation plug (see Figures 29.3, C and 29.6, A)

When inner cannula is removed, cuff deflated, and decannulation plug inserted, air flows around tube, through fenestration in outer cannula, and up over vocal cords. The patient can then use voice.

• Signs or symptoms of aspiration need further evaluation by a speech pathologist or radiologist. • N  ever insert the decannulation plug in the tracheostomy tube until the cuff is deflated and inner cannula is removed. Prior insertion will prevent the patient from breathing (no air inflow). This may precipitate a respiratory arrest. • Assess for signs of respiratory distress when a fenestrated cannula is first used. If this occurs, the cap should be removed, the inner cannula replaced, and the cuff reinflated. • Cuff management is as described above.

Speaking tracheostomy tube (Portex, National) with cuff, two external tubings (see Figure 29.6, B)

Has two tubings, one leading to cuff and one to opening above the cuff. When port is connected to air source, air flows out of opening and up over the vocal cords, allowing voicing with cuff inflated.

• Once tube is inserted, wait 2 days before use so that the stoma can close around the tube and prevent leaks. • When the patient wishes to speak, connect port to compressed air (or oxygen). Be certain to identify correct tubing. If gas enters the cuff, it will overinflate and rupture, necessitating an emergency tube change. Use lowest flow (typically 4–6 L/min) that permits use of the voice. High flows dehydrate mucosa. • Cover port adaptor. This will cause the air to flow upward. Instruct patient to speak in short sentences because voice becomes a whisper with long sentences. • Disconnect flow when patient does not want to speak, to prevent mucosal dehydration. • Cuff management is as described above.

Tracheostomy tube (Bivona Fome-­ Cuf) foam-­filled cuff (see Figure 29.3, D)

Cuff is filled with plastic foam. Before insertion, cuff is deflated. After insertion, cuff is allowed to fill passively with air. Pilot tubing is not capped, and no cuff pressure monitoring is required.

• Before insertion, withdraw all air from the cuff, using a 20-­mL syringe. Cap pilot balloon tubing to prevent re-­entry of air. After tracheostomy is inserted, remove cap from pilot tubing, allowing cuff to passively reinflate. • Do not inject air into tubing or cap pilot balloon tubing while in the patient. Air will flow in and out in response to pressure changes (e.g., with head turning). Place tag on tubing, alerting staff not to cap or inflate cuff. • Deflate cuff daily via pilot balloon to evaluate integrity of cuff. Also assess ability to easily deflate cuff. Difficulty deflating cuff indicates a need for tube change. If aspirate returns with air, the cuff is no longer intact. • Tube can be used for up to 1 mo in patients on home mechanical ventilation. This is a good choice for patients who require an inflated cuff at home because teaching about cuff pressure is simplified.

MLT, minimal leak technique.

When the patient can protect the airway from aspiration and does not require mechanical ventilation, a cuffless tracheostomy tube should be used. Retention sutures are often placed in the tracheal cartilage when the tracheotomy is performed. The free ends should be taped to the skin in a place and manner that leaves them accessible if the tube becomes dislodged. Care should be taken not to dislodge the tracheostomy tube during the first few days when the stoma is not mature (healed). Because tube replacement can be difficult, several precautions are required: (1) a replacement tube of equal or smaller size is kept at the bedside, readily available for emergency reinsertion; (2) tracheostomy tapes are not changed for at least 24 hours after the insertion procedure; and (3) the first tube change is performed by a physician, usually no sooner than 7 days after the tracheotomy.

If accidental decannulation occurs, the retention sutures (if present) are grasped and the opening is spread with a tracheal dilator or hemostat, and the replacement tube is guided in, using the obturator. To permit airflow, the obturator is immediately removed once the tube is inserted. Another method is to insert a suction catheter to allow passage of air. The new tube is threaded over the catheter, followed by removal of the suction catheter. If the tube cannot be replaced, the level of respiratory distress is assessed. Minor dyspnea may be alleviated by use of semi-­ Fowler’s position until assistance arrives. Severe dyspnea may progress to respiratory arrest; if this situation occurs, the stoma should be covered with a sterile dressing, and the patient should be ventilated with bag–mask ventilation until help arrives. After the first tube change, the tube should be changed approximately once a month. When a tracheostomy has been

578

SECTION 5  Conditions of Oxygenation: Ventilation

Tracheostomy tie strings

Esophagus Flange

Inflated cuff

B

Outer cannula 15-mm adapter Cuff Inflation tube

Pilot balloon

Hollow inner cannula

Obturator

A

One-way valve

Rounded tip

Fenestrated tube

C

D

FIG. 29.3  Types of tracheostomy tubes. A, Parts of a tracheostomy tube. B, Tracheostomy tube inserted in the airway with an inflated cuff. C, Fenestrated tracheostomy tube with cuff, inner cannula, decannulation plug, and pilot balloon. D, Tracheostomy tube with a foam cuff and obturator (one cuff is deflated on tracheostomy tube). (See Table 29.6 and NCP 29.1 for related nursing management.)

in place for several months, the healed tract will be well formed. The patient can then be taught to change the tube using clean technique at home. Teaching will vary depending on how ill the patient is and what device has been selected.  SWALLOWING DYSFUNCTION The patient who cannot protect the airway from aspiration requires an inflated cuff. However, an inflated cuff may promote swallowing dysfunction (dysphagia) because the cuff interferes with the normal function of the muscles used to swallow. For this reason, it is important to evaluate the risk for aspiration with the cuff deflated. The patient may be able to swallow without aspirating when the cuff is deflated but not when it is inflated. The cuff may then be left deflated or a cuffless tube substituted (Figure 29.6).  VOCALIZATION WITH A TRACHEOSTOMY TUBE Many techniques promote use of the voice in the patient with a tracheostomy. The patient who can breathe spontaneously may be able to talk by deflating the cuff, which allows exhaled air to flow upward over the vocal cords. This can be enhanced by the patient occluding the tube with a finger or plug. Frequently, a small cuffless tube is inserted so exhaled air can pass freely around the tube. These tracheostomy tubes and valves have been designed to facilitate use of the voice. The nurse can be an advocate in promoting use of these specialized devices. Their use can provide great psychological benefit and facilitate self-­ care for the patient with a tracheostomy. A fenestrated tube has openings on the surface of the outer cannula that permit air from the lungs to flow over the vocal cords (see Figures 29.3, C and 29.6, A). A fenestrated tube

FIG. 29.4  Suctioning tracheostomy with closed system suction catheter.

Source: Potter, P. A., Perry, A. G., Stockert, P. A., et al. (2011). Basic nursing: Essentials for practice (7th ed., p. 826). Mosby.

allows the patient to breathe spontaneously through the larynx, speak, and cough up secretions with the tracheostomy tube in place. It can be used by the patient who can swallow without risk for aspiration but requires suctioning for secretion removal. It may also be used by the patient who requires mechanical ventilation for less than 24 hours a day (e.g., during sleep). Before the fenestrated tube is used, the patient’s ability to swallow without aspiration is determined (see Table 29.5 and Nursing Care Plan [NCP] 29.1, available on the Evolve website). If there is no aspiration, (1) the inner cannula is removed,

CHAPTER 29  Nursing Management: Upper Respiratory Conditions

579

TABLE 29.7    PROCEDURE FOR SUCTIONING A

TRACHEOSTOMY TUBE

1. The nurse should assess the need for suctioning q2h. Indications include coarse crackles or wheezes over large airways, moist cough, and restlessness or agitation if accompanied by decrease in SpO2 or PaO2. The patient should not be suctioned routinely or if able to clear secretions with cough. 2. If suctioning is indicated, the nurse should explain procedure to the patient. 3. The necessary sterile equipment should be collected: suction catheter (no larger than half the lumen of the tracheostomy tube), gloves, water, cup, and drape. If a closed tracheal suction system is used, the catheter is enclosed in a plastic sleeve and reused. No additional equipment is needed. 4. The next step is to adjust suction pressure until the dial reads between 100 and 150 mm Hg pressure (for adults) with tubing occluded. For infants and children, the pressure should read between 50 and 100 mm Hg, depending on the size of the child. (Note: The nurse should check the institution or hospital’s policy and procedure manuals for specific guidelines.) 5. The nurse should wash hands and put on goggles, mask, and gloves. 6. Sterile technique should be used to open package, fill cup with water, put on gloves, and connect catheter to suction. One hand should be designated as contaminated for disconnecting, bagging, and operating the suction control, and water should be suctioned through the catheter to test the system. 7. The nurse must assess SpO2 and heart rate and rhythm to provide baseline for detecting change during suctioning. 8. Preoxygenation should be provided by using a reservoir-­equipped MRB connected to 100% oxygen or by asking the patient to take three to four deep breaths while administering oxygen. The method chosen will depend on the patient’s underlying disease and acuity of illness. The patient who has had a tracheostomy for an extended period and is not acutely ill may be able to tolerate suctioning without use of an MRB. 9. The nurse should gently insert the catheter without suction to minimize the amount of oxygen removed from the lungs and then insert the catheter approximately 13 to 15 cm. Suctioning should be stopped if an obstruction is met. 10. Then the catheter should be withdrawn 1 to 2 cm and suction applied intermittently while withdrawing the catheter in a rotating manner. If secretion volume is large, suctioning should be applied continuously. 11. Suctioning time should be limited to 10 seconds. Suctioning should be discontinued if heart rate decreases from baseline by 20 beats per minute, increases from baseline by 40 beats per minute, a dysrhythmia occurs, or SpO2 decreases to less than 90%. 12. After each suction pass, the nurse should oxygenate with three to four breaths by MRB or deep breaths with oxygen. 13. Single-­use catheters should not be reintroduced into the tracheostomy tube. (The nurse should check the institution’s policy and procedure manuals.) 14. The procedure should be repeated until airway is clear, and insertions of suction catheter should be limited to as few as needed. 15. Oxygen concentration should be returned to prior setting. 16. The nurse should suction the oropharynx or use mouth suction. 17. The catheter should be disposed of by wrapping it around fingers of gloved hand and pulling glove over catheter. Then equipment should be discarded in a proper waste container. 18. The nurse should auscultate to assess changes in lung sounds and then record time, amount, and character of secretions and response to suctioning. MRB, manual resuscitation bag.

(2) the cuff is deflated, and (3) the decannulation cap is placed in the tube (see Figure 29.6, A). It is important to perform the steps in order because severe respiratory distress may result if the tube is capped before the inner cannula is removed and the cuff deflated. When a fenestrated cannula is first used, the nurse should frequently assess the patient for signs of respiratory distress.

A

B

C

D FIG. 29.5  Changing tracheostomy ties. A, A slit is cut about 2.5 cm (1

in) from the end. The slit end is put into the opening of the faceplate. B, A loop is made with the other end of the tape. C, The tapes are tied together with a double knot on the side of the neck, avoiding any blood vessels. D, A tracheostomy tube holder can be used in place of twill ties to make tracheostomy tube stabilization more secure. Source: D, Dale Medical Products, Inc.

If the patient is not able to tolerate the procedure, the cap should be removed, the inner cannula replaced, and the cuff reinflated. A disadvantage of fenestrated tubes is the potential for development of tracheal polyps from tracheal tissue granulating into the fenestrated openings. A speaking tracheostomy tube has two pigtail tubes. One tubing connects to the cuff and is used for cuff inflation, and the second connects to an opening just above the cuff (see Figure 29.6, B). When the second tubing is connected to a low-­flow (4–6 L/min) air source, sufficient air moves up over the vocal cords to produce the voice. The patient can then use the voice, even though the cuff is inflated. When a speaking tracheostomy valve is used, a cuffless tube must be in place, or the cuff must be deflated, to allow exhalation (Figure 29.7). Ability to tolerate cuff deflation without aspiration or respiratory distress must also be evaluated in patients using this device. If there is no aspiration, the cuff is deflated, and the valve is placed over the tracheostomy tube opening. The speaking valve contains a thin plastic diaphragm that opens on inspiration and closes on expiration. During inspiration, air flows in through the valve. During expiration, the diaphragm prevents exhalation and air flows upward over the vocal cords and into the mouth. If speaking devices are not used, the patient should be provided with a paper and pencil, a whiteboard with marker, or a computer tablet (e.g., iPad). A word (communication) board can usually be obtained from speech therapy, or one can be devised with pictures of common needs and an alphabet for spelling words. A referral to a speech language pathologist should be considered. 

580

SECTION 5  Conditions of Oxygenation: Ventilation

INFORMATICS IN PRACTICE Communication Devices for Patients With Laryngectomy • A  ssisting with communication will improve a patient’s quality of life after a laryngectomy. • A tablet (e.g., iPad) or smartphone can be used with a downloaded text-­ to-­ speech application. These applications allow the patient to type in text, and then a computer voice says the text aloud. • The nurse can also teach the patient how to use a keyboard-­based communication program. The patient types on a traditional keyboard and generates speech that is transmitted through hand-­held speakers.

Trachea

Cuff inflation tube

A

Cap

Esophagus Fenestration Deflated cuff

Inner cannula

TABLE 29.8    TRACHEOSTOMY CARE 1. The nurse should explain procedure to patient. 2. A tracheostomy care kit should be used or necessary sterile equipment should be collected (e.g., suction catheter, gloves, water, basin, drape, tracheostomy ties, tube brush or pipe cleaners, 4 × 4– inch gauze pads, normal saline or sterile water, and tracheostomy dressing [optional]). Note: Clean rather than sterile technique is used at home. 3. The patient should be positioned in a semi-­Fowler’s position. 4. The needed materials should be assembled on a bedside table next to the patient. 5. The nurse should wash hands and put on goggles and clean gloves. 6. The next step is to auscultate chest sounds. If wheezes or coarse crackles are present, the patient should be suctioned if unable to cough up secretions (see Table 29.7) and then the nurse should remove soiled dressing and clean gloves. 7. The nurse should open sterile equipment, pour sterile normal saline into basins, and put on sterile gloves. 8. The inner cannula, if present, should be unlocked and removed. Many tracheostomy tubes do not have inner cannulas. Care for these tubes includes all steps except for inner cannula care. 9. If a disposable inner cannula is used, it should be replaced with a new cannula. If a nondisposable cannula is used, the following applies: a. Inner cannula should be immersed in sterile normal saline and the inside and outside of the cannula cleaned using a tube brush or pipe cleaners. b. Inner cannula should be rinsed in normal saline and shaken to dry. c. Inner cannula should be inserted into outer cannula with the curved part downward and then locked in place. 10. Dried secretions should be removed from the stoma, outer cannula, and neck plate, using a 4 × 4–inch gauze pad soaked in normal saline. Then the area around the stoma should be gently patted dry. 11. The nurse should maintain position of tracheal retention sutures, if present, by taping above and below the stoma. 12. Tracheostomy ties should be changed as follows: Secure new ties to flanges before removing the old ones. Tie tracheostomy ties securely with room for one finger between ties and skin (see Figure 29.5). To prevent accidental tube removal, secure the tracheostomy tube by gently applying pressure to the flange of the tube during the tie changes. Tracheostomy ties should not be changed for first 72 hr after the tracheotomy procedure. 13. As an alternative, some patients prefer tracheostomy ties made of Velcro, which are easier to adjust. 14. If drainage is excessive, dressings should be placed around tube (see Figure 29.5). A tracheostomy dressing or unlined gauze should be used. The gauze should not be cut because threads may be inhaled or wrap around the tracheostomy tube. Dressing should be changed frequently—wet dressings promote infection and stoma irritation. 15. The nurse should repeat care three times a day and as needed.

Trachea

Cuff inflation tube

Esophagus Inflated cuff

B

Compressed O2 or air (4-6 L/min)

Occlude port

FIG. 29.6  Speaking tracheostomy tubes. A, Fenestrated tracheostomy tube

with cuff deflated, inner cannula removed, and tracheostomy tube capped to allow air to pass over the vocal cords. B, Speaking tracheostomy tube. One tube is used for cuff inflation. The second tube is connected to a source of compressed air or oxygen. When the port on the second tube is occluded, air flows up over the vocal cords, allowing use of the voice with an inflated cuff. (See Table 29.6 and NCP 29.1 for related nursing management.)

FIG. 29.7  Passy-Muir Tracheostomy & Ventilator Swallowing and Speaking

Valve (PMV®). The valve is placed over the hub of the tracheostomy tube after the cuff is deflated. Multiple options are available and can be used for ventilated and nonventilated patients. The PMV is a bias-closed, one-way valve that allows air to enter the lungs during inspiration and redirects air upward over the vocal cords into the mouth during expiration. Source: Image courtesy of Passy Muir, Inc. Irvine, CA.

DECANNULATION When the patient can adequately exchange air and expectorate secretions, the tracheostomy tube can be removed. The stoma is closed with tape strips and covered with an occlusive dressing. The dressing must be changed if it gets soiled or wet. The patient should be instructed to splint the stoma with the fingers when coughing, swallowing, or speaking. Epithelial tissue begins to form in 24 to 48 hours, and the opening will close in several days. Surgical intervention to close the tracheostomy is not required. 

CHAPTER 29  Nursing Management: Upper Respiratory Conditions

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LARYNGEAL POLYPS Laryngeal polyps may develop on the vocal cords from extensive vocal use (e.g., excessive talking, singing) or irritation (e.g., intubation, cigarette smoking). The most common symptom is hoarseness. Polyps may be treated conservatively with voice rest. Surgical removal may be indicated for large polyps, which may cause dyspnea and stridor. Polyps are usually benign but may be removed because they may later become malignant. 

HEAD AND NECK CANCER Head and neck cancer is a group of cancers that start on mucosal surfaces and is typically squamous cell in origin. This category of tumours includes those of the paranasal sinuses, the oral cavity, and the nasopharynx, oropharynx, and larynx. (Cancer of the oral cavity is discussed in Chapter 44.) Although this type of cancer is uncommon, disability is great because of the potential loss of voice, disfigurement, and social consequences.

Clinical Manifestations Early signs and symptoms of head and neck cancer vary with the tumour location (Carr, 2016). Cancer of the oral cavity may first be signaled by a painless growth in the mouth, an ulcer that does not heal, or a change in fit of dentures. Pain is a late symptom that may be aggravated by acidic food. Cancers of the oropharynx, hypopharynx, and supraglottic larynx rarely produce early symptoms and are usually diagnosed in late stages. The patient may experience a persistent unilateral sore throat or otalgia (ear pain). Hoarseness may be a symptom of early laryngeal cancer. If a lump in the neck or hoarseness lasts longer than 2 weeks, a medical evaluation is indicated. Some patients experience what feels like a lump in the throat or a change in voice quality. Late stages of head and neck cancers have easily detectable signs and symptoms, including pain, dysphagia, decreased tongue mobility, airway obstruction, and cranial nerve neuropathies. The nurse should thoroughly examine the oral cavity, including the areas under the tongue and the dentures. The floor of the mouth, the tongue, and the lymph nodes in the neck should be bimanually palpated. There may be thickening of the normally soft and pliable oral mucosa. Leukoplakia (white patch) or erythroplakia (red patch) may be seen and should be noted for later biopsy. Both leukoplakia and carcinoma in situ (localized to a defined area) may precede invasive carcinoma by many years.  Diagnostic Studies If lesions are suspected, the upper airways may be examined using indirect laryngoscopy—using a laryngeal mirror to visualize the laryngeal area—or a flexible nasopharyngoscope. The larynx and vocal cords are visually inspected for lesions and tissue mobility. A CT scan, magnetic resonance imaging (MRI), or positron emission tomography (PET) scan may be performed to detect local and regional spread. Neoplastic tissue is identifiable because it contains tissue of greater density or because it distorts, displaces, or destroys normal anatomical structures. Typically, multiple biopsy specimens are obtained to determine the extent of the disease.  Interprofessional Care The stage of the disease will be determined on the basis of tumour size (T), number and location of involved nodes (N), and extent of metastasis (M). TNM staging classifies disease over the range between stage I through stage IV and guides treatment. Choice of treatment is based on medical history,

FIG. 29.8  Excision of laryngeal cancer. This cancer of the right vocal cord meets criteria for resection by transoral cordectomy. The cord is fully mobile and the lesion can be fully exposed. It does not approach or cross the anterior commissure.

extent of disease, cosmetic considerations, urgency of treatment, and patient choice. Approximately one third of patients with head and neck cancers have highly confined lesions that are stage I or II at diagnosis. Such patients can undergo radiation therapy or surgery with the goal of cure. Radiation therapy may be effective in curing early vocal cord lesions. This therapy is usually successful in eliminating the tumour while preserving the quality of the voice. If radiation therapy is not successful or the lesion is too advanced for this therapy, surgery may be performed. A cordectomy (partial removal of one vocal cord) is used when there is a superficial tumour involving one cord (Figure 29.8). A hemilaryngectomy involves removal of thyroid cartilage, a portion of the larynx, and one vocal cord or part of a cord and necessitates a temporary tracheostomy. A supraglottic laryngectomy involves removing structures above the true cords—the false vocal cords and epiglottis. The patient is left at high risk for aspiration following surgery and requires a temporary tracheostomy. Both a hemilaryngectomy and a supraglottic laryngectomy allow the voice to be preserved, but quality is breathy and hoarse. Advanced lesions are treated by a total laryngectomy in which the entire larynx and pre-­epiglottic region is removed and a permanent tracheostomy performed. Airflow patterns before and after total laryngectomy are shown in Figure 29.9. Radical neck dissection frequently accompanies total laryngectomy to decrease the risk for lymphatic spread. Depending on the extent of involvement, extensive dissection and reconstruction may be performed. This procedure involves wide excision of the lymph nodes and their lymphatic channels (Figure 29.10). The following structures may also be removed or transected: sternocleidomastoid muscle and other closely associated muscles, internal jugular vein, mandible, submaxillary gland, part of the thyroid and parathyroid glands, and the spinal accessory nerve. A modified neck dissection is performed whenever possible as an alternative to a radical neck dissection. The dissection is modified by sparing as many structures as possible to limit disfigurement and functional loss. A modified neck dissection usually involves dissection of the major cervical lymphatic vessels and lateral cervical space, with preservation of nerves and vessels, including the sympathetic and vagus nerves, spinal accessory nerves, and internal jugular vein. Neck dissection with vocal cord cancer usually involves one side of the neck. However, if the lesion is midline, a bilateral neck dissection may be performed. In this case, it is always modified on at least one side to minimize structural and functional deficits (Rothrock, 2019).

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SECTION 5  Conditions of Oxygenation: Ventilation

Nasal cavity

Hard palate

Nasal cavity

Soft palate

Air entering nose and mouth for speech

Pharynx Epiglottis Speech Vocal cords

Esophagus

Larynx Trachea

Surgical tie-off

Soft palate Pharynx Esophagus

Air flowing to lungs in and out of opening in neck Trachea

Lungs

Lungs

Diaphragm

A

Hard palate

Diaphragm

B

FIG. 29.9  A, Normal airflow in and out of the lungs. B, Airflow in and out of the lungs after total laryngectomy. Patients use esophageal speech by trapping air in the esophagus and releasing it to create sound. Source: The American Cancer Society.

FIG. 29.10  Radical neck incision with drains in place.

The patient may refuse surgical intervention for advanced lesions because of the extent of the procedure, or the patient may be judged to be at too great a medical risk to undergo the procedure. In these situations, external radiation therapy may be used as the sole treatment or in combination with chemotherapy (Rothrock, 2019). In addition, brachytherapy, a concentrated and localized method of delivering radiation that involves placing a radioactive source into or near the tumour, may be used to treat head and neck cancer. The goal of brachytherapy is to deliver high doses of radiation to the target area while limiting exposure of surrounding tissues. Thin, hollow, plastic needles are inserted into the tumour area, and radioactive iridium seeds are placed in the needles. The seeds emit continuous radiation. Brachytherapy can be used alone or combined with external radiation or surgical intervention. (Radiation therapy and brachytherapy are discussed in Chapter 18.) Nutritional Therapy.  The patient’s nutritional status should be assessed before surgery as 60% of patients with head and neck cancer initially present with malnutrition (Carr, 2016). After radical neck surgery, the patient may be unable to take in nutrients through the normal route of ingestion because of swelling, the location of sutures, or difficulty swallowing. Parenteral

fluids will be given for the first 24 to 48 hours. Tube feedings are usually given via a nasogastric, nasointestinal, or gastrostomy tube that was placed during surgery. (Nasogastric and gastrostomy feedings are described in Chapter 42.) The nurse must observe for tolerance of the feedings and adjust amount, time, and formula if nausea, vomiting, diarrhea, or distension occurs. The patient is instructed about the tube feedings. When the patient can swallow, small amounts of water are given. Close observation for difficulty swallowing is essential. Suctioning may be necessary to prevent aspiration. Swallowing difficulties should be anticipated when the patient resumes eating. All patients should be referred to a speech pathologist for a dysphagia/swallowing assessment and recommendations during treatment. The type and degree of difficulty vary, depending on the surgical procedure. When a supraglottic laryngectomy is performed, the surgeon excises the upper portion of the larynx, including the epiglottis and the false vocal cords. The patient can speak because the true vocal cords remain intact. However, a new technique, the supraglottic swallow, must be learned to compensate for removal of the epiglottis and minimize risk for aspiration (Table 29.9). When the patient is learning this technique, it may be helpful to start with carbonated beverages because the effervescence provides cues about the liquid’s position. With this exception, thin, watery fluids should be avoided because they are difficult to swallow and increase the risk for aspiration. A better choice is nonpourable puréed foods, which are thicker and allow more control during swallowing. Swallowing can be enhanced by thickening liquids with a commercially available thickening agent. Consultation with a dietitian can assist in creating an appropriate diet texture while ensuring nutritional and caloric needs are maintained. Good nutrition is important during radiation therapy because calories and protein are needed for tissue repair. Antiemetics or analgesics may be given before meals to reduce nausea and mouth pain. Bland foods may be better tolerated than more highly flavoured foods. Caloric intake may be increased by adding dry milk to foods during preparation, selecting foods high in calories, and using oral supplements. It is helpful to add sauces and gravies to food, which adds calories and moistens food so that it is more easily swallowed. If an adequate intake cannot be maintained, enteral feedings may be used. When eating, the patient should always be positioned with the head elevated. 

CHAPTER 29  Nursing Management: Upper Respiratory Conditions TABLE 29.9    PATIENT & CAREGIVER TEACHING

GUIDE

Steps for Performing the Supraglottic Swallow The following information should be included when teaching the patient and caregiver how to perform the supraglottic swallow. . Take a deep breath to aerate lungs. 1 2. Perform the Valsalva manoeuvre to approximate the vocal cords. 3. Place food in the mouth and swallow. Some food will enter the airway and remain on top of the closed vocal cords. 4. Cough to remove food from top of vocal cords. 5. Swallow so food is moved from top of vocal cords. 6. Breathe after cough–swallow sequence to prevent aspiration of food collected on top of vocal cords.

NURSING MANAGEMENT HEAD AND NECK CANCER NURSING ASSESSMENT Subjective and objective data that should be obtained from a person with head and neck cancer are presented in Table 29.10.  NURSING DIAGNOSES Nursing diagnoses for the patient with head and neck cancer include but are not limited to the following: • Inadequate airway clearance resulting from presence of artificial airway and excessive mucus • Potential for aspiration resulting from presence of oral/nasal tube and impaired ability to swallow • Anxiety resulting from unmet needs (lack of knowledge about surgical procedure and pain management) • Acute pain resulting from physical injury agent (surgery) • Reduced verbal communication resulting from physiological condition (removal of vocal cords) Additional information on nursing diagnoses for the patient with head and neck cancer is presented in NCP 29.2, available on the Evolve website.  PLANNING The overall goals are that the patient will have (1) a patent airway, (2) no spread of cancer, (3) no complications related to therapy, (4) adequate nutritional intake, (5) minimal to no pain, (6) the ability to communicate, and (7) an acceptable body image.  NURSING IMPLEMENTATION HEALTH PROMOTION.  Development of head and neck cancer is closely related to personal habits, primarily tobacco use, including the use of cigarettes, vaping, cigars, chewing tobacco, and snuff. Prolonged alcohol use has been implicated as a potentiating factor in head and neck cancer. Excessive sun exposure to the lips also increases the risk for oral cancer. The nurse should include information about risk factors in health teaching (Carr, 2016). If cancer has been diagnosed, tobacco cessation is still important. The patient with head and neck cancer who continues to smoke during radiation therapy has a lower rate of response and survival than the patient who does not smoke during radiation therapy. In addition, risk for a second primary cancer is significantly increased in patients who continue to smoke.  ACUTE INTERVENTION.  The patient and the family must be taught about the type of therapy to be performed and care required. Assessment of concerns is integral to the plan of care.

583

TABLE 29.10    NURSING ASSESSMENT Head and Neck Cancer Subjective Data Important Health Information Past health history: Positive family history; prolonged tobacco use (cigarettes, pipes, cigars, chewing tobacco, smokeless tobacco); prolonged, heavy alcohol use Medications: Prolonged use of over-­the-­counter medication for sore throat, decongestants

Symptoms Mouth ulcer that does not heal, change in fit of dentures, change in appetite, weight loss, swallowing difficulty (e.g., sensation of lump in throat, pain with swallowing, aspiration when swallowing) Fatigue with minimal exertion Sore throat, hoarseness, change in voice quality, referred ear pain

Objective Data Respiratory Hoarseness, chronic laryngitis, nasal voice, palpable neck mass and lymph nodes (tender, hard, fixed), tracheal deviation; dyspnea, stridor (late sign)

Gastrointestinal White (leukoplakia) or red (erythroplakia) patches inside mouth, ulceration of mucosa, asymmetrical tongue, exudate in mouth or pharynx, mass or thickening of mucosa

Possible Findings Mass on direct or indirect laryngoscopy; tumour on soft tissue radiographic study, computed tomographic scan, magnetic resonance imaging, or positron emission tomography; positive biopsy

The patient and family must cope with the psychological impact of the diagnosis of cancer, alteration of physical appearance, and possible need for alternative methods of communication (Carr, 2016). The care plan should include assessment of the patient’s support system. The patient may not have someone to provide assistance after discharge, may be unemployed, or may be employed in a job that cannot be continued. Radiation Therapy.  The nurse can suggest interventions to reduce adverse effects of radiation therapy. (Radiation is discussed in Chapter 18.) Patients should be encouraged to take frequent rest periods and engage in light, regular exercise, such as walking. Dry mouth (xerostomia), the most frequent and annoying adverse effect, typically begins within a few weeks of treatment. The patient’s saliva decreases in volume and becomes thick. The change may be temporary or permanent. Pilocarpine hydrochloride (Salagen) increases saliva production and should be started before the initiation of radiation therapy and continued for 90 days. Other interventions include fluids, sugarless gum or candy, nonalcoholic mouth rinses (baking soda or glycerin solutions), and artificial saliva. The patient may also experience stomatitis, especially if the oral cavity is in the field of therapy causing irritation, ulceration, and pain. Normal saline mouth rinses after meals and at bedtime can clean and soothe irritated tissues. Commercial mouthwashes and hot or spicy foods should be avoided because they are irritating. If the problem is severe, a mouthwash mixture of equal parts of antacid, diphenhydramine (Benadryl), and topical lidocaine is suggested. Skin over the irradiated area often becomes reddened and sensitive to touch. Patients commonly require a break from their scheduled radiation program because of altered skin integrity.

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SECTION 5  Conditions of Oxygenation: Ventilation

Only prescribed lotions and products should be used during radiation therapy. All exposure to the sun should be avoided to reduce discomfort.  Surgical Therapy.  Preoperative care for the patient who is to have a radical neck dissection involves consideration of the patient’s physical and psychosocial needs. Physical preparation is the same as for any major surgery, with special emphasis on oral hygiene. Explanations and emotional support are of special significance and should include postoperative measures relating to communication and feeding. The surgical procedure should be explained to the patient and family or caregivers, and the nurse should make sure that the information is understood. Teaching must be tailored to the planned surgical procedure. For surgeries that involve a laryngectomy, teaching should include information about expected changes in speech. The nurse or speech pathologist should demonstrate means of communicating other than speaking that can be used temporarily or permanently. This may include some type of communication board. After surgery, maintenance of a patent airway is essential. The inflammation in the surgical area may compress the trachea. A tracheostomy tube will be in place. The patient will be placed in a semi-­Fowler’s position to decrease edema and limit tension on the suture lines. Vital signs should be monitored frequently because of the risk for hemorrhage and respiratory compromise. Pressure dressings, packing, or drainage tubes (Hemovac, Jackson Pratt) may be used for wound management, depending on the type of surgical procedure. When a radical neck dissection is performed, wound suction using a portable system, such as a Hemovac, is generally used. If skin flaps are employed, dressings are typically not used. This allows better visualization of the incision and helps prevent excessive pressure on tissue (see Figure 29.10). The drainage should be serosanguineous and gradually decrease in volume over 24 hours. Patency of drainage tubes should be monitored every 4 hours to ensure that they are properly removing serous drainage and for the amount and character of drainage. If the tubing becomes obstructed, fluid will accumulate under the skin flap and predispose to impaired wound healing and infection. After drainage tubes are removed, the area should be closely monitored for any swelling. If fluid continues to accumulate, aspiration may be necessary. Immediately after surgery, the patient with a laryngectomy requires frequent suctioning via the laryngectomy tube. Secretions typically change in amount and consistency over time. The patient may initially have copious blood-­tinged secretions that diminish and thicken. Standard administration of saline boluses via the tracheostomy tube to loosen secretions is no longer recommended as it may increase risk for infection (Altobelli, 2017). The patient will benefit from the use of a humidifier while at home. Following a neck dissection, an exercise program should be instituted to maintain strength and movement in the affected shoulder and the neck. This is especially important when the spinal accessory nerve and the sternocleidomastoid muscles are removed or damaged. Without exercise, the patient will be left with a “frozen” shoulder and limited range of motion in the neck. This exercise program should be continued following discharge to prevent future functional disabilities. The patient may need the neck supported to be able to move the head after surgery. 

Speech Sound waves Electrolarynx

Esophagus

Air to and from lungs Trachea

A Esophagus

Voice prosthesis Housing Tracheostoma valve Trachea Air from lungs

B

Voice prosthesis in stoma

FIG. 29.11  A, The sound waves created by the electrolarynx allow the person to speak. B, The Blom–Singer voice prosthesis and valve.

Voice Rehabilitation.  A speech pathologist should meet with the patient preoperatively and following a total laryngectomy to discuss voice restoration options. The International Association of Laryngectomees, an association of patients who have had laryngectomies, focuses on assisting patients to re-­establish speech. Local groups, called Lost Cord Clubs, often provide member volunteers to visit the patient, preferably before surgery. Several options are available to restore speech. These include use of a voice prosthesis, esophageal speech, and an electrolarynx. The most used voice prosthesis is the Blom–Singer (Figure 29.11). This soft plastic device is inserted into a fistula made between the esophagus and the trachea. The puncture may be created at the time of surgery or afterward, depending on the preference of the surgeon. A red rubber catheter is placed in the tracheoesophageal puncture and must remain in place until a tract is formed. Once the tract is formed, the voice prosthesis is inserted. This prosthesis allows air from the lungs to enter the esophagus by way of the tracheal stoma. A one-­way valve prevents aspiration of food or saliva from the esophagus into the tracheostomy. To produce the voice, the patient manually blocks the stoma with the finger. Air moves from the lungs, through the prosthesis, into the esophagus, and out the mouth. The voice is produced by the air vibrating against the esophagus, and speech

CHAPTER 29  Nursing Management: Upper Respiratory Conditions

FIG. 29.12  Artificial larynx. Battery-­powered electronic artificial larynx for

a patient who has had a total laryngectomy. Source: Courtesy CLG Photographics, Inc., St. Louis.

sounds are formed into words by moving the tongue, jaw, and lips. A valve may also be used with this device. When the valve is in place, the stoma does not need to be closed with the finger to speak. The prosthesis must be cleaned regularly and replaced when it becomes blocked with mucus. An electrolarynx is a handheld, battery-­ powered device that creates speech with the use of sound waves. There are two main types: the intra-­oral type and the neck type. One intra-­ oral device, the Cooper-­Rand, has a plastic tube that is placed in the corner of the roof of the mouth to create vibrations. To create the most normal sound when using this device, the patient should (1) avoid trying to use their tongue to hold the tube in place; (2) compress the tone generator for short intervals and speak in phrases, rather than full sentences; (3) speak using large movements of the lips, tongue, and jaw, rather than keeping the mouth partially closed; (4) talk face-­to-­face with the listener; and (5) practise because it takes time to develop this skill. With the neck type of artificial larynx, the device is placed against the neck rather than in the mouth. This device is used after surgical healing is complete and no edema remains (Figure 29.12). With experience, the patient can learn to move the lips in ways that create somewhat normal-­sounding speech. With both devices, voice pitch is low, and the sound is mechanical. Esophageal speech is a method of swallowing air, trapping it in the esophagus, and releasing it to create sound. The air causes vibration of the pharyngoesophageal segment to create sound (which initially is like a belch). With practice, 50% of patients develop some speech skills, but only 10% develop fluent speech.  Stoma Care.  Before discharge, the patient should be instructed in the care of the laryngectomy stoma. The area around the stoma should be washed daily with a moist cloth. If a laryngectomy tube is in place, the entire tube must be removed at least daily and cleaned in the same manner as a tracheostomy tube. The inner cannula may have to be removed and cleaned more frequently. A scarf, a loose shirt, or a crocheted shield can be used to shield the stoma. The patient should cover the stoma when coughing (because mucus may be expectorated) and during any activity (e.g., shaving, applying makeup) that might lead to inhalation of foreign materials. Because water can easily enter the stoma, the patient should wear a plastic collar when taking a shower. Swimming is contraindicated. Initially, humidification will be administered via a tracheostomy mask. After discharge, a bedside humidifier can be used. A high oral fluid intake must be maintained, especially in dry weather. The patient should be told the importance of wearing a medical alert bracelet or other identification that alerts others in an

585

emergency of the need for neck breathing. Because the patient no longer breathes through the nose, the ability to smell smoke and food may be lost. The patient should be advised to install smoke and carbon monoxide detectors in the home. It is important for food to be colourful, attractively prepared, and nutritious because taste may also be diminished secondary to the loss of smell as well as to radiation therapy.  Depression.  Depression is common in the patient who has had a radical neck dissection. The patient may not be able to speak because of the laryngectomy and cannot control saliva. The facial appearance may be significantly altered, with swelling, edema, and deformities. Many physical changes are reversible as the edema subsides and the tracheostomy tube is removed. Depression may also be related to concern about the prognosis. The nurse should encourage verbalization of feelings, conveying acceptance, and help the patient regain an acceptable self-­concept. A psychiatric referral for the patient experiencing prolonged or severe depression should be considered.  Sexuality.  Surgery and the presence of foreign attachments such as tracheostomy and gastrostomy tubes may affect body image dramatically. The patient may feel less desirable sexually. The nurse can assist the patient by having discussions with the patient regarding sexuality and encouraging them to discuss this problem with the sexual partner. It may be difficult for the patient to discuss sexual issues verbally because of the alteration in communication. The nurse can help the patient plan how to communicate with the sexual partner and offer support and guidance to the sexual partner. Helping the patient see that sexuality involves much more than appearance may relieve some anxiety.  AMBULATORY AND HOME CARE.  The patient is often discharged with a tracheostomy and a nasogastric or gastrostomy feeding tube. Home health care may be needed initially as the family’s or patient’s ability to perform self-­care activities is evaluated. The patient and the family must be taught how to manage tubes and whom to call if there are problems. The patient can resume exercise, recreation, and sexual activity when able. Most patients can return to work 1 to 2 months after surgery. However, many never return to full-­time employment. Loss of speech, loss of the ability to taste and smell, inability to produce audible sounds (including laughing and weeping), and the presence of a permanent tracheal stoma that produces undesirable mucus are often overwhelming to the patient. Although changes are discussed before surgery, the patient may not be prepared for the extent of these changes. If the patient has a partner, the reaction of this person to the patient’s altered appearance is important. Reconstructive surgery may be performed at the time of the initial surgery or soon after the tumour is removed. Various types of flaps and grafts are used. It may be necessary to rebuild the nose or the mandible or to close oral cutaneous openings. Prosthetic materials, such as Silastic and Plastigel (which is soft), are often used to reconstruct various deformities. Metastatic cancer is often painful, leaving the affected person in a severely debilitated state. If pain is significant, a pain control regimen should be instituted to provide comfort, and referral should be made to hospice if indicated.  EVALUATION Expected outcomes for the patient with head and neck cancer who is treated surgically are addressed in NCP 29.2, available on the Evolve website.

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SECTION 5  Conditions of Oxygenation: Ventilation

CASE STUDY Laryngeal Cancer Patient Profile

Discussion Questions

T. P., 60 years old (pronoun he/him), was admitted for evaluation of mild pain on swallowing and a persistent sore throat over the past year. He has a history of type 2 diabetes mellitus. 

1. W  hat information in the assessment suggests that T. P. is at risk for cancer of the larynx? 2. What diagnostic tests are typically performed to evaluate the extent of this condition? 3.  Priority decision: What are the priority teaching strategies for T. P. before and after laryngectomy? 4. Discuss methods used to restore speech after laryngectomy. 5. Is there anything in his history that may affect wound healing after surgery? 6.  Priority decision: While in the recovery room, T. P. develops shortness of breath. What are the priority nursing interventions? 7. What teaching is required to help this patient assume self-­care after his surgery? What precautions should the patient take because of his stoma? 8. While on the medical-­surgical unit, T. P. is tearful and is staring at the wall. What should the nurse do? 9. Priority decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any interprofessional issues? 10. Evidence-­informed practice: How could the nurse best meet T. P.’s communication needs during the first few postoperative days?

Subjective Data • • • • •

 tates that his symptoms worsened in the past 2 months S Has used various cold remedies to relieve symptoms, without relief Has lost weight because of decrease in appetite and difficulty swallowing Has smoked three packs of cigarettes a day for 40 years Consumes four to six cans of beer a day 

Objective Data Laryngoscopy • Subglottic mass 

Physical Examination • Enlarged cervical nodes 

Computed Tomographic Scan • Subglottic lesion with lymph node involvement 

Interprofessional Care • P  ercutaneous gastrostomy tube inserted preoperatively for enteral tube feeding • Total laryngectomy with tracheostomy with inflated cuff • Nasogastric tube postoperatively 

Answers are available at http://evolve.elsevier.com/Canada/Lewis/medsurg.

 REVIEW QUESTIONS 5. W  hich nursing action related to the tracheostomy tube cuff pressure would prevent excessive pressure on tracheal capillaries? a. Monitor pressure every 2 to 3 days. b. Ensure pressure is less than 20 mm Hg or 25 cm H2O. c. Ensure pressure is less than 30 mm Hg or 35 cm H2O. d. Ensure pressure is sufficient to fill the pilot balloon until it is tense. 6. Which of the following is not an early symptom of head and neck cancer? a. Hoarseness b. Change in fit of dentures c. Mouth ulcers that do not heal d. Decreased mobility of the tongue 7. While in the recovery room, a client with a total laryngectomy is suctioned and has bloody mucus with some clots. Which of the following nursing interventions would apply? a. Notify the physician immediately. b. Place the client in the prone position to facilitate drainage. c. Instill 3 mL of normal saline into the tracheostomy tube to loosen secretions. d. Continue the assessment of the client, including oxygen saturation, respiratory rate, and breath sounds. 8. How should the client use a voice prosthesis? a. Place a vibrating device in the mouth. b. Place a speaking valve over the stoma. c. Block the stoma entrance with a finger. d. Swallow air using the Valsalva manoeuvre. 1. d; 2. d; 3. c, d, e; 4. c; 5. b; 6. d; 7. d; 8. c.

The number of the question corresponds to the same-­numbered objective at the beginning of the chapter. 1. A client is seen in the clinic for an episode of epistaxis, which is controlled by placement of anterior nasal packing. During discharge teaching, what should the nurse instruct the client to do? a. Use ASA (Aspirin) for pain relief. b. Remove the packing later that day. c. Skip the next dose of antihypertensive medication. d. Avoid vigorous nose blowing and strenuous activity. 2. A client with allergic rhinitis reports severe nasal congestion, sneezing, and watery, itchy eyes and nose at various times of the year. What should the nurse advise the client to do? a. Avoid all intranasal sprays and oral antihistamines. b. Limit the duration of use of nasal decongestant spray to 10 days. c. Use oral decongestants at bedtime to prevent symptoms during the night. d. Keep a diary of when the allergic reaction occurs and what precipitates it. 3. A client is seen at the clinic with fever, muscle aches, sore throat with yellowish exudate, and headache. Which of the following does the nurse anticipate that the interprofessional management will include? (Select all that apply.) a. Antiviral agents to treat influenza b. Treatment with antibiotics starting ASAP c. A throat culture or rapid strep antigen test d. Supportive care, including cool, bland liquids e. Comprehensive history to determine possible etiology 4. What type of tracheostomy tube prevents the use of the voice? a. Cuffless tracheostomy tube b. Fenestrated tracheostomy tube c. Tube with an inflated foam cuff d. Cuffed tube with the cuff deflated

For even more review questions, visit http://evolve.elsevier.com/ Canada/Lewis/medsurg.

CHAPTER 29  Nursing Management: Upper Respiratory Conditions REFERENCES Altobelli, N. (2017). Chapter 36: Airway management. In R. M. Kacmarek, J. K. Stoller, & A. J. Heuer (Eds.), Egan’s fundamentals of respiratory care (11th ed., pp. 739–789). Mosby Elsevier. Boggild, A., Yuan, L., Low, D. E., et al. (2011). The impact of influenza on the Canadian First Nations. Journal of Public Health, 102(5), 345–348. https://doi.org/10.1007/BF03404174. (Seminal). Brennan-­Olsen, S. L., Vogrin, S., Leslie, W. D., et al. (2017). Fractures in Indigenous compared to non-­Indigenous populations: A systematic review of rates and aetiology. Bone Reports, 6, 146–158. https://doi.org/10.1016/j.bonr.2017.04.00 Byun, H., Chung, J. H., Lee, S. H., et al. (2020). Association of hypertension with the risk and severity of epistaxis. JAMA Otolaryngology–Head & Neck Surgery, 147(1), 1–7. https://doi.org/10.1001/ jamaoto.2020.2906 Calhoun, W. J., Omachi, T. A., Reddy, S. R., et al. (2016). Allergic status is associated with increased number of asthma exacerbations. American Journal of Respiratory and Critical Care Medicine, 193, A4970. American Thoracic Society. https://doi.org/10.1164/ ajrccm-­conference.2016.193.1_MeetingAbstracts.A4970 Carr, E. (2016). Head and neck cancers. In J. K. Itano, J. M. Brant, F. A. Conde, et al. (Eds.), Core curriculum for oncology (5th ed., pp. 139–157). Elsevier Mosby. Cash, J. C., Cook, M., & Duke, V. (2020). Acute sinusitis/rhinosinusitis. 7. Nasal guidelines. In J. C. Cash, D. Fraser, L. Corcoran, et al. (Eds.), Canadian family practice guidelines. Springer. Cooper, K., & Gosnell, K. (2019). Adult health nursing (8th ed.). Mosby. Fasanmi, O. G., Odetokun, I. A., Balogun, F. A., et al. (2017). Public health concerns of highly pathogenic avian influenza H5N1 endemicity in Africa. Veterinary World, 10(10), 1194–1204. https://doi. org/10.14202/vetworld.2017.1194-­1204 Gordon, J., Kirlew, M., Schreiber, Y., et al. (2015). Acute rheumatic fever in First Nations communities in northwestern Ontario: Social determinants of health “bite the heart. Canadian Family Physician, 61(10), 881–886. (Seminal). Infection Prevention and Control (IPAC) Canada. (2021). Seasonal influenza, avian influenza and pandemic influenza. https://ipac-­ canada.org/influenza-­resources.php Patton, K., & Thibodeau, G. (2016). Anatomy and physiology (9th ed.). Mosby. Public Health Agency of Canada (PHAC). (2015). An Advisory Committee Statement (ACS)-National Advisory Committee on Immunization (NACI): Canadian immunization guide chapter on influenza and statement on seasonal influenza vaccine for 20152016. https://www.phac-aspc.gc.ca/naci-­ccni/assets/pdf-­flu-2015-­ grippe-­eng.pdf

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Public Health Agency of Canada (PHAC). (2018). Canadian pan­demic influenza preparedness: Planning guidance for the health sector. https://www.canada.ca/en/public-health/services/flu-influenza/ canadian-pandemic-influenza-preparedness-planning-guidancehealth-sector/table-of-contents.html#pre Public Health Agency of Canada (PHAC). (2021). Coronavirus (COVID-19) SARS-CoV-2. https://ipac-canada.org/coronavirusresources.php Rondanelli, M., Miccono, A., Lamburghini, S., et al. (2018). Self-­care for common colds: The pivotal role of vitamin D, vitamin C, zinc, and echinacea in three main immune interactive clusters (physical barriers, innate and adaptive immunity) involved during an episode of common colds—Practical advice on dosages and on the time to take these nutrients/botanicals in order to prevent or treat common colds. Evidence-­Based Complementary and Alternative Medicine, 2018, 36. https://doi.org/10.1155/2018/5813095 Rothrock, J. (2019). Alexander’s care of the patient in surgery (16th ed.). Mosby. Stacy, K. M. (2018). Pulmonary therapeutic management. In L. D. Urden, K. M. Stacy, & M. E. Lough (Eds.), Critical care nursing: Diagnosis and management (8th ed., pp. 487–519). Elsevier Mosby. Tung, H. Y., Landers, C., Li, E., et al. (2016). Allergen-­encoded signals that control allergic responses. Current Opinion in Allergy and Clinical Immunology, 16(1), 51–58. https://doi.org/10.1097/ ACI.0000000000000233

RESOURCES Resources for this chapter are listed in Chapters 30 and 31. For additional Internet resources, see the website for this book at http:// evolve.elsevier.com/Canada/Lewis/medsurg.

CHAPTER

30

Nursing Management

Lower Respiratory Conditions Cydnee Seneviratne Originating US chapter by Eugene Mondor

WEBSITE http://evolve.elsevier.com/Canada/Lewis/medsurg • • • •

 eview Questions (Online Only) R Key Points Answer Guidelines to Case Study Student Case Studies • Lung Cancer • Pulmonary Embolism and Respiratory Failure

• Customizable Nursing Care Plans • Pneumonia • Thoracotomy

• C  onceptual Care Map Creator • Audio Glossary • Content Updates

LEARNING OBJECTIVES 1. Describe the pathophysiology, types, and clinical manifestations of pneumonia and interprofessional care of patients with pneumonia. 2. Explain the nursing management of the patient with pneumonia. 3. Describe the pathogenesis, classification, clinical manifestations, complications, and diagnostic abnormalities of tuberculosis and the nursing and interprofessional management of the patient with tuberculosis. 4. Identify the causes, clinical manifestations, and nursing and interprofessional management of pulmonary fungal infections. 5. Explain the pathophysiology, clinical manifestations, and nursing and interprofessional management of bronchiectasis and lung abscess. 6. Identify the causative factors, clinical features, and management of environmental lung diseases. 7. Describe the causes, risk factors, pathogenesis, and clinical manifestations of lung cancer and the nursing and interprofessional management of the patient with lung cancer.

8. Identify the mechanisms involved and the clinical manifestations of pneumothorax, fractured ribs, and flail chest. 9. Describe the purpose of chest tubes and the methods of their action, as well as related nursing responsibilities in the care of a patient with a chest tube. 10. Explain the types of chest surgery and appropriate preoperative and postoperative care. 11. Compare and contrast extrapulmonary and intrapulmonary restrictive lung disorders in terms of causes, clinical manifestations, and interprofessional management. 12. Describe the pathophysiology, clinical manifestations, and management of pulmonary hypertension and cor pulmonale. 13. Discuss the use of lung transplantation as a treatment for pulmonary disorders.

KEY TERMS acute bronchitis atelectasis blebs bronchiectasis chylothorax community-­acquired pneumonia (CAP) cor pulmonale empirical therapy empyema

  

flail chest hemothorax hospital-­acquired pneumonia (HAP) lung abscess pleural effusion pleurisy (pleuritis) pneumoconiosis pneumonia pneumothorax

A wide variety of conditions affect the lower respiratory system. Lung diseases that are characterized primarily by an obstructive disorder, such as asthma, emphysema, chronic bronchitis, and cystic fibrosis, are discussed in Chapter 31. All other lower respiratory conditions are discussed in this chapter.

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pulmonary edema pulmonary embolism (PE) pulmonary hypertension tension pneumothorax thoracentesis thoracotomy tuberculosis (TB)

Respiratory tract infections are a common cause of morbidity and mortality worldwide. In Canada, respiratory diseases, including chronic obstructive pulmonary disease (COPD), bronchitis, and pneumonia, account for some of the most common reasons for hospitalization (Canadian Institute for Health

CHAPTER 30  Nursing Management: Lower Respiratory Conditions Information, 2021). During the 2019/2020 influenza season, there were up to 52,169 laboratory-­confirmed influenza cases by February 2020. The majority of influenza A cases were diagnosed in adults 65 years and older (46%), and influenza B cases diagnosed were in the younger population—children under the age of 19 years (57%) and persons between 20 and 44 years of age (30%) (Government of Canada, 2020). Although information regarding the COVID-­19 pandemic is constantly evolving as the world grapples with its impact on individuals and families, it is known that patients with chronic lung disease or recent surgical interventions need to avoid contact with any COVID-­ 19-­positive individuals. Finally, tuberculosis (TB), although potentially curable and preventable, is a worldwide public health threat of epidemic proportion. In many places throughout this chapter, bronchitis, pneumonia, and TB statistics are representative of the Canadian population including the Indigenous people in Canada. However, what the statistics do not show or explain are the challenges that Indigenous populations have faced regarding risk factors, access to health care, and continuity of care for lower respiratory conditions. For example, Indigenous children in Canada between the ages of 5 to 13 years are at higher risk for bronchitis, and Indigenous adults over the age of 18 are at risk for higher rates of pneumonia (Dalcin et al., 2018). Modifiable risk factors such as obesity, exposure to smoke, and mould and dampness in the home are preventable public health factors that have been poorly addressed in Indigenous communities and require further attention. In addition, Indigenous people in Canada have historically experienced a health care system that has been brutal and scarring to Indigenous communities. The most concerning example of stereotyping and improper access to care is TB incidence among Indigenous communities in Canada. First Nations communities are disproportionately affected by TB, with factors such as overcrowding, poor housing, poverty, and inappropriate access to health care contributing to this higher incidence. Canadian history related to the treatment of Indigenous people diagnosed with TB is laden with negative experiences for members of First Nations communities. For example, according to Lux (2018), Indian hospitals such as the Camsell Indian Hospital in Edmonton, Alberta were primary care and research hospitals for TB in Canada. Indigenous people were sent to Indian hospitals, where they were diagnosed with TB and assigned to anti-­TB medication trials. After Indian hospitals were shut down, access to proper care did not improve, although unethical experiments decreased. TB remains a rampant and concerning health issue for some Indigenous communities, indicating the need to address determinants of health related to poverty, poor living conditions, and, most importantly, access to appropriate health care.

ACUTE BRONCHITIS Acute bronchitis is an inflammation of the bronchi in the lower respiratory tract that is usually caused by infection. It is one of the most common conditions seen in primary care. It usually occurs as a sequel to an upper respiratory tract infection. A type of acute bronchitis is acute exacerbation of chronic bronchitis (AECB). AECB represents acute infection superimposed on chronic bronchitis. AECB is a potentially serious condition that may lead to respiratory failure. (Chronic bronchitis is discussed in Chapter 31.) The cause of most cases of acute bronchitis is viral (rhinovirus, influenza). However, bacterial causes are also common

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in smokers (e.g., Streptococcus pneumoniae, Haemophilus influenzae) and nonsmokers (e.g., Mycoplasma pneumoniae, Chlamydia pneumoniae). In acute bronchitis, persistent cough following an acute upper airway infection (e.g., rhinitis, pharyngitis) is the most common symptom. Cough is often accompanied by production of clear, mucoid sputum, although some patients produce purulent sputum. Associated symptoms include fever, headache, malaise, and shortness of breath on exertion. Physical examination may reveal mildly elevated temperature, pulse, and respiratory rate with either normal breath sounds or expiratory wheezing. Chest radiographic studies can differentiate acute bronchitis from pneumonia because there is no radiographic evidence of consolidation or infiltrates with bronchitis. Acute bronchitis is usually self-­ limiting, and the treatment is generally supportive, including fluids, rest, and anti-­ inflammatory agents. Cough suppressants or bronchodilators may be prescribed for symptomatic treatment of nocturnal cough or wheezing. Antibiotics are generally not prescribed unless the person has a prolonged infection associated with constitutional symptoms (which indicate systemic disease effects), including mild to moderate pain; the person is a smoker; or the person has COPD. The patient with AECB is usually treated empirically with broad-­spectrum antibiotics. Often, the patient with COPD is taught to recognize symptoms of acute bronchitis and to begin a course of antibiotics when symptoms occur. Many health care providers believe that a more severe infection often results if the patient delays taking antibiotics until after a clinical examination. Early initiation of antibiotic treatment in patients with COPD has resulted in a decrease in relapses and a decrease in hospital admissions. 

PNEUMONIA Pneumonia is an acute inflammation of the lung parenchyma caused by a microbial agent. The discovery of sulpha medications and penicillin was pivotal in the treatment of pneumonia. Since that time, there has been remarkable progress in the development of antibiotics to treat pneumonia. However, despite new antimicrobial agents, pneumonia is still common and is associated with significant morbidity and mortality rates.

Etiology Normally, the airway distal to the larynx is sterile because of protective defence mechanisms. These mechanisms include the following: filtration of air, warming and humidification of inspired air, epiglottis closure over the trachea, cough reflex, mucociliary escalator mechanism, secretion of immunoglobulin A, and alveolar macrophages (see Chapter 28). Factors Predisposing to Pneumonia.  Pneumonia is more likely to result when defence mechanisms become incompetent or are overwhelmed by the virulence or quantity of infectious agents. Decreased consciousness depresses the cough and epiglottal reflexes, which may allow aspiration of oropharyngeal contents into the lungs. Tracheal intubation interferes with the normal cough reflex and the mucociliary escalator mechanism. It also bypasses the upper airways, in which filtration and humidification of air normally take place. The mucociliary escalator mechanism is impaired by air pollution, cigarette smoking, viral upper respiratory infections (URIs), and normal changes of aging. In the presence of malnutrition, the functions

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SECTION 5  Conditions of Oxygenation: Ventilation

TABLE 30.1    FACTORS PREDISPOSING TO

PNEUMONIA

• Aging • Air pollution • Altered consciousness: alcohol use disorder, head injury, seizures, anaesthesia, drug overdose, stroke • Altered oropharyngeal flora • Aspiration • Bed rest and prolonged immobility • Chronic diseases: chronic lung disease, diabetes mellitus, heart disease, cancer, end-­stage renal disease • Debilitating illness • Human immunodeficiency virus (HIV) infection • Immunosuppressive medications (corticosteroids, cancer chemotherapy, immunosuppressive therapy after organ transplant) • Inhalation or aspiration of noxious substances • Intestinal and gastric feedings • Malnutrition • Smoking • Tracheal intubation (endotracheal intubation, tracheostomy) • Upper respiratory tract infection

of lymphocytes and polymorphonuclear leukocytes are altered. Certain diseases, such as leukemia, alcoholism, and diabetes mellitus, are associated with an increased frequency of Gram-­ negative bacilli in the oropharynx. (Gram-­negative bacilli are not normal flora in the respiratory tract.) Altered oropharyngeal flora can also occur secondary to antibiotic therapy given for an infection elsewhere in the body. A summary of the factors predisposing to pneumonia is provided in Table 30.1.  Acquisition of Organisms.  Organisms that cause pneumonia reach the lung by three methods: 1. Aspiration from the nasopharynx or oropharynx. Many of the organisms that cause pneumonia are normal inhabitants of the pharynx in healthy adults. 2. Inhalation of microbes present in the air (e.g., M. pneumoniae, fungal pneumonias) 3. Hematogenous spread from a primary infection elsewhere in the body. An example is Staphylococcus aureus. 

Types of Pneumonia Pneumonia can be caused by bacteria, viruses, Mycoplasma, fungi, parasites, and chemicals. Although pneumonia can be classified according to the causative organism, a clinically effective way to classify pneumonia is as community-­acquired or hospital-­acquired. Classifying pneumonia is important because of differences in the likely causative organisms and the selection of appropriate antibiotics. Community-­Acquired Pneumonia.  Community-­acquired pneumonia (CAP) is defined as a lower respiratory tract infection of the lung parenchyma with onset in the community or during the first 2 days of hospitalization. The incidence of CAP is highest in the winter months. Smoking is an important risk factor. The causative organism in CAP is identified only 50% of the time. Organisms that are commonly implicated in CAP include S. pneumoniae and atypical organisms (e.g., Legionella, Mycoplasma, Chlamydia, viral). Modifying risk factors include the presence of COPD, recent use of antibiotics, and conditions incurring risk of aspiration. In 2000, the Canadian Infectious Disease Society and the Canadian Thoracic Society conducted an evidence-­informed update of the Canadian guidelines for initial management of CAP (Mandell et al., 2000). Considering that there are over 100

microorganisms that cause pneumonia, in addition to chest radiography and clinical evaluation, assessment and diagnosis need to be based on serology results as well as sputum culture, pleural fluid culture, or both, and blood cultures. Pharmacological intervention should include specific antimicrobial selection based on type of pneumonia, including where acquired, and modifying factors such as pathogens (Table 30.2).  Hospital-­Acquired Pneumonia.  Hospital-­acquired pneumonia (HAP) is pneumonia occurring 48 hours or longer after hospital admission and not incubating at the time of hospitalization. HAP accounts for 25% of all critical care unit infections. It is the second most common hospital-­associated infection in Canada and has high mortality and morbidity rates (Wu et al., 2017). The microorganisms responsible for HAP are different from those organisms implicated in CAP. Bacteria are responsible for the majority of HAP infections, including Pseudomonas, Enterobacter, S. aureus, methicillin-­resistant Staphylococcus aureus (MRSA), and S. pneumoniae. Many of the organisms causing HAP enter the lungs after aspiration of particles from the patient’s own pharynx. Immunosuppressive therapy, general debility, and endotracheal intubation may be predisposing factors. Contaminated respiratory therapy equipment is another source of infection.  Fungal Pneumonia.  Fungi may also be a cause of pneumonia (see Pulmonary Fungal Infections section later in this chapter).  Aspiration Pneumonia.  Aspiration pneumonia refers to the sequelae of abnormal entry of secretions or substances into the lower airway. It usually follows aspiration of material from the mouth or the stomach into the trachea and subsequently the lungs. The person who has aspiration pneumonia usually has a history of loss of consciousness (e.g., as a result of seizure, anaesthesia, head injury, stroke, alcohol intake). With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Another risk factor is tube feedings. The dependent portions of the lung are most often affected, primarily the superior segments of the lower lobes and the posterior segments of the upper lobes, which are dependent in the supine position. The aspirated material—food, water, vomitus, or toxic fluids—is the pathological triggering mechanism for the development of this type of pneumonia. There are three distinct forms of aspiration pneumonia. If the aspirated material is an inert substance (e.g., barium), the initial manifestation is usually caused by mechanical obstruction of airways. When the aspirated materials contain toxic fluids, such as gastric juices, there is chemical injury to the lung with infection as a secondary event, usually 48 to 72 hours later; this is identified as chemical (noninfectious) pneumonitis. The most important form of aspiration pneumonia is bacterial infection. The infecting organism is usually one of the normal oropharyngeal flora, and multiple organisms, including both aerobes and anaerobes, are isolated from the sputum of the patient with aspiration pneumonia. Antibiotic therapy is based on an assessment of the severity of illness, where the infection was acquired (community or hospital), and the type of organisms present.  Opportunistic Pneumonia.  Patients with altered immune response are highly susceptible to respiratory infections. Specific individuals considered at risk include those with severe protein–calorie malnutrition; those with immune deficiencies; those who have received transplants and been treated with immunosuppressive medications; and patients who are being treated with radiation therapy, chemotherapeutic agents, or

CHAPTER 30  Nursing Management: Lower Respiratory Conditions

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TABLE 30.2    EMPIRICAL ANTIMICROBIAL SELECTION FOR ADULT PATIENTS WITH COMMUNITY-­

ACQUIRED PNEUMONIA

Type of Pneumonia Outpatient without modifying factors Outpatient with modifying factors

Long-­term care resident in long-­ term care facility

Modifying Factors and/or Pathogens

COPD (no recent antibiotics or oral steroids within past 3 mo) COPD (antibiotics or oral steroids within past 3 mo)—Haemophilus influenzae and enteric Gram-­ negative rods Suspected macroaspiration—oral anaerobes Streptococcus pneumoniae, enteric Gram-­negative rods, H. influenzae

Long-­term care resident in hospital Hospitalized patient on medical ward Hospitalized patient in critical care unit

S. pneumoniae, Legionella pneumophila, Chlamydia pneumoniae Pseudomonas aeruginosa not suspected (S. pneumoniae, L. pneumophila, C. pneumoniae, enteric Gram-­negative rods implicated) P. aeruginosa suspected

First Choice

Second Choice

Macrolide*

Doxycycline

Newer macrolides†

Doxycycline

“Respiratory” fluoroquinolone‡

Amoxicillin–clavulanate + macrolide or second-­generation cephalosporin + macrolide

Amoxicillin–clavulanate ± macrolide, or fourth-­generation fluoroquinolone‡ (e.g., moxifloxacin) “Respiratory” fluoroquinolone‡ alone or amoxicillin–clavulanate + macrolide Identical to treatment for other hospitalized patients (see below) “Respiratory” fluoroquinolone‡

Third-­generation fluoroquinolones‡ (e.g., levofloxacin) + clindamycin or metronidazole Second-­generation cephalosporin + macrolide

IV “respiratory” fluoroquinolone + cefotaxime, ceftriaxone, or β-­lactam–β-­lactamase inhibitor Antipseudomonal fluoroquinolone (e.g., ciprofloxacin) + antipseudomonal β-­lactam (e.g., ceftazidime, carbapenem, piperacillin– tazobactam) or aminoglycoside (e.g., gentamicin, tobramycin, amikacin)

Second-­, third-­, or fourth-­generation cephalosporin + macrolide IV macrolide + cefotaxime, ceftriaxone, or β-­lactam–β-­lactamase inhibitor Triple therapy with antipseudomonal β-­lactam + aminoglycoside + macrolide

COPD, chronic obstructive pulmonary disease; IV, intravenous. *Macrolide—erythromycin, azithromycin, clarithromycin. †Newer macrolide—azithromycin, clarithromycin. ‡Respiratory fluoroquinolone—levofloxacin (third generation), gatifloxacin, and moxifloxacin (fourth generation); trovafloxacin (fourth generation) is restricted because of potential severe hepatoxicity. Source: Mandell, L. A., & Marrie, T. J. (2000). Canadian guidelines for the initial management of community-­acquired pneumonia: An evidence-­based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. Clinical Infectious Diseases, 31(2), 383–421, by permission of Oxford University Press.

corticosteroids (especially for a prolonged period). These individuals have a variety of altered conditions, including altered B-­and T-­lymphocyte function, depressed bone marrow function, and decreased levels or function of neutrophils and macrophages. In addition to the risk for bacterial and viral pneumonia, immunocompromised patients may develop an infection from microorganisms that do not normally cause disease, such as Pneumocystis jiroveci (formerly P. carinii) and cytomegalovirus (CMV). P. jiroveci is an opportunistic pathogen whose natural habitat is the lung. This organism rarely causes pneumonia in healthy individuals. P. jiroveci pneumonia (PJP) affects 70% of human immunodeficiency virus (HIV)–infected individuals and is the most common opportunistic infection in patients with acquired immune deficiency syndrome (AIDS). In this type of pneumonia, the chest radiograph usually shows a diffuse bilateral alveolar pattern of infiltration. In widespread disease, the lungs are massively consolidated. Clinical manifestations are insidious and include fever, tachypnea, tachycardia, dyspnea, nonproductive cough, and hypoxemia. Pulmonary physical findings are minimal in proportion to the serious nature of the disease. Treatment consists of antibiotics. In populations at risk for development of P. jiroveci pneumonitis (e.g., patients with hematological malignancies or

AIDS), antibiotic prophylaxis may be advocated. (PJP is discussed in Chapter 17.) CMV is a cause of viral pneumonia in the immunocompromised patient, particularly in transplant recipients. CMV, a type of herpesvirus, gives rise to latent infections and reactivation with shedding of infectious virus. This type of interstitial pneumonia can be a mild disease, or it can be fulminant and produce pulmonary insufficiency and death. Often, CMV coexists with other opportunistic bacterial or fungal agents in causing pneumonia. Ganciclovir (Cytovene) is recommended for treatment of CMV pneumonia. 

Pathophysiology Pneumococcal pneumonia is the most common cause of bacterial pneumonia. However, regardless of causative factors, pneumonia is characterized by four stages of the disease process: 1. Congestion. After the pneumococcus organisms reach the alveoli via droplets or saliva, there is an outpouring of fluid into the alveoli. The organisms multiply in the serous fluid, and the infection is spread. The pneumococci damage the host by their overwhelming growth and interference with lung function. 2. Red hepatization. There is massive dilation of the capillaries, and alveoli are filled with organisms, neutrophils, red

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PATHOPHYSIOLOGY MAP Aspiration of S. pneumoniae

Release of bacterial endotoxin

Inflammatory response Attraction of neutrophils; release of inflammatory mediators; accumulation of fibrinous exudate, red blood cells, and bacteria

Red hepatization and consolidation of lung parenchyma

Leukocyte infiltration (neutrophils and macrophages)

Gray hepatization and deposition of fibrin on pleural surfaces; phagocytosis in alveoli

Resolution of infection Macrophages in alveoli ingest and remove degenerated neutrophils, fibrin, and bacteria FIG. 30.1  Pathophysiological course of pneumococcal pneumonia.

blood cells, and fibrin (Figure 30.1). The lung appears red and granular, similar to the liver, which is why the process is called hepatization. 3. Grey hepatization. Blood flow decreases, and leukocytes and fibrin consolidate in the affected part of the lung. 4. Resolution. Complete resolution and healing occur if there are no complications. The exudate becomes lysed and is processed by the macrophages. The normal lung tissue is restored, and the person’s gas-­ exchange ability returns to normal. 

Clinical Manifestations Patients with pneumonia usually have a constellation of symptoms, including sudden onset of fever, chills, a cough producing purulent sputum, and pleuritic chest pain (in some cases). In the older person or debilitated patient, confusion or stupor (possibly related to hypoxia) may be the predominant finding. On physical examination, signs of pulmonary consolidation, such as dullness to percussion, increased fremitus, bronchial breath sounds, and crackles, may be found. The typical pneumonia syndrome is usually caused by the most common pathogen in CAP, which is S. pneumoniae, but can also be caused by other bacterial pathogens, such as H. influenzae. Pneumonia may also manifest atypically with a more gradual onset, a dry cough, and extrapulmonary manifestations such as headache, myalgias, fatigue, sore throat, nausea, vomiting, and diarrhea. On physical examination, crackles are often heard. This presentation of symptoms is classically produced by M. pneumoniae but can also be caused by Legionella and C. pneumoniae. Patients with hematogenous S. aureus pneumonia may have only dyspnea and fever. This necrotizing infection causes destruction of lung tissue, and these patients are usually very sick.

Manifestations of viral pneumonia are highly variable but may be characterized by chills, fever, dry, nonproductive cough, and extrapulmonary symptoms. Viral pneumonia may be found in association with systemic viral diseases such as measles, varicella-­zoster, herpes simplex, or influenza virus infection. 

Complications Most cases of pneumonia run an uncomplicated course. Complications generally develop more frequently in individuals with underlying chronic diseases and may include the following: 1. Pleurisy (inflammation of the pleura) is a relatively common accompanying condition of pneumonia. 2. Pleural effusion can occur. Usually, the effusion is sterile and is reabsorbed in 1 to 2 weeks. Occasionally, it necessitates aspiration by means of thoracentesis. 3. Atelectasis (collapsed, airless alveoli) of one or part of one lobe may occur. These areas usually clear with effective coughing and deep breathing. 4. Delayed resolution results from persistent infection and is seen on radiograph as residual consolidation. Usually, the physical findings return to normal within 2 to 4 weeks. Delayed resolution occurs most frequently in patients who are older or malnourished or have alcohol use disorder or COPD. 5. Lung abscess is not a common complication of pneumonia. It may be seen with pneumonia caused by S. aureus and Gram-­negative pneumonias (see Lung Abscess later in this chapter). 6. Empyema (accumulation of purulent exudate in the pleural cavity) is relatively infrequent but necessitates antibiotic therapy and drainage of the exudate by a chest tube or by open surgery. 7. Pericarditis results from spread of the infecting organism from an infected pleura or via a hematogenous route to the pericardium (the fibroserous sac around the heart). 8.  Bacteremia can occur with pneumococcal pneumonia, more so in older patients. 9. Meningitis can be caused by S. pneumoniae. The patient with pneumonia who is disoriented, confused, or somnolent should have a lumbar puncture to evaluate the possibility of meningitis. 1 0. Endocarditis can develop when the organisms attack the endocardium and the valves of the heart. The clinical manifestations are similar to those of acute infective endocarditis (see Chapter 39). Diagnostic Studies The common diagnostic measures for pneumonia are presented in Table 30.3. History, physical examination, and chest radiographic study often provide enough information to make management decisions without doing costly laboratory tests. The chest radiograph often shows a typical pattern characteristic of the infecting organism and is an invaluable adjunct in the diagnosis of pneumonia. Lobar or segmental consolidation suggests a bacterial cause, usually S. pneumoniae or Klebsiella. Diffuse pulmonary infiltrates are most commonly caused by infection with viruses, Legionella, or pathogenic fungi. Cavitary shadows suggest the presence of a necrotizing infection with destruction of lung tissue commonly caused by S. aureus, Gram-­negative bacteria, or Mycobacterium tuberculosis. Pleural effusions, which can occur in up to 30% of patients with CAP, can also be seen on radiographic study.

CHAPTER 30  Nursing Management: Lower Respiratory Conditions TABLE 30.3    INTERPROFESSIONAL CARE Pneumonia Diagnostic • History and physical examination • Chest radiograph • Gram stain examination of sputum • Sputum culture and sensitivity test (if medication-­resistant pathogen or organism not covered by empirical therapy) • Pulse oximetry or ABGs (if indicated) • Complete blood cell count, differential, and routine blood chemistries (if indicated) • Blood cultures (if indicated)

Interprofessional Therapy • Appropriate antibiotic therapy • Increased fluid intake (at least 3 L/day) • Limited activity and rest • Antipyretics • Analgesics • Oxygen therapy (if indicated)

ABGs, arterial blood gases.

Sputum cultures are recommended in the case of the suspected presence of a drug-­resistant pathogen or an organism that is not covered by the usual empirical therapy (therapy based on observation and experience, implemented when the condition’s exact cause is not known). A Gram stain examination of the sputum provides information on the predominant causative organism. A sputum culture should be collected before initiating antibiotic therapy as a means to intervene for patients with community-­or hospital-­acquired pneumonia. Because of the poor sensitivity and specificity of sputum cultures, any sputum culture results should be correlated with the predominant organisms found on Gram stain examination results. Before treatment, two blood cultures may be done for patients who are seriously ill. Although microbial studies are expected before treatment, initiation of antibiotics should not be delayed. Arterial blood gases (ABGs), if obtained, usually reveal hypoxemia. Leukocytosis is found in the majority of patients with bacterial pneumonia, usually with a white blood cell (WBC) count greater than 15 × 109/L with the presence of bands (immature neutrophils). 

Interprofessional Care Prompt treatment with the appropriate antibiotic almost always cures bacterial and mycoplasma pneumonia. In uncomplicated cases, the patient responds to medication therapy within 48 to 72 hours. Indications of improvement include decreased temperature, improved breathing, and reduced chest pain. Abnormal physical findings can last for more than 7 days. In addition to antibiotic therapy, supportive measures may be used, including oxygen therapy to treat hypoxemia, analgesics to relieve the chest pain for patient comfort, and antipyretics such as acetylsalicylic acid (ASA; Aspirin) or acetaminophen (Tylenol) for significantly elevated temperature. During the acute febrile phase, the patient’s activity should be restricted, and rest should be encouraged and planned. The Health Quality Ontario and Ministry of Health and Long-­Term Care CAP guidelines (2013) recommend airway clearance, supportive therapy, antiviral therapy during flu season, smoking cessation, and vaccinations for CAP in addition to antibiotic therapy. Most individuals with mild to moderate illness who have no other underlying disease process can be treated on an outpatient basis. If there is a serious underlying disease or if the pneumonia is accompanied by severe dyspnea, hypoxemia, or other complications, the patient should be hospitalized.

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Currently, there is no definitive treatment for viral pneumonia. An antiviral medication, amantadine, is approved for oral use in the treatment of influenza A virus. The neuraminidase inhibitors zanamivir (Relenza) and oseltamivir (Tamiflu) are active against both influenza A and B (see Chapter 29). An influenza vaccine is modified annually to reflect the anticipated strains in the upcoming season. The flu vaccine is considered a mainstay of prevention and is recommended annually for individuals considered to be at risk for influenza, including older persons, long-­term care residents, patients with COPD or diabetes mellitus, and health care workers (Government of Canada 2016). For older persons with signs and symptoms of influenza, including those who have received the influenza vaccine, treatment with amantadine or a neuraminidase inhibitor is recommended. During epidemics of influenza A, especially in long-­term care facilities, chemoprophylaxis with these agents is recommended for unvaccinated patients, immunodeficient patients, or those who have received the vaccine within the past 2 weeks. Pneumococcal Vaccine.  Pneumococcal vaccine is indicated primarily for the individual considered at risk who (1) has a chronic illness such as lung or heart disease or diabetes mellitus, (2) is recovering from a severe illness, (3) is 65 years of age or older, or (4) resides in a long-­term care facility. Vaccination is particularly important because the rate of medication-­resistant S. pneumoniae infections is increasing. Pneumococcal vaccine can be given simultaneously with other vaccines such as the flu vaccine, but each should be administered in a separate site. The current recommendation is that pneumococcal vaccine is good for a person’s lifetime. However, in the immunosuppressed individual at risk for development of fatal pneumococcal infection (e.g., asplenic patient; patient with nephrotic syndrome, renal failure, or AIDS; or transplant recipient), revaccination is recommended every 5 years.  Medication Therapy.  The main problems with the use of antibiotics to treat pneumonia are the development of resistant strains of organisms and the patient’s hypersensitivity or allergic reaction to certain antibiotics. Most cases of CAP in otherwise healthy adults do not require hospitalization. The Canadian Infectious Diseases Society and Canadian Thoracic Society have guidelines aimed at classifying patients to determine therapy options (see Table 30.2). The oral antibiotic therapy administered is frequently empirical treatment with broad-­spectrum antibiotics. Once the patient is assigned a treatment classification, therapy can be based on the likely infecting organism. For HAP, empirical antibiotic therapy should be based on the likely pathogens in the various patient groups. Even with extensive diagnostic testing, an etiological organism is often not identified. It is important to recognize when a patient is not responding to treatment. Therapy may require modification based on the patient’s culture results or clinical response. Clinical response is evaluated by factors such as a change in fever, sputum purulence, leukocytosis, oxygenation, or radiographic study patterns. Improvement is often not apparent for the first 48 to 72 hours, and therapy need not be altered during this period unless deterioration is noted or culture results dictate that a different antibiotic should be used. Common antibiotics for HAP include cephalosporins (third-­generation antipseudomonal [ceftazidime]), a β-­lactam or β-­lactamase inhibitor, vancomycin (for MRSA), aminoglycosides (gentamicin), and antipseudomonal quinolones (ciprofloxacin). Patients with ventilator-­associated pneumonia may experience rapid deterioration. Patients who deteriorate or fail to

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respond to therapy will require aggressive evaluation to assess noninfectious etiologies, complications, other coexisting infectious processes, or pneumonia caused by a resistant pathogen. It may be necessary to broaden antimicrobial coverage while awaiting results of cultures and other studies, such as computed tomographic (CT) scan, ultrasound, or lung scans.  Nutritional Therapy.  Fluid intake of at least 3 L/day is important in the supportive treatment of pneumonia. If the patient has heart failure, fluid intake must be individualized. If oral intake cannot be maintained, intravenous (IV) administration of fluids and electrolytes may be necessary for the acutely ill patient. An intake of at least 1 500 calories per day should be maintained to provide energy for the increased metabolic processes in the patient. Small, frequent meals are better tolerated by the patient with dyspnea. 

NURSING MANAGEMENT PNEUMONIA NURSING ASSESSMENT Subjective and objective data that should be obtained from a patient with pneumonia are presented in Table 30.4.  NURSING DIAGNOSES Nursing diagnoses for the patient with pneumonia may include but are not limited to the following: • Reduced gas exchange (resulting from fluid and exudate accumulation with the alveoli and surrounding lung tissue) • Inadequate breathing pattern resulting from pain • Acute pain resulting from biological injury agent (infection) • Reduced stamina resulting from respiratory condition, physical deconditioning Additional information on nursing diagnoses for the patient with pneumonia is presented in Nursing Care Plan (NCP) 30.1, available on the Evolve website.  PLANNING The overall goals are that the patient with pneumonia will have (a) clear breath sounds, (b) normal breathing patterns, (c) no signs of hypoxia, (d) a normal chest radiograph, and (e) no complications related to pneumonia.  NURSING IMPLEMENTATION HEALTH PROMOTION.  Many nursing interventions are available to help prevent the occurrence of pneumonia as well as the morbidity associated with it. Teaching a patient to practise good health habits, such as proper diet and hygiene, adequate rest, and regular exercise, can help the patient maintain the natural resistance to infecting organisms. If possible, exposure to people with URIs should be avoided. If a URI occurs, it should be treated promptly with supportive measures (e.g., rest, fluids). If symptoms persist for more than 7 days, the person should obtain medical care. Individuals at risk for pneumonia (e.g., people who are chronically ill, older persons) should be encouraged to obtain both influenza and pneumococcal vaccines. In the hospital, the nursing role involves identifying the patient at risk (see Table 30.1) and taking measures to prevent the development of pneumonia. The patient with altered consciousness should be placed in positions (e.g., side-­lying, upright) that will prevent or minimize the risk for aspiration. The patient should be turned and repositioned at least every 2 hours to facilitate adequate lung expansion and to discourage pooling of secretions.

TABLE 30.4    NURSING ASSESSMENT Pneumonia Subjective Data Important Health Information Past health history: Lung cancer, COPD, diabetes mellitus; cigarette smoking; alcohol use disorder; recent upper respiratory tract infection; chronic debilitating disease; malnutrition; altered consciousness; AIDS; exposure to chemical toxins, dust, or allergens; immobility or prolonged bed rest Medications: Use of antibiotics, corticosteroids, chemotherapy, or any other immunosuppressants Surgery or other treatments: Recent abdominal or thoracic surgery, splenectomy, endotracheal intubation, general anaesthesia; tube feedings

Symptoms • Fatigue, weakness, malaise • Anorexia, nausea, vomiting • Fever, chills • Dyspnea, cough (productive or nonproductive), nasal congestion, pain with breathing • Chest pain, sore throat, headache, abdominal pain, muscle aches

Objective Data General Fever, restlessness, or lethargy; splinting of affected area

Respiratory Tachypnea; dyspnea, nasal congestion, pharyngitis; asymmetrical chest movements or retraction; decreased excursion; nasal flaring; use of accessory muscles (neck, abdomen); grunting; crackles, friction rub on auscultation; dullness on percussion over consolidated areas, increased tactile fremitus on palpation; pink, rusty, purulent, green, yellow, or white sputum (amount may be scant to copious)

Cardiovascular Tachycardia

Neurological Changes in mental status, ranging from confusion to delirium

Possible Findings Leukocytosis; abnormal ABGs with ↓ or normal PaO2, ↓ PaCO2, and ↑ pH initially, and later ↓ PaO2, ↑ PaCO2, and ↓ pH; positive sputum Gram stain examination and culture; patchy or diffuse infiltrates, abscesses, pleural effusion, or pneumothorax on chest radiographic study ABGs, arterial blood gases; AIDS, acquired immune deficiency syndrome; COPD, chronic obstructive pulmonary disease; PaCO2, partial pressure of carbon dioxide in arterial blood; PaO2, partial pressure of oxygen in arterial blood.

The patient who has a feeding tube generally requires that measures be taken to prevent aspiration (see Chapter 42). Although feeding tubes are small, an interruption in the integrity of the lower esophageal sphincter still exists and can allow reflux of gastric and intestinal contents. The patient who has difficulty swallowing (e.g., a patient who has had a stroke) needs assistance in eating, drinking, and taking medication to prevent aspiration. The patient who has recently had surgery and others who are immobile need assistance with turning and measures to facilitate deep breathing at frequent intervals (see Chapter 22). The nurse must be careful to avoid overmedication with opioids or sedatives, which can cause a depressed cough reflex and accumulation of fluid in the lungs. Presence of the gag reflex should be ascertained before the administration of fluids or food to the individual who has had local anaesthesia to the throat. To reduce the incidence of health care–associated infections, the nurse should practice strict medical asepsis and adherence to infection-­control guidelines. Poor hand hygiene practices allow spread of pathogens via the hands of the health care worker.

CHAPTER 30  Nursing Management: Lower Respiratory Conditions Staff members should wash their hands or, if hands are not visibly soiled, use hand rubs with 60% alcohol before providing care to a patient. Respiratory devices can harbour microorganisms and have been associated with outbreaks of pneumonia. Strict sterile aseptic technique should be used when suctioning the trachea of a patient.  ACUTE INTERVENTION.  Although many patients with pneumonia are treated on an outpatient basis, the nursing care plan for a patient with pneumonia (see NCP 30.1, available on the Evolve website) is applicable to outpatients and inpatients. It is important for the nurse to remember that pneumonia is an acute, infectious disease. Although most cases of pneumonia are potentially completely curable, complications can result. The nurse must be aware of these complications and their manifestations. The infection-­control nurse can be a valuable resource in assisting with the care of patients with pneumonia. Therapeutic positioning for patients with pneumonia ensures stable oxygenation status. The “good lung down” position is used for patients with unilateral lung disease, in whom better oxygenation is achieved when the unaffected lung (good lung) is placed in the down (lateral) position to achieve maximum lung expansion. Incentive spirometry, turning, coughing, and deep breathing all increase lung volume, mobilize secretions, and prevent atelectasis. Exercise and early ambulation augment bronchial hygiene and are encouraged as tolerated.  AMBULATORY AND HOME CARE.  The patient needs to be reassured that complete recovery from pneumonia is possible. It is extremely important to emphasize the need to take all of any medications prescribed and to return for follow-­up medical care and evaluation. The patient needs to be taught about the medication–medication and the food–medication interactions for the prescribed antibiotic. Adequate rest is needed to maintain progress toward recovery and to prevent a relapse. The patient should be told that it may take weeks to feel the usual vigour and sense of well-­being. A prolonged period of convalescence may be necessary for the older or chronically ill patient. The patient considered to be at risk for pneumonia should be told about available vaccines and should discuss them with the health care provider. Deep-­breathing exercises should be practised for 6 to 8 weeks after the patient is discharged from the hospital.  EVALUATION.  The expected outcomes for the patient with pneumonia are presented in NCP 30.1, available on the Evolve website. 

TUBERCULOSIS Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis. It usually involves the lungs, but it also occurs in the larynx, the kidneys, the bones, the adrenal glands, the lymph nodes, and the meninges and can be disseminated throughout the body. TB is a reportable communicable disease; it kills more people worldwide than any other infectious disease, with an estimated 8.8 million of the world’s population having been infected. In Canada, the number of reported cases of active TB has remained relatively stable and low in the global context. In 2020, the Public Health Agency of Canada (PHAC) reported that as of 2017 there was a 2.6% increase from 1 750 to 1 796 of Canadian-­born people diagnosed with TB. In addition, foreign-­ born individuals make up the majority of cases (71.8%), and Canadian-­born Indigenous people (21.5 per 100 000 population) continue to have the highest reported number of TB cases

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DETERMINANTS OF HEALTH Tuberculosis Income and Social Status Low socioeconomic groups have higher rates of TB. 

Physical Environments Residing in overcrowded institutions (e.g., long-­term care facilities, correctional facilities) and urban homelessness increase the risk for acquiring TB. 

Personal Health Practices and Coping Skills Smoking and air pollution increase the risk for TB. 

Culture TB is most prevalent among immigrants and Indigenous people.

References Public Health Agency of Canada. (2018). The time is now—Chief Public Health Officer spotlight on eliminating tuberculosis in Canada. https://www.canada.ca/content/dam/phac-­aspc/documents/corporate/pub lications/chief-­public-­health-­officer-­reports-­state-­public-­health-­canada/elimi nating-­tuberculosis/PHAC_18-­086_TB_Report_E_forwebcoding.pdf TB, tuberculosis.

in Canada, with the Inuit population having the highest rate (300 times higher than in the Canadian, non-Indigenous population) (Indigenous Services Canada, 2020; LaFreniere et  al., 2019). It is important to note that 80.4% of TB cases reported did result in successful treatment and patient outcomes. As stated above, the populations most at risk in Canada are the Indigenous and immigrant populations. The rate of TB among Canadian-­born Indigenous peoples living on reserve is 40 times higher than the national average. Factors or challenges that Canadian-­born Indigenous people face that can influence transmission of TB are food insecurity, overcrowding, poorly ventilated homes, comorbidities (e.g., diabetes, HIV), and smoking (Indigenous Services Canada, 2020).

Etiology and Pathophysiology M. tuberculosis, a Gram-­positive, acid-­fast bacillus, is usually spread from person to person via airborne droplets, which are produced when the infected individual with pulmonary or laryngeal TB coughs, sneezes, speaks, or sings. Once released into a room, the organisms are dispersed and can be inhaled. TB is not highly infectious, and transmission usually requires close, frequent, or prolonged exposure. Brief exposure to a few tubercle bacilli rarely causes an infection. The disease cannot be spread by hands, books, glasses, dishes, or other fomites. The very small droplets, 1 to 5 mcm in size, contain M. tuberculosis. Because they are so small, the particles remain airborne indoors for minutes to hours. Once inhaled, these small particles lodge in the bronchiole and alveolus. Factors that influence the likelihood of transmission include the (a) number of organisms expelled into the air, (b) concentration of organisms (small spaces with limited ventilation would mean higher concentration), (c) length of time of exposure, and (d) immune system of the exposed person. M. tuberculosis replicates slowly and spreads via the lymphatic system. The organisms find favourable environments for growth primarily in the upper lobes of the lungs, the kidneys, epiphyses of the bone, the cerebral cortex, and adrenal glands. Healing of the primary lesion usually takes place by resolution, fibrosis, and calcification. The granulation tissue surrounding

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the lesion may become more fibrous and form a collagenous scar around the tubercle. A Ghon complex is formed, consisting of the Ghon tubercle and regional lymph nodes. Calcified Ghon complexes may be seen on chest radiographic studies. When a TB lesion regresses and heals, the infection enters a latent period in which it may persist without producing clinical symptoms of illness. The infection may develop into clinical disease if the persisting organisms begin to multiply rapidly, or it may remain dormant. People who are infected with M. tuberculosis but do not have TB disease cannot spread the infection to other people. TB infection occurs when the bacteria are inhaled but there is an ineffective immune response and the bacteria become inactive. The majority of people mount effective immune responses to encapsulate these organisms for the rest of their lives, preventing primary infection from progressing to disease. TB infection in a person who does not have the active TB disease is not considered a case of TB and is often referred to as latent tuberculosis infection (LTBI). If the initial immune response is not adequate, control of the organisms is not maintained, and clinical disease results. Dormant but viable organisms persist for years. Reactivation of TB can occur if the host’s defence mechanisms become impaired. The reasons for reactivation are not well understood, but they are related to decreased resistance found in older persons, individuals with concomitant diseases, and persons who receive immunosuppressive therapy. 

Clinical Manifestations In the early stages of TB, the person is usually free of symptoms. Many cases are found incidentally when routine chest radiographic studies are done, especially in older persons. Systemic manifestations may initially consist of fatigue, malaise, anorexia, weight loss, low-­grade fevers, and night sweats. The weight loss may not be excessive until late in the disease and is often attributed to overwork or other factors. A characteristic pulmonary manifestation is a cough that becomes frequent and produces mucoid or mucopurulent sputum. Dyspnea is unusual. Chest pain characterized as dull or tight may be present. Hemoptysis is not a common finding and is usually associated with more advanced cases. Sometimes TB has more acute, sudden manifestations: The patient has high fever, chills, generalized flulike symptoms, pleuritic pain, and a productive cough. The HIV-­infected patient with TB often has atypical physical examination and chest radiographic examination findings. Classical signs such as fever, cough, and weight loss may be attributed to PCP or other HIV-­associated opportunistic diseases. Clinical manifestations of respiratory conditions in patients with HIV must be carefully investigated to determine the cause.  Complications Miliary Tuberculosis.  If a necrotic Ghon complex erodes through a blood vessel, large numbers of organisms invade the bloodstream and spread to all body organs. This is called miliary or hematogenous TB. The patient may be either acutely ill with fever, dyspnea, and cyanosis or chronically ill with systemic manifestations of weight loss, fever, and gastrointestinal (GI) disturbance. Hepatomegaly, splenomegaly, and generalized lymphadenopathy may be present.  Pleural Effusion and Empyema.  A pleural effusion is caused by the release of caseous material into the pleural space. The

bacteria-­containing material triggers an inflammatory reaction and a pleural exudate of protein-­rich fluid. A form of pleurisy called dry pleurisy may result from a superficial tubercular lesion involving the pleura. It appears as localized pleuritic pain on deep inspiration. Empyema is less common than effusion but may occur from large numbers of organisms spilling into the pleural space, usually from rupture of a cavity.  Tuberculosis Pneumonia.  Acute pneumonia may result when large amounts of tubercle bacilli are discharged from the liquefied necrotic lesion into the lung or lymph nodes. The clinical manifestations are similar to those of bacterial pneumonia, including chills, fever, productive cough, pleuritic pain, and leukocytosis.  Other Organ Involvement.  Although the lungs are the primary site of TB, other body organs may also be involved. The meninges may become infected. Bone and joint tissue may be involved in the infectious disease process. The kidneys, the adrenal glands, the lymph nodes, and the genital tract (in both females and males) may also be infected. 

Diagnostic Studies Tuberculin Skin Testing.  The body’s immune response can be demonstrated by hypersensitivity to a tuberculin skin test. A positive reaction occurs 2 to 12 weeks after the initial infection, corresponding to the time needed to mount an immune response. Purified protein derivative (PPD) of tuberculin is used primarily to detect the delayed hypersensitivity response. (The procedure for performing the tuberculin skin test is described in Chapter 28.) Once acquired, sensitivity to tuberculin tends to persist throughout life. A positive reaction indicates the presence of a TB infection, but it does not show whether the infection is latent or active, that is, causing a clinical illness. Because the response to TB skin testing may be decreased in the immunocompromised patient, induration reactions equal to or greater than 5 mm are considered positive. Sometimes, a repeat PPD can cause an accelerated response (the “booster” effect). Thus, two-­step testing is recommended for initial screening of health care workers who will be getting regularly retested in the future and for those who have a decreased response to allergens. This procedure helps identify individuals with past disease and prevent a later positive PPD test from being misinterpreted as a new, infection-­related PPD conversion. See Chapter 28, Table 28.12, for guidelines in interpreting positive TB skin tests. Recent guidelines for targeted tuberculin testing emphasize targeting only high-­risk groups and discourage testing low-­risk individuals.  Chest Radiographic Study.  Although the findings on chest radiographic examination are important, it is not possible to make a diagnosis of TB solely on the basis of this examination. This is because other diseases can mimic the radiographic appearance of TB. The abnormality most commonly found in TB is multinodular lymph node involvement with cavitation in the upper lobes of the lungs. Calcification of the lung lesions generally occurs within several years of the infection.  Bacteriological Studies.  The demonstration of tubercle bacilli bacteriologically is essential for establishing a diagnosis. Microscopic examination of stained sputum smears for acid-­ fast bacilli (AFB) is usually the first bacteriological evidence of the presence of tubercle bacilli. Three consecutive sputum specimens are collected on different days and sent for smear and culture. In addition to sputum, material for examination can be

CHAPTER 30  Nursing Management: Lower Respiratory Conditions obtained from gastric washings, cerebrospinal fluid (CSF), or pus from an abscess. The most accurate means of diagnosis is the culture technique. The major disadvantage of this method is that it may take 6 to 8 weeks for the mycobacteria to grow. The advantage is that it can detect small quantities (as few as 10 bacteria/mL of specimen). Nucleic acid amplification (NAA) is a rapid diagnostic test for TB. Test results are available in a few hours. They are more sensitive than AFB smears but less sensitive than TB cultures. NAA does not replace routine sputum smears and cultures, but it offers a health care provider increased confidence in the diagnosis. Since 2007, Canada has been testing using QuantiFERON­TB Gold In-­Tube. The patient’s blood is mixed with mycobacterial antigens and is then measured using an enzyme-­linked immunosorbent assay (ELISA). If the patient is infected with TB organisms, the lymphocytes in the blood will recognize the antigens. 

Interprofessional Care Hospitalization for initial treatment of TB is not necessary in most patients. Most patients are treated on an outpatient basis TABLE 30.5    INTERPROFESSIONAL CARE Tuberculosis Diagnostic

Interprofessional Therapy

• History and physical examination • Tuberculin skin test • Chest radiographic study • Bacteriological studies • Sputum smear • Sputum culture

• Long-­term treatment with antimicrobial medications (see Tables 30.6 and 30.7) • Follow-­up bacteriological studies and chest radiographic examinations

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(Table 30.5), and many can continue to work and maintain their lifestyles with few changes. Hospitalization may be used for diagnostic evaluation, for those who are severely ill or debilitated, and for those who experience adverse medication reactions or treatment failures. The mainstay of TB treatment is medication therapy. Medication therapy is used to treat an individual with clinical disease and to prevent disease in an infected person. Medication Therapy Active Disease.  Standard therapy for active TB has been revised because of the global increase in prevalence of multidrug-­ resistant tuberculosis (MDR TB) (World Health Organization [WHO], 2014). MDR TB occurs when resistance develops to two or more anti-­TB medications. In Canada, MDR TB risk factors include previous TB treatment, birth outside of Canada, and exposure to an individual or individuals diagnosed with infectious medication-­resistant TB. Prevention over management of MDR TB is recommended to prevent resistance. Treatment is individualized, and an initial phase of treatment for a minimum of 8 months is recommended. The patient with active TB should be managed aggressively; treatment usually consists of a combination of at least four medications. The reason for combination therapy is to increase the therapeutic effectiveness and decrease the development of resistant strains of M. tuberculosis. It has been shown that single-­ medication therapy can result in rapid development of resistant strains. Medications are divided into first-­ line and second-­ line medications. The four first-­line medications used in Canada are isoniazid (INH), rifampin (RMP), pyrazinamide (PZA), and ethambutol (EMB) (Table 30.6). The most commonly used second-­line medications include fluoroquinolones (e.g., moxifloxacin, levofloxacin) and injectables (e.g., streptomycin, amikacin). Second-­line medications are used in special situations such as medication-­resistant tuberculosis.

TABLE 30.6    MEDICATION THERAPY First-­Line Medication Therapy for Tuberculosis Medication

Mechanisms of Action

Adverse Effects

Comments

Isoniazid (INH)

Bactericidal; interferes with DNA metabolism of tubercle bacillus

Peripheral neuritis, hepatotoxicity, hypersensitivity (skin rash, arthralgia, fever), optic neuritis

Rifampin (RMP)

Bactericidal; has broad-­ spectrum effects, inhibits RNA polymerase of tubercle bacillus Bactericidal; exact mechanism unknown

Medication interactions, rash, hepatitis, febrile reaction, GI disturbance, peripheral neuropathy, hypersensitivity Hepatitis, arthralgia, fever, skin rash, hyperuricemia, GI symptoms, jaundice (rare) Skin rash, GI disturbance, malaise, peripheral neuritis, optic neuritis

Metabolism primarily by liver and excretion by kidneys; pyridoxine (vitamin B6) administration during high-­dose therapy as prophylactic measure; use as single prophylactic agent for active TB in individuals whose PPD converts to positive; ability to cross blood–brain barrier; safe in pregnancy* Most commonly used with INH; low incidence of adverse effects; suppression of effect of birth control pills; possibility of orange urine and bodily fluids; safe in pregnancy High rate of effectiveness when used with streptomycin or capreomycin

First-­Line Medications

Pyrazinamide (PZA)

Ethambutol (EMB)

Bacteriostatic; inhibits RNA synthesis

Adverse effects uncommon and reversible with discontinuation of medication; most commonly used as substitute medication when adverse effects occur with INH or RMP; safe in pregnancy*

DNA, deoxyribonucleic acid; GI, gastrointestinal; PPD, purified protein derivative; RNA, ribonucleic acid; TB, tuberculosis. *Pyridoxine (vitamin B6) supplements should be prescribed for patients who may be or are pregnant or who are breastfeeding or are diagnosed with renal failure, diabetes, seizures, malnutrition, or substance use disorder, as these patients are at risk for symptoms of pyridoxine deficiency. Canadian tuberculosis standards suggest pyridoxine dose of 25 mg. Source: © All rights reserved. Canadian Tuberculosis Standards, 7th Edition. Public Health Agency of Canada, 2013. Adapted and reproduced with permission from the Minister of Health, 2021.

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TABLE 30.7    MEDICATION THERAPY Medication Regimen Options for Treatment of Tuberculosis Standard

Initial Phase (first 2 mo)

Continuation Phase

Regimen 1*

INH + RMP + PZA ± EMB† daily or 5 days/wk INH + RMP ± EMB daily or 5 days/wk

INH + RMP for 4 mo daily or 3 times/wk INH + RMP for 7 mo daily or 3 times/wk

Regimen 2

*Regimen 1 is preferred (Nahid et al., 2016; BC Centre for Disease Control, 2019). †EMB can be stopped as soon as drug susceptibility testing results are available, and the strain is pan-­sensitive. PZA is continued for the full 2 months. EMB, ethambutol; INH, isoniazid; PZA, pyrazinamide; RMP, rifampin. Source: © All rights reserved. Canadian Tuberculosis Standards, 7th Edition. Public Health Agency of Canada, 2013. Adapted and reproduced with permission from the Minister of Health, 2021.

TABLE 30.8    INDICATIONS FOR TREATMENT OF

LATENT TUBERCULOSIS INFECTION

Treatment is indicated with positive tuberculin skin tests in people with the following: • Known or suspected HIV infection • Recent contact with infectious TB • Presence of lung scar Treatment is indicated with significant tuberculin skin test reaction in the following situations: • Special clinical situations (immunosuppression therapy, use of corticosteroids, diabetes mellitus, silicosis, chronic renal failure, organ transplant, hematological malignancies) • If the person was born in a high-­prevalence country, is a resident of a communal setting, is a health care worker, or is Indigenous HIV, human immunodeficiency virus; TB, tuberculosis. Source: Adapted from Public Health Agency of Canada & Canadian Lung Association. (2014). Canadian tuberculosis standards (7th ed.). https://www.canada.ca/en/public-­ health/services/infectious-­diseases/canadian-­tuberculosis-­standards-­7th-­edition.html

Various medication and dosing regimens are available (Table 30.7). Fixed-­dose combination anti-­TB medications may enhance adherence to treatment recommendations. Patients on antiretroviral treatment for HIV cannot take RMP because it can impair the effectiveness of the antiretroviral medications. Other medications are primarily used for treatment of resistant strains or when the patient develops adverse effects to the primary medications. Many second-­line medications carry a greater risk for adverse effects and necessitate closer monitoring. In follow-­up care for patients on long-­term therapy, it is important to monitor the effectiveness of medications and the development of adverse effects. Usually, sputum specimens are initially obtained weekly and then monthly to assess the effectiveness of the medication. Although TB tends to have a rapidly progressive course in the patient co-­infected with HIV, it responds well to standard medication. Treatment should occur for at least 6 months beyond the conversion of sputum cultures to negative status. Follow-­up care is important to ensure adherence, as nonadherence is a major factor in the emergence of multidrug resistance and treatment failures. Many individuals do not adhere to the treatment program in spite of understanding the disease process and the value of treatment. Furthermore, completing therapy is crucial because of the danger of reactivation of TB and the development of MDR TB seen in patients who do not complete their full course of therapy. Directly observed therapy (DOT) is recommended for patients known to be at risk for nonadherence to therapy. DOT is an expensive but essential public health issue. DOT involves observing the ingestion of every dose

of medication for the TB patient’s entire course of treatment. In many regions, the public health nurse administers DOT at a clinic site. The patient needs to have follow-­up visits for 12 months after completion of therapy to check for the presence of resistant strains. DOT protocols and options in remote or rural areas and in Indigenous communities remain problematic. Teaching patients about the adverse effects of these medications and when to seek medical attention is critical. The major adverse effect of INH, RMP, and PZA is hepatitis. Thus liver function tests should be monitored. Baseline liver function tests are done at the start of treatment, and routine monitoring of liver function is done if baseline tests are abnormal.  Latent Tuberculosis Infection.  LTBI occurs when an individual becomes infected with M. tuberculosis but does not become acutely ill. Medication therapy can be used to prevent a TB infection from developing into a clinical disease. Previously used terms such as preventive therapy and chemoprophylaxis were confusing. Therefore, LTBI is the preferred term. The indications for treatment of LTBI are presented in Table 30.8. The medication generally used in treatment of LTBI is INH. It is effective and inexpensive and can be administered orally.  Vaccine.  Immunization with bacille Calmette–Guérin (BCG) vaccine to prevent TB is currently in use in many parts of the world. Although millions of people have been vaccinated with BCG, the efficacy of the vaccine is not clear. BCG vaccination can result in a positive PPD reaction. The BCG vaccine reaction will wane over time, and the mean PPD reaction size among people who received BCG is less than 10 mm. Because it may be difficult to determine the relevance of increases in individuals who have undergone BCG vaccination, the PHAC and Canadian Lung Association (2014) recommend that a conversion to “positive” be defined as a reaction of 10 mm or greater. People who receive BCG are from high-­prevalence areas of the world, and it is important that a positive skin reaction be evaluated for TB. 

NURSING MANAGEMENT TUBERCULOSIS NURSING ASSESSMENT It is important to determine whether the patient was ever exposed to a person with TB. The patient should be assessed for productive cough, night sweats, afternoon temperature elevation, weight loss, pleuritic chest pain, and crackles over the apices of the lungs. If the patient has a productive cough, an early-­morning sputum specimen will be required for an AFB smear to detect the presence of mycobacteria.  NURSING DIAGNOSES Nursing diagnoses for the patient with TB may include but are not limited to the following: • Inadequate airway clearance resulting from excessive mucus, retained secretions • Potential for infection (of others) resulting from insufficient knowledge to avoid exposure to pathogens • Inadequate health management resulting from insufficient knowledge of therapeutic regimen, insufficient social support  PLANNING The overall goals are that the patient with TB will (a) adhere to the therapeutic regimen, (b) have no recurrence of disease, (c) have normal pulmonary function, and (d) take appropriate measures to prevent the spread of the disease. 

CHAPTER 30  Nursing Management: Lower Respiratory Conditions NURSING IMPLEMENTATION HEALTH PROMOTION.  The ultimate goal related to TB in Canada is eradication. Selective screening programs in known risk groups are of value in detecting individuals with TB. The person with a positive tuberculin skin test should have a chest radiographic examination to assess for the presence of TB. Another important measure is to identify the contacts of the individual who has TB. These contacts should be assessed for the possibility of infection and the need for prophylactic medication therapy.  ACUTE INTERVENTION.  Acute in-­hospital care is seldom required for the patient with TB. If hospitalization is needed, it is usually for a brief period. Patients strongly suspected of having TB should (a) be placed in respiratory isolation, (b) receive four-­medication therapy, and (c) receive an immediate medical workup, including chest radiographic examination, sputum smear, and culture. Respiratory isolation is indicated for the patient with pulmonary or laryngeal TB until the patient is considered to be noninfectious (effective medication therapy, clinical improvement, three negative AFB smears). A negative-­pressure isolation room that offers six or more exchanges per hour may be used. Ultraviolet radiation of the air in the upper part of the room is another approach for reducing airborne TB organisms. Therefore, ultraviolet lights are commonly seen in clinics and homeless shelters. Masks are needed to filter out droplet nuclei. Use of institution-­approved high-­efficiency particulate air (HEPA) masks is indicated. The mask must be moulded to fit tightly around the nose and mouth. The patient should be taught to cover the nose and mouth with paper tissue every time they cough, sneeze, or produce sputum. The tissues should be thrown into a paper bag and disposed of with the trash, burned, or flushed down the toilet. The patient should also be taught careful handwashing techniques to be used after handling sputum and soiled tissues. Special precautions should be taken during high-­risk procedures such as sputum induction, aerosolized pentamidine treatments, intubation, bronchoscopy, or endoscopy.  AMBULATORY AND HOME CARE.  Patients who have responded clinically are discharged home despite positive smears if their household contacts have already been exposed and the patient is not posing a risk to susceptible people. Determination of absolute noninfection requires negative cultures. Most treatment failures occur because the patient neglects to take the medication, discontinues it prematurely, or takes it irregularly. On discharge, the physician may order a combination of medications to increase the likelihood of adherence, ensure that all medications are taken, and reduce the risk of developing drug resistance. It is important for the nurse to develop a therapeutic, consistent relationship with each patient. The nurse must understand the patient’s lifestyle and be flexible in planning a program that facilitates the patient’s participation in and completion of therapy. The nurse should ensure that the patient fully understands the need for dedication to the prescribed regimen. Ongoing reassurance helps the patient understand that adherence can mean cure. If the patient cannot or will not adhere to a self-­ administered medication regimen, medication may have to be given by a responsible person on a daily or intermittent basis (see the Ethical Dilemmas box). The public health department must be notified if patient adherence to the medication regimen is questionable so that follow-­up of close contacts can be accomplished. In some cases, the public health nurse will be responsible for DOT. In other situations, a spouse, grown child, other relative living with the patient, or co-­worker may be asked to supervise medication taking.

599

ETHICAL DILEMMAS Patient Adherence Situation The health clinic for the homeless discovers that a man with tuberculosis has not been adhering to instructions for taking his medication. He tells the nurse that it is hard for him to get to the clinic to obtain the medication, much less to keep on a schedule. The nurse is concerned not only about this patient but also about the risks to the other people at the shelter, in the park, and at the meal sites. 

Important Points for Consideration • A  dherence is a complex issue involving a person’s culture and values, perceived risk for disease, availability of resources, access to treatment, and perceived consequences of available choices. • Nurses in the community are concerned not only with providing benefits and supporting decision making for individual patients but also with the health and well-­being of the entire community. • Greater harm may result for the community when more virulent drug-­ resistant strains of microorganisms develop as a consequence of partial treatment or inability of the patient to complete a course of therapy. • Advocacy for the patient and the community obliges the nurse to involve other members of the health care team, such as those in social services, to assist in obtaining the necessary resources or support to facilitate the patient’s completion of the course of treatment. • If the patient is unable to adhere to the treatment program, even with necessary supports in place, concern for the public’s health would take priority and necessitate placing him in a supervised living situation until his treatment is completed. 

Clinical Decision-­Making Questions 1. U  nder what circumstances are health care providers justified in overriding a patient’s autonomy or decision making? 2. How would the nurse determine whether there were cultural beliefs interfering with this man’s ability to understand the importance of completing the treatment? What would the nurse do about it?

When the treatment regimen has been completed, there is evidence of negative cultures, the patient is improving clinically, and there is radiological evidence of improvement, most individuals can be considered adequately treated. Follow-­up care may be indicated during the subsequent 12 months, including bacteriological studies and chest radiographic examinations. Because approximately 5% of individuals experience relapses, the patient should be taught to recognize the symptoms that indicate recurrence of TB. If these symptoms occur, immediate medical attention should be sought. The patient needs to be instructed about certain factors that could reactivate TB, such as immunosuppressive therapy, malignancy, and prolonged debilitating illness. If the patient experiences any of these events, the health care provider must be told so that reactivation of TB can be closely monitored. In some situations, it may be necessary to put the patient on antiT ­ B therapy.  EVALUATION The following are the expected outcomes for the patient with TB: • Patient will have complete resolution of the disease. • Patient will have normal pulmonary function. • Patient will have absence of any complications. • Patient will have no transmission of TB. 

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ATYPICAL MYCOBACTERIA Pulmonary disease that closely resembles TB may be caused by atypical acid-­fast mycobacteria. This type of pulmonary disease is indistinguishable from TB clinically and radiologically but can be differentiated by bacteriological culture. These organisms are not believed to be airborne and thus are not transmitted by droplet nuclei. Atypical mycobacteria may also invade the cervical lymph nodes, causing lymphadenitis. This type of pulmonary disease typically occurs in White men with a history of COPD, cystic fibrosis, or silicosis. Mycobacterium avium-­intracellulare (MAI) is a common cause of opportunistic infections in the patient with HIV infection (see Chapter 17). Treatment depends on identification of the causative agent and determination of drug sensitivity. Many of the medications used in treating TB are used in combating infections from atypical mycobacteria. 

PULMONARY FUNGAL INFECTIONS Pulmonary fungal infections are increasing in incidence. They appear most frequently in seriously ill patients being treated with corticosteroids, antineoplastic immunosuppressive medications, or multiple antibiotics. They are also more common in patients with AIDS or cystic fibrosis. Types of fungal infections are presented in Table 30.9. These infections are not transmitted from person to person, and the patient does not have to be placed in isolation. The clinical manifestations are similar to those of bacterial pneumonia. Skin and serology tests are available to assist in identifying the infecting organism. However, identification of the organism in a sputum specimen or in other body fluids is the best diagnostic indicator. In addition, fungal infections in the mouth and throat (thrush) can be prevented if the patient performs an oral rinse after using inhalant therapy, specifically a corticosteroid.

Interprofessional Care Amphotericin B (Fungizone) is the medication most widely used in treating serious systemic fungal infections. It must be given intravenously to achieve adequate blood and tissue levels because it is poorly absorbed from the GI tract. Amphotericin B is considered a toxic drug with many possible adverse effects, including hypersensitivity reactions, fever, chills, malaise, nausea and vomiting, thrombophlebitis at the injection site, and abnormal renal function. Many of the adverse effects during infusion can be avoided by premedicating with an anti-­ inflammatory or with diphenhydramine (Benadryl) 1 hour before the infusion. Monitoring renal function and ensuring adequate hydration are essential while a person is receiving this medication. Renal changes are at least partially reversible. Amphotericin infusions are incompatible with most other medications. Amphotericin is frequently administered every other day after daily therapy for an initial period of several weeks. Total treatment with the medication may range from 4 to 12 weeks. Oral antifungal medications such as ketoconazole (Nizoral), fluconazole (Diflucan), and itraconazole (Sporanox) have also been successful in the treatment of fungal infections. Their effectiveness in treatment allows an alternative to the use of amphotericin B in many cases. Effectiveness of therapy can be monitored with fungal serology titres. 

TABLE 30.9    FUNGAL INFECTIONS OF THE

LUNG

Organism

Characteristics

Histoplasmosis Histoplasma capsulatum

Indigenous to soil of the St. Lawrence River valleys; inhalation of mycelia into lungs; infected individual often free of symptoms; generally self-­limiting, chronic disease similar to TB

Coccidioidomycosis Coccidioides immitis

Indigenous to semi-­arid regions of southwestern United States (not normally found in Canada); inhalation of arthrospores into lungs; suppurative (pus-­forming) and granulomatous reaction in lungs; symptomatic infection in one third of individuals

Blastomycosis Blastomyces dermatitidis

Indigenous to southern Canada; inhalation of fungus into lungs; progression of disease often insidious; possible involvement of skin

Cryptococcosis Cryptococcus neoformans

True yeast; indigenous worldwide in soil and pigeon excreta; inhalation of fungus into lungs; possible meningitis

Aspergillosis Aspergillus niger or A. fumigatus

True mould inhabiting mouth; widely distributed; invasion of lung tissue resulting in possible necrotizing pneumonia; in individual with asthma, allergic bronchopulmonary aspergillosis may necessitate corticosteroid therapy

Candidiasis Candida albicans

Leading cause of mycotic infections in hospitalized and immunocompromised hosts; ubiquitous and frequent colonization of upper respiratory and gastrointestinal tracts; infections often follow broad-­spectrum antibiotic therapy (systemic or inhaled); possible development of localized pulmonary infiltrate to widespread bilateral consolidation with hypoxemia

Actinomycosis Actinomyces israelii

Not a true fungus; anaerobic; Gram-­positive bacteria with branching hyphae; presence of necrotizing pneumonia after aspiration; pneumonitis; commonly in lower lobes with abscess or empyema formation

Nocardiosis Nocardia asteroides

Not a true fungus; aerobic; soil saprophyte widely distributed in nature; acquisition of infection from nature; rarely present in sputum without accompanying disease

Pneumocystis Pneumonia (PCP) Pneumocystis jiroveci

Rarely causes pneumonia in healthy individuals; fungus present in the environment; common opportunistic pneumonia in people with impaired immune systems, HIV infection, or both

HIV, human immunodeficiency virus; TB, tuberculosis.

CHAPTER 30  Nursing Management: Lower Respiratory Conditions Mucus and pus

A

B

Cylindrical

Mucus

Saccular FIG. 30.2  Pathological changes in bronchiectasis. A, Longitudinal section of bronchial wall where chronic infection has caused damage. B, Collection of purulent material in dilated bronchioles, leading to persistent infection.

BRONCHIECTASIS Etiology and Pathophysiology Bronchiectasis is characterized by permanent, abnormal dilation of one or more large bronchi. The pathophysiological change that results in dilation is destruction of the elastic and muscular structures of the bronchial wall. There are two pathological types of bronchiectasis: saccular and cylindrical (Figure 30.2). Saccular bronchiectasis occurs mainly in large bronchi and is characterized by cavity-­like dilations. The affected bronchi end in large sacs. Cylindrical bronchiectasis involves medium-­sized bronchi that are mildly to moderately dilated. Almost all forms of bronchiectasis are associated with bacterial infections. A wide variety of infectious agents can initiate bronchiectasis, including adenovirus, influenza virus, S. aureus, Klebsiella, and anaerobes. Infections cause the bronchial walls to weaken, and pockets of infection begin to form. When the walls of the bronchial system are injured, the mucociliary mechanism is damaged, allowing bacteria and mucus to accumulate within the pockets. The infection becomes worse and results in bronchiectasis. 

Clinical Manifestations The hallmark of bronchiectasis is persistent or recurrent cough with production of greater than 20 mL of purulent sputum per day. The cough is paroxysmal and is often stimulated by position changes. Other manifestations include exertional dyspnea, fatigue, weight loss, anorexia, and fetid breath. On auscultation of the lungs, crackle and wheezing may be heard. Sinusitis frequently accompanies diffuse bronchiectasis. The manifestations of advanced, widespread bronchiectasis are generalized wheezing, digital clubbing, and cor pulmonale.  Diagnostic Studies An individual with a chronic productive cough with copious purulent sputum (which may be blood streaked) should be suspected of having bronchiectasis. Chest radiographic studies are usually done and may show streaky infiltrates or may be normal.

601

The availability of high-­resolution CT scans of the chest, which have excellent sensitivity for detecting bronchiectasis, has made diagnosis easier. Bronchoscopy can also be useful in identifying the source of secretions, in identifying sites of hemoptysis, or for collecting microbiological samples. Sputum may provide additional information regarding the severity of impairment and the presence of active infection. Pulmonary function studies may be abnormal in advanced bronchiectasis, showing a decrease in vital capacity, expiratory flow, and maximum voluntary ventilation. Complete blood cell count may be normal or show evidence of leukocytosis or anemia from chronic infection. 

Interprofessional Care Bronchiectasis is difficult to treat. Therapy is aimed at treating acute flare-­ups and preventing decline in lung function. Antibiotics are the mainstay of treatment and are given on the basis of sputum culture results. Long-­term suppressive therapy with antibiotics is occasionally used but is fraught with risks for antibiotic resistance. A form of treatment gaining popularity is the use of nebulized antibiotics. Studies indicate that they are safe and may reduce the number of flare-­ups and hospitalizations in bronchiectatic patients (Rubin & Williams, 2014). Antipseudomonal antibiotics, such as tobramycin, are commonly used. Concurrent bronchodilator therapy is given to prevent bronchospasm. Other forms of medication therapy may include mucolytic agents and expectorants. Maintaining good hydration is important to liquefy secretions. Chest physiotherapy and other airway clearance techniques are important to facilitate expectoration of sputum. (These techniques are discussed in Chapter 31.) The individual should reduce exposure to excessive air pollutants and irritants, avoid cigarette smoking, and obtain pneumococcal and influenza vaccinations. Surgical resection of parts of the lungs, although not used as often as in the past, may be done if more conservative treatment is not effective. Surgical resection of an affected lobe or segment may be indicated for the patient with repeated bouts of pneumonia, hemoptysis, and disabling complications. Surgery is not advisable when there is diffuse or widespread involvement. For select patients who are disabled in spite of maximal therapy, lung transplantation is an option. (Lung transplantation is discussed later in this chapter.) 

NURSING MANAGEMENT BRONCHIECTASIS The early detection and treatment of lower respiratory tract infections will help prevent complications such as bronchiectasis. Any obstructing lesion or foreign body should be removed promptly. Other measures to decrease the occurrence or progression of bronchiectasis include avoiding cigarette smoking and decreasing exposure to pollution and irritants. An important nursing goal is to promote drainage and removal of bronchial mucus. Various airway clearance techniques can be effectively used to facilitate secretion removal. The patient should be taught deep-­breathing exercises and effective ways to cough (see Chapter 31, Table 31.17). Chest physiotherapy with postural drainage should be done on affected parts of the lung (see Chapter 31, Figure 31.22). Some individuals require elevation of the foot of the bed by 10 to 15 cm to facilitate drainage. Pillows may be used in the hospital and at home

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SECTION 5  Conditions of Oxygenation: Ventilation

to help the patient assume postural drainage positions. A Flutter mucus clearance device is a handheld device that provides airway vibration during the expiratory phase of breathing (see Chapter 31, Figure 31.23). Two to four 15-­minute sessions daily by a patient who has been properly trained can provide satisfactory mucus clearance. Positive expiratory pressure therapy is a breathing manoeuvre against an expiratory resistance often used in conjunction with nebulized medications. (Respiratory therapy procedures are explained in Chapter 31.) Administration of the prescribed antibiotics, bronchodilators, or expectorants is critical. The patient needs to understand the importance of taking the prescribed regimen of medications to obtain maximum effectiveness. The patient should be aware of possible adverse effects and of the adverse effects that must be reported to the health care provider. Health teaching must include information regarding the importance of getting adequate rest, avoiding overexertion, consuming adequate nutrients, ensuring hydration, and performing oral care. Unless there are contraindications such as concomitant heart failure or renal disease, the patient should be instructed to drink at least 3 L of fluid daily. Generally, the patient should be counselled to use low-­sodium fluids to avoid systemic fluid retention. Direct hydration of the respiratory system may also prove beneficial in the expectoration of secretions. Usually, a bland aerosol with normal saline solution delivered by a jet-­type nebulizer is used. The patient with bronchiectasis should avoid using ultrasonic nebulizers because they often induce bronchospasm. At home, a steamy shower can prove effective; expensive equipment that requires frequent cleaning is usually unnecessary. It is important that the patient medicate with an inhaled bronchodilator 10 to 15 minutes before using a bland aerosol, to prevent bronchoconstriction. The patient and caregivers should be taught to recognize significant clinical manifestations to be reported to the health care provider. These manifestations include increased sputum production, grossly bloody sputum, increasing dyspnea, fever, chills, and chest pain. 

LUNG ABSCESS Etiology and Pathophysiology A lung abscess is a pus-­containing lesion of the lung parenchyma that gives rise to a cavity. The cavity is formed by necrosis of the lung tissue. In many cases, the causes and pathogenesis of lung abscesses are similar to those of pneumonia. Most lung abscesses are caused by aspiration of material from the oral cavity (the gingival crevices) into the lungs. In general, infectious agents including enteric Gram-­negative organisms (e.g., Klebsiella), S. aureus, and anaerobic bacilli (e.g., Bacteroides) are responsible for lung abscesses and the associated infection and necrosis of the lung tissue. A lung abscess can also result from a lung infarct secondary to pulmonary embolus, malignant growth, TB, and various parasitic and fungal diseases of the lung. The areas of the lung most commonly affected are the superior segments of the lower lobes and the posterior segments of the upper lobes. Fibrous tissue usually forms around the abscess in an attempt to wall it off. The abscess may erode into the bronchial system, causing the production of foul-­smelling sputum. It may grow toward the pleura and cause pleuritic pain. Multiple small abscesses can occur within the lung. 

Clinical Manifestations and Complications The onset of a lung abscess is usually insidious, especially if anaerobic organisms are the primary cause. A more acute onset occurs with aerobic organisms. The most common manifestation is a cough that produces purulent sputum (often dark brown) that is foul smelling and foul tasting. Hemoptysis is common, especially at the time that an abscess ruptures into a bronchus. Other common manifestations are fever, chills, prostration, pleuritic pain, dyspnea, cough, and weight loss. Physical examination of the lungs indicates dullness to percussion and decreased breath sounds on auscultation over the segment of lung involved. There may be transmission of bronchial breath sounds to the periphery if the communicating bronchus becomes patent and drainage of the segment begins. Crackles may also be present in the later stages as the abscess drains. Oral examination often reveals dental caries, gingivitis, and periodontal infection. Complications that can occur include chronic pulmonary abscess, bronchiectasis, and brain abscess as a result of the hematogenous spread of infection, and bronchopleural fistula and empyema as a result of abscess perforation into the pleural cavity.  Diagnostic Studies A chest radiographic examination will reveal a solitary cavitary lesion with fluid. CT scanning is used if there is suspicion of cavitation not clearly seen. A lung abscess, in contrast to other types of abscesses, does not require assisted drainage, as long as there is drainage via the bronchus. Routine sputum cultures can be collected, but contaminants can confuse the results and it is difficult to isolate anaerobic bacteria. Pleural fluid and blood cultures may be obtained. Bronchoscopy may be used in cases of abscess in which drainage is delayed or in which there are factors that suggest an underlying malignancy. 

NURSING AND INTERPROFESSIONAL MANAGEMENT LUNG ABSCESS Antibiotics given for a prolonged period (up to 2 to 4 months) are usually the primary method of treatment. Penicillin has historically been the medication of choice because of the frequent presence of anaerobic organisms. However, recent studies suggest that the anaerobic bacteria involved in abscesses of the lung produce β-­lactamase, which is resistant to penicillin. Clindamycin has been shown to be superior to penicillin and is the standard treatment for an anaerobic lung infection. Patients with putrid lung abscesses usually show clinical improvement with decreased fever within 3 to 4 days of beginning antibiotics. Because of the need for prolonged antibiotic therapy, the patient must be aware of the importance of continuing the medication for the prescribed period. As well, the patient needs to know about adverse effects to be reported to the health care provider. Sometimes, the patient is asked to return periodically during the course of antibiotic therapy for repeat cultures and sensitivity tests to ensure that the infecting organism is not becoming resistant to the antibiotic. When antibiotic therapy is completed, the patient is re-­evaluated. The nurse should teach the patient how to cough effectively (see Chapter 31, Table 31.17). Chest physiotherapy and postural drainage are sometimes used to drain abscesses located in the lower or posterior portions of the lung. Postural drainage according to the lung area involved will aid in the removal

CHAPTER 30  Nursing Management: Lower Respiratory Conditions of secretions (see Chapter 31, Figure 31.22). Frequent (every 2 to 3 hours) mouth care is needed to relieve the foul-­smelling odour and taste from the sputum. Diluted hydrogen peroxide and mouthwash are often effective. Rest, good nutrition, and adequate fluid intake are all supportive measures to facilitate recovery. If dentition is poor and dental hygiene is not adequate, the patient should be encouraged to obtain dental care. Surgery is rarely indicated but occasionally may be necessary when reinfection of a large cavitary lesion occurs or to establish a diagnosis when there is evidence of an underlying neoplasm or chronic associated disease. The usual procedure in such cases is a lobectomy or pneumonectomy. An alternative to surgery is percutaneous drainage, but this has a high risk for contamination of the pleural space. 

ENVIRONMENTAL LUNG DISEASES Environmental or occupational lung diseases result from inhaled dust or chemicals. The duration of exposure and the amount of inhalant have a major influence on whether the exposed individual will have lung damage, as does the susceptibility of the host. Pneumoconiosis is a general term for lung diseases caused by the inhalation and retention of dust particles. The literal meaning of pneumoconiosis is “dust in the lungs.” Examples of this condition are silicosis, asbestosis, berylliosis, and hantavirus, a potentially fatal disease transmitted by inhalation of aerosolized rodent excreta particles, which has had outbreaks reported in Canada and the United States. The classical response to the inhaled substance is diffuse parenchymal infiltration with phagocytic cells. This eventually results in diffuse pulmonary fibrosis (excess connective tissue). Fibrosis is the result of tissue repair after inflammation. Pneumoconiosis and other environmental lung diseases are presented in Table 30.10. Chemical pneumonitis results from exposure to toxic chemical fumes. Acutely, there is diffuse lung injury characterized as pulmonary edema. Chronically, the clinical picture is that of bronchiolitis obliterans, which is usually associated with a normal chest radiograph or one that shows hyperinflation. An example is silo filler’s disease. Hypersensitivity pneumonitis or extrinsic allergic alveolitis is the response seen when antigens to which an individual is allergic are inhaled. Examples include bird fancier’s lung and farmer’s lung. Although the incidence of many occupational respiratory diseases has declined, occupational asthma is the most common occupational lung disease (Canadian Centre for Occupational Health and Safety [CCOHS], 2021a). Occupational asthma refers to the development of symptoms of shortness of breath, wheezing, cough, and chest tightness as a result of exposure to dust or fumes that trigger an allergic response. The obstruction may initially be reversible or intermittent, but continued exposure results in permanent obstructive changes. The best-­known causative agent in occupational asthma is toluene di-­isocyanate (TDI), which is used in the production of rigid polyurethane foam. Lung cancer, either squamous cell carcinoma or adenocarcinoma, is the most frequent cancer associated with asbestos exposure. People who have experienced more exposure are at a greater risk for disease. There is a minimum lapse of 15 to 19 years between first exposure and development of lung cancer. Mesotheliomas, both pleural and peritoneal, are also associated with asbestos exposure.

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Clinical Manifestations Acute symptoms of pulmonary edema may be seen following early exposure to chemical fumes. However, symptoms of many environmental lung diseases may not occur until at least 10 to 15 years after the initial exposure to the inhaled irritant. Dyspnea and cough are often the earliest manifestations. Chest pain and cough with sputum production usually occur later. Complications that often result are pneumonia, chronic bronchitis, emphysema, and lung cancer. Manifestations of these complications can be the reason the patient seeks health care. Cor pulmonale is a late complication, especially in conditions characterized by diffuse pulmonary fibrosis. Pulmonary function studies often show reduced vital capacity. A chest radiograph will often reveal lung involvement specific to the primary condition. CT scans have been shown to be useful in detecting early lung involvement.  Interprofessional Care The best approach to management is to try to prevent or decrease environmental and occupational risks. Well-­designed, effective ventilation systems can reduce exposure to irritants. Wearing a mask is appropriate in some occupations. Periodic inspections and monitoring of workplaces by agencies such as the Canadian Centre for Occupational Health and Safety reinforce the obligations of employers to provide a safe work environment (CCOHS, 2021b). In addition, the Canada Labour Code requires that an occupational health and safety committee be established in all workplaces with 20 or more regular employees (Human Resources and Skills Development Canada, 2017). Cigarette smoking adds increased insult to the lungs, so persons at risk for occupational lung disease should not smoke. In addition, secondhand smoke is an important source of exposure that increases risk for development of lung cancer. This risk has led to regulations requiring a smoke-­free workspace for all employees. Early diagnosis is essential if the disease process is to be halted. Places of employment in which there is a known risk for lung disease may require periodic chest radiographic examinations and pulmonary function studies for exposed employees. This measure can help detect pulmonary changes before symptoms develop. There is no specific treatment for most environmental lung diseases. The best treatment is to decrease or stop exposure to the harmful agent. Strategies are directed toward providing symptom relief. If there are coexisting conditions, such as pneumonia, chronic bronchitis, emphysema, or asthma, they are treated. 

LUNG CANCER Lung cancer, the most preventable cancer, is the leading cause of cancer-­related deaths in men and women in Canada. In 2020, lung cancer accounted for 1.8 million deaths worldwide, making it the deadliest of all cancers (WHO, 2021). In 2020, lung cancer was one of the most commonly diagnosed cancers in Canada and accounted for 2.21 million cases. Lung cancer has a low 5-­year survival rate of 19%, based on 2012–2014 data (Canadian Cancer Society, 2021a). Lung cancer most commonly occurs in people who have a long history of cigarette smoking and who are 40 to 75 years of age, with peak incidence between 55 and 65 years of age.

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TABLE 30.10    ENVIRONMENTAL LUNG DISEASES Agents and Industries

Description

Complications

Disease appears 15–35 yr after first exposure. Interstitial fibrosis develops. Pleural plaques, which are calcified lesions, develop on pleura. Dyspnea, basal crackles, and decreased vital capacity are early manifestations.

Diffuse interstitial pulmonary fibrosis; lung cancer, especially in cigarette smokers; mesothelioma (rare type of cancer affecting pleura and peritoneal membrane)

Formation of noncaseating granulomas is seen. Acute pneumonitis occurs after heavy exposure. Interstitial fibrosis can also occur.

Progress of disease possible even after removal of stimulating inhalant

Asbestosis Asbestos fibres present in insulation, construction material (roof tiling, cement products), shipyards, textiles (for fireproofing), automobile clutch and brake linings

Berylliosis Beryllium dust present in aircraft manufacturing, metallurgy, rocket fuels

Bird Fancier’s, Breeder’s, or Handler’s Lung Bird droppings or feathers

Hypersensitivity pneumonitis is present.

Progressive fibrosis of lung

Airway obstruction is caused by contraction of smooth muscles. Chronic disease results from severe airway obstruction and decreased elastic recoil.

Progression of chronic disease after cessation of dust exposure

Byssinosis Cotton, flax, and hemp dust (textile industry)

Coal Worker’s Pneumoconiosis (Black Lung) Coal dust

Incidence is high (20–30%) in coal workers. Deposits of carbon dust cause lesions to develop along respiratory bronchioles. Bronchioles dilate because of loss of wall structure. Chronic airway obstruction and bronchitis develop. Dyspnea and cough are common early symptoms.

Progressive, massive lung fibrosis; increased risk for chronic bronchitis and emphysema in smokers

Hypersensitivity pneumonitis occurs. Acute form is similar to pneumonia, with manifestations of chills, fever, and malaise. Chronic, insidious form is type of pulmonary fibrosis.

Progressive fibrosis of lung

Farmer’s Lung Inhalation of airborne material from mouldy hay or similar matter

Hantavirus Pulmonary Syndrome (HPS) Rodent droppings inhaled while in rodent-­infested areas

Acute hemorrhagic fever associated with severe pulmonary and cardiovascular collapse and death. Incubation period is 1–4 wk with prodrome (3–5 days) of flulike symptoms. No cure or specific treatment exists.

Critical care unit with careful monitoring of fluid and electrolyte balance and blood pressure; supportive therapy and early intervention vital; research on this virus is done in high-­level biocontainment facilities

Dust deposits are found in lung.

—

In chronic disease, dust is engulfed by macrophages and may be destroyed, resulting in fibrotic nodules. Acute disease results from intense exposure in short period. Within 5 yr, it progresses to severe disability from lung fibrosis.

Increased susceptibility to tuberculosis; progressive, massive fibrosis; high incidence of chronic bronchitis

Chemical pneumonitis occurs.

Progressive bronchiolitis obliterans

Siderosis Iron oxide present in welding materials, foundries, iron ore mining

Silicosis Silica dust present in quartz rock in mining of gold, copper, tin, coal, lead; also present in sandblasting, foundries, quarries, pottery making, masonry

Silo Filler’s Disease Nitrogen oxides from fermentation of vegetation in freshly filled silo

Etiology Cigarette smoking is the most important risk factor in the development of lung cancer. Smoking is responsible for approximately 85% of all lung cancers in Canada (Canadian Cancer Society, 2021c). Tobacco smoke contains 60 carcinogens in addition to substances (e.g., carbon monoxide, nicotine) that interfere with normal cell development. Cigarette smoking, a lower-­airway irritant, causes a change in the bronchial epithelium, which usually returns to normal when smoking is discontinued. The risk for lung cancer is gradually lowered when smoking ceases and it continues to decline

with time. After 10 years following cessation of smoking, the risk for lung cancer is cut in half (Canadian Lung Association, 2016). In 2017, 8% of Canadian youth between the ages of 15 and 19 were smokers. The risk of developing lung cancer is directly related to total exposure to cigarette smoke, measured by total number of cigarettes smoked in a lifetime, age of smoking onset, depth of inhalation, tar and nicotine content, and use of unfiltered cigarettes. Side-­stream smoke (smoke from burning cigarettes and cigars) contains the same carcinogens found in mainstream smoke (smoke inhaled by the smoker). According to the Canadian

CHAPTER 30  Nursing Management: Lower Respiratory Conditions Cancer Society (2021d) approximately 800 nonsmokers in Canada die from secondhand smoke. Compared with nonsmokers, those who smoke pipes and cigars have also been shown to have an increased risk of developing lung cancer. Cigar smokers are at higher risk for lung cancer than pipe smokers. In fact, rates of lung cancer caused by heavy smoking of cigars and inhalation of smoke from small cigars have been shown to correlate with the rates of lung cancer caused by cigarette smoking. Vaping and e-­cigarettes, for the short term, have been suggested as an alternative to conventional cigarettes and cigars to help people quit smoking. Although long-­term studies have yet to be been conducted, use of vaping and e-­cigarette products has been shown to induce exogenous lipoid pneumonia, diffuse alveolar hemorrhage, and vaping-­associated bronchiolitis obliterans; long-­term use may cause life-­threatening lung disease Francesco, 2020). The Canadian Cancer Society (2021e) recommends complete cessation of any type of cigarette or tobacco product use via vape or e-­cigarette to decrease risk of lung cancer. Another major risk factor for lung cancer is inhaled carcinogens. These include asbestos, radon, nickel, iron and iron oxides, uranium, polycyclic aromatic hydrocarbons, chromates, arsenic, and air pollution. Exposure to these substances is common for employees of industries such as mining, smelting, or chemical or petroleum manufacturing. The cigarette smoker who is also exposed to one or more of these chemicals or to high amounts of air pollution is at significantly higher risk for lung cancer. There are marked variations in a person’s propensity to develop lung cancer. To date, no genetic abnormality has conclusively been defined for lung cancer. It is known that the carcinogens in cigarette smoke directly damage deoxyribonucleic acid (DNA). One theory is that people have different genetic carcinogen-­metabolizing pathways. 

Pathophysiology The pathogenesis of primary lung cancer is not well understood. More than 90% of cancers originate from the epithelium of the bronchus (bronchogenic). They grow slowly, and it takes 8 to 10 years for a tumour to reach 1 cm in size, which is the smallest detectable lesion on a radiographic study. Lung cancers occur primarily in the segmental bronchi or beyond and have a preference for the upper lobes of the lungs (Figures 30.3 and 30.4). Pathological changes in the bronchial system show nonspecific inflammatory changes with hypersecretion of mucus, desquamation of cells, reactive hyperplasia of the basal cells, and metaplasia of normal respiratory epithelium into stratified squamous cells. Primary lung cancers are often categorized into two broad subtypes (Table 30.11): non–small cell lung cancer (NSCLC; 85 to 90%) and small cell lung cancer (SCLC; 10 to 15%) (Canadian Cancer Society, 2021b). Lung cancers metastasize primarily by direct extension and via the blood circulation and the lymph system. The common sites for metastatic growth are liver, brain, bones, scalene lymph nodes, and adrenal glands. Paraneoplastic Syndrome.  Certain lung cancers cause paraneoplastic syndrome, which is characterized by various systemic manifestations caused by factors (e.g., hormones, enzymes, antigens) produced by the tumour cells. SCLCs are most commonly associated with paraneoplastic syndrome. The systemic manifestations seen are hormonal, dermatological, neuromuscular, vascular, hematological, and connective tissue syndromes.

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FIG. 30.3  Lung cancer. Peripheral adenocarcinoma. The tumour shows prominent black pigmentation, suggestive of having evolved in an anthracotic scar. Source: Damjanov, I., & Linder, J. (1996). Anderson’s pathology (10th ed.). Mosby.

FIG. 30.4  Lung carcinoma. The grey-­white tumour tissue is infiltrating the

lung. Histologically, this tumour is identified as a squamous cell carcinoma. Source: Kumar, V., Abbas, A. K., Aster, J. C., et al. (2010). Robbins and Cotran pathologic basis of disease (8th ed.). Saunders.

Examples of paraneoplastic syndromes include hypercalcemia, syndrome of inappropriate antidiuretic hormone (SIADH) secretion, anemia, leukocytosis, hypercoagulable disorders, and neurological syndromes. These syndromes can respond temporarily to symptomatic treatment, but they are impossible to control without successful treatment of the underlying lung cancer. 

Clinical Manifestations Lung cancer is clinically silent for most individuals for the majority of its course. The clinical manifestations of lung cancer are usually nonspecific and appear late in the disease process. Manifestations depend on the type of primary lung cancer, its location, and metastatic spread. Often, there is extensive metastasis before symptoms become apparent. Persistent pneumonitis that is a result of obstructed bronchi may be one of the earliest manifestations, causing fever, chills, and cough. One of the most significant symptoms, and often the one reported first, is a persistent cough that may produce sputum. Sputum may be blood-­tinged because of bleeding caused by

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TABLE 30.11    COMPARISON OF THE TYPES OF PRIMARY LUNG CANCER Cell Type

Risk Factors

Characteristics

Response to Therapy

Accounts for 30% of lung cancers; is more common in men; arises from the bronchial epithelium; produces earlier symptoms because of bronchial obstructive characteristics; does not have a strong tendency to metastasize; metastasizes locally by direct extension; causes cavitating pulmonary lesions Accounts for approximately 40% of lung cancers; is more common in women; often has no clinical manifestations until widespread metastasis is present; metastasizes via bloodstream; is most commonly located in peripheral portions of lungs* Accounts for 10% of lung cancers; commonly causes cavitation; is highly metastatic via lymphatics and blood; commonly peripheral rather than central

Surgical resection is often attempted; life expectancy is better than for small cell lung cancer.

Accounts for 20–25% of lung cancers; is most malignant form; tends to spread early via lymphatics and bloodstream; is frequently associated with endocrine disturbances; predominantly central and can cause bronchial obstruction and pneumonia

This cancer has the poorest prognosis; however, chemotherapy advances have been substantial; radiation is used as adjuvant therapy as well as palliative measure. Average median survival is 12–18 mo.

Non–Small Cell Lung Cancer (NSCLC) Squamous cell (epidermoid) carcinoma

Almost always associated with cigarette smoking; is associated with exposure to environmental carcinogens (e.g., uranium, asbestos)

Adenocarcinoma

Has been associated with lung scarring and chronic interstitial fibrosis; is not related to cigarette smoking

Large cell undifferentiated carcinoma

High correlation with cigarette smoking and exposure to environmental carcinogens

Surgical resection is often attempted; cancer does not respond well to chemotherapy.

Surgery is not usually attempted because of high rate of metastases; tumour may be radiosensitive but often recurs.

Small Cell Lung Cancer (SCLC) Small cell anaplastic undifferentiated (includes oat cell)

Associated with cigarette smoking, exposure to environmental carcinogens

*See Figure 30.3.

malignancy, but hemoptysis is not a common early symptom. Chest pain may be present and localized or unilateral, ranging from mild to severe. Dyspnea and an auscultatory wheeze may be present if there is bronchial obstruction. Later manifestations may include nonspecific systemic symptoms such as anorexia, fatigue, weight loss, and nausea and vomiting. Hoarseness may be present as a result of involvement of the recurrent laryngeal nerve. Unilateral paralysis of the diaphragm, dysphagia, and superior vena cava obstruction may occur because of intrathoracic spread of the malignancy. There may be palpable lymph nodes in the neck or the axilla. Mediastinal involvement may lead to pericardial effusion, cardiac tamponade, and dysrhythmias. 

Diagnostic Studies Chest radiographic studies are widely used in the diagnosis of lung cancer. The findings may show the presence of the tumour or abnormalities related to the obstructive features of the tumour such as atelectasis and pneumonitis. The radiograph can also show evidence of metastasis to the ribs or vertebrae and the presence of pleural effusion. CT scanning is the single most effective noninvasive technique for evaluating lung cancer. CT scans of the brain and bone scans complete the evaluation for metastatic disease. With CT scans, the location and extent of masses in the chest can be identified, as well as any mediastinal involvement or lymph node enlargement. Magnetic resonance imaging (MRI) may be used in combination with or instead of CT scans. Positron emission tomography (PET) can be a useful diagnostic tool in early clinical staging. PET allows measurement of differential metabolic activity in normal and diseased tissues. A definitive diagnosis of lung cancer is made by identifying malignant cells. Sputum specimens are usually obtained for

cytological studies. An early-­morning specimen that has been obtained by having the patient cough deeply provides the most accurate results. However, malignant cells may not be obtained even in the presence of a lung cancer. The use of the fibre-­optic bronchoscope is important in the diagnosis of lung cancer, particularly when the lesions are endobronchial or close to an airway. It provides direct visualization and allows biopsy specimens to be obtained. A biopsy is usually the best method for establishing the presence of a malignant tumour. Mediastinoscopy—the insertion of a scope via a small anterior chest incision into the mediastinum—is done to examine for metastasis in the anterior mediastinum or in the hilum or in the chest extrapleurally. It is also used to determine the stage of the lung cancer, an important step toward preparing a treatment plan. Video-­assisted thoracoscopy (VAT), which involves the insertion of a scope into a small thoracic incision, may be used to explore areas inaccessible by mediastinoscopy. Pulmonary angiography and lung scans may be performed to assess overall pulmonary status. Fine-­needle aspiration (FNA) may be used to obtain a tissue sample to determine tumour histology. FNA is most useful in cases involving a peripheral lesion near the chest wall, and it is usually attempted to avoid a thoracotomy. If a thoracentesis is performed to relieve a pleural effusion, the fluid should be analyzed for malignant cells. (Table 30.12 summarizes the diagnostic management of lung cancer.) Staging.  Staging of NSCLC is performed according to the tumour–node–metastasis (TNM) staging system in a manner similar to that for other tumours (Table 30.13). Assessment criteria are T, which denotes tumour size, location, and degree of invasion; N, which indicates regional lymph node involvement; and M, which represents the presence or absence of distant metastases. Depending on the TNM designation, the tumour

CHAPTER 30  Nursing Management: Lower Respiratory Conditions TABLE 30.12    INTERPROFESSIONAL CARE Lung Cancer Diagnostic

Interprofessional Therapy

• History and physical examination • Chest radiographic examination • Sputum for cytological study • Bronchoscopy • CT scan • MRI • PET • Spirometry (preoperative) • Mediastinoscopy • VAT • Pulmonary angiography • Lung scan • Fine-­needle aspiration

• Surgery • Radiation therapy • Chemotherapy • Biological therapy • Bronchoscopic laser therapy • Phototherapy • Airway stenting • Cryotherapy • Respiratory therapy • Nutritional therapy

CT, computed tomography; MRI, magnetic resonance imaging; PET, positron emission tomography; VAT, video-­assisted thoracoscopy.

TABLE 30.13    LUNG CANCER STAGING Grouping Stage

Tumour

Node

Metastasis

Occult carcinoma Stage 0 Stage IA1 Stage 1A2 Stage 1A3 Stage IB Stage IIA Stage IIB

TX Tis T1a T1b T1c T2a T2b T1a–T2b T3 T1a–T2b T3 T4 T1a–T2b T3/T4 T3/T4 Any T Any T

N0 N0 N0 N0 N0 N0 N1 N1 N0 N2 N1 N0/N1 N3 N2 N3 Any N Any N

M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1a/M1b M1c

Stage IIIA

Stage IIIB Stage IIIC Stage IVA Stage IVB

Used with the permission of the American College of Surgeons. The original source for this material is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer Science and Business Media LLC, www.springer.com.

is then staged, which assists in estimating prognosis and determining the appropriate therapy. Staging of SCLC has not been useful because the cancer has usually metastasized by the time a diagnosis is made. Instead, SCLC is determined to be limited (confined to one hemothorax and to regional lymph nodes) or extensive (any disease exceeding those boundaries).  Screening for Lung Cancer.  In 2016, new guidelines were published recommending the screening of asymptomatic adults aged 55 to 74 with at least a 30 pack-­year smoking history (who currently smoke or quit smoking less than 15 years ago). Screening is done using a low-­dose CT scan every year for 3 consecutive years (Canadian Task Force on Preventive Health Care, 2016). 

Interprofessional Care Cancer Care Ontario has published evidence-­informed clinical guidelines for treating lung cancer. The guidelines can be accessed

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at its website in the Cancer Care Ontario Toolbox, under Guidelines & Advice. (See Resources at the end of the chapter.) Surgical Therapy.  Surgical resection is considered the treatment of choice in NSCLC stages I and II because the disease is potentially curable with resection. For other NSCLC stages, surgery may be indicated in conjunction with radiation therapy, chemotherapy, or both. In limited-­stage SCLC, which is rare, surgical resection, chemotherapy, and radiation therapy may be recommended. When the tumour is considered operable with a potential for cure, the patient’s cardiopulmonary status must be evaluated to determine the ability to withstand surgery. This is done by clinical studies of pulmonary function, ABGs, and others, as indicated by the individual’s status. Contraindications for thoracotomy include hypercapnia, pulmonary hypertension, cor pulmonale, and markedly reduced lung function. Coexisting conditions such as cardiac, renal, and liver disease may also be contraindications for surgery. A tumour may be considered inoperable. If operable, the type of surgery performed is usually a lobectomy (removal of one or more lobes of the lung) and, less often, a pneumonectomy (removal of one entire lung).  Radiation Therapy.  Radiation therapy is used as a curative approach in the individual who has a resectable tumour but who is considered a poor surgical risk. There has been improved survival when radiation therapy is used in combination with surgery and chemotherapy. Adenocarcinomas are the most radioresistant type of cancer cell. Although SCLCs are radiosensitive, radiation (even when used in combination with chemotherapy) does not significantly improve the mortality rate because of the early metastases of this type of cancer. Radiation therapy is also done as a palliative procedure to reduce distressing symptoms such as cough, hemoptysis, bronchial obstruction, and superior vena cava syndrome. It can be used to treat pain caused by metastatic bone lesions or cerebral metastasis. Radiation used as a preoperative or postoperative adjuvant measure has not been found to significantly increase survival in the patient with lung cancer.  Stereotactic Radiotherapy.  Stereotactic radiotherapy (SRT), also called stereotactic surgery or radiosurgery, is a type of radiation therapy that uses high doses of radiation delivered very accurately to the tumour. SRT provides an option to older patients, patients with severe lung or heart disease, and other patients in poor health who are not good candidates for surgery. SRT is an outpatient procedure that uses special positioning procedures and radiology techniques so that a higher dose of radiation can be delivered to the tumour and a smaller part of the healthy lung is exposed.  Chemotherapy.  Chemotherapy may be used in the treatment of nonresectable tumours or as adjuvant therapy to surgery in NSCLC with distant metastases. A variety of chemotherapy agents and multidrug regimens (i.e., policies) including combination chemotherapy have been used. These drugs include etoposide (VePesid), carboplatin, cisplatin, paclitaxel, vinorelbine, cyclophosphamide (Procytox), ifosfamide (Ifex), docetaxel (Taxotere), gemcitabine, topotecan (Hycamtin), and irinotecan (Camptosar). Chemotherapy has improved survival in patients with advanced NSCLC and is now considered standard treatment.  Biological Therapy.  Biological (targeted) therapy as adjuvant therapy has been used in individuals with cancer, including malignant lung tumours. (Biological therapy is discussed in Chapter 18.) 

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Other Therapies

Prophylactic Cranial Radiation.  Brain metastasis is a com-

mon complication of SCLC. Most chemotherapy agents do not adequately penetrate the blood–brain barrier. Prophylactic cranial radiation may be used as a potential way to improve the prognosis of patients, especially those who have a complete response to chemotherapy. Toxicity of this therapy may include scalp erythema, fatigue, and alopecia.  Bronchoscopic Laser Therapy.  Bronchoscopic laser therapy makes it possible to remove obstructing bronchial lesions. The thermal energy of the laser is transmitted to the target tissue. It is a complicated procedure that often requires general anaesthesia to control the patient’s cough reflex. Relief of the symptoms from airway obstruction as a result of thermal necrosis and shrinkage of the tumour can be dramatic. However, it is not a curative therapy for cancer.  Phototherapy.  Photodynamic therapy is a safe, nonsurgical therapy for lung cancer. Porfimer (Photofrin) is injected intravenously and selectively concentrates in tumour cells. After a set time (usually 48 hours), the tumour is exposed to laser light, producing a toxic form of oxygen that destroys tumour cells. Necrotic tissue is removed through a bronchoscope.  Airway Stenting.  Stents can be used alone or in combination with other techniques for palliation of dyspnea, cough, or respiratory insufficiency. The advantage of an airway stent is that it supports the airway wall against collapse or external compression and can impede extension of the tumour into the airway lumen.  Cryotherapy.  Cryotherapy is a technique in which tissue is destroyed as a result of freezing. Bronchoscopic cryotherapy is used to ablate (destroy) bronchogenic carcinomas, especially polypoid lesions. A repeat bronchoscopy is performed 8 to 10 days after the first session. The second examination enables assessment of cryodestruction, removal of any slough, and repeat cryotherapy if required for the treatment of large lesions. 

NURSING MANAGEMENT LUNG CANCER NURSING ASSESSMENT It is important to determine the patient’s and family’s understanding of the diagnostic tests (those completed as well as those planned), the diagnosis or potential diagnosis, the treatment options, and the prognosis. At the same time, the nurse can assess the level of anxiety experienced by the patient, as well as the support provided and needed by the patient’s significant others. Subjective and objective data that should be obtained from a patient with lung cancer are presented in Table 30.14.  NURSING DIAGNOSES Nursing diagnoses for the patient with lung cancer may include but are not limited to the following: • Inadequate airway clearance resulting from excessive mucus, retained secretions, foreign body in airway (tumour) • Inadequate breathing pattern resulting from body position that inhibits lung expansion (space-­occupying lesion) • Reduced gas exchange resulting from tumour obstructing airflow • Anxiety resulting from unmet needs (lack of knowledge of the disease process) • Grieving resulting from new cancer diagnosis and therapeutic regimen 

TABLE 30.14    NURSING ASSESSMENT Lung Cancer Subjective Data Important Health Information Past health history: Exposure to secondhand smoke; airborne carcinogens (e.g., asbestos, uranium, chromates, hydrocarbons, arsenic) or other pollutants; urban living environment; chronic lung disease, including TB, COPD, bronchiectasis; smoking history; frequent respiratory infections; family history of lung cancer Medications: Use of cough medicines or other respiratory medications

Symptoms • Anorexia, nausea, vomiting, dysphagia (late symptom), weight loss • Persistent cough (productive or nonproductive), dyspnea, hemoptysis (late symptom) • Fatigue, fever, chills • Chest pain or tightness, shoulder and arm pain; headache; bone pain (late symptom)

Objective Data General Fever, neck and axillary lymphadenopathy, paraneoplastic syndromes (e.g., SIADH secretion)

Integumentary Jaundice (liver metastasis); edema of neck and face (superior vena cava syndrome), digital clubbing

Respiratory Wheezing, hoarseness, stridor, unilateral diaphragm paralysis, pleural effusions (late signs)

Cardiovascular Pericardial effusion, cardiac tamponade, dysrhythmias (late signs)

Neurological Unsteady gait (brain metastasis)

Musculoskeletal Pathological fractures, muscle wasting (late sign)

Possible Findings Observance of lesion on chest radiographic examination, CT scan, lung scan, or PET scan; MRI findings of mediastinal invasion, positive sputum or bronchial washings for cytological studies; positive fibre-­optic bronchoscopy and biopsy findings; low serum sodium and hypercalcemia (paraneoplastic syndrome) COPD, chronic obstructive pulmonary disease; CT, computed tomography; MRI, magnetic resonance imaging; PET, positron emission tomography; SIADH, syndrome of inappropriate antidiuretic hormone; TB, tuberculosis.

PLANNING The overall goals are that the patient with lung cancer will have (a) effective breathing patterns, (b) adequate airway clearance, (c) adequate oxygenation of tissues, (d) minimal to no pain, and (e) a realistic attitude toward treatment and prognosis.  NURSING IMPLEMENTATION HEALTH PROMOTION.  The best way to halt the epidemic of lung cancer is for people to stop smoking. Important nursing activities that can work toward this goal include promoting smoking-­ cessation programs and actively supporting education and policy changes related to smoking. Significant policy changes have taken place as a result of the recognition that side-­stream smoke is a health hazard: There are now laws that (a) require designation of nonsmoking areas in most public places, (b) prohibit smoking, and (c) ban smoking on airline flights. Other actions aimed at controlling tobacco use include restrictions on

CHAPTER 30  Nursing Management: Lower Respiratory Conditions tobacco advertising on television and warning-­label requirements for cigarette packaging. These are examples of beginning steps toward the goal of a smokeless society. Despite the small advances being made, tobacco-­ producer organizations such as marketing boards and tobacco companies still have strong political influences. The nurse should make an effort to assist patients who smoke to stop smoking. There are many resources available to help in this regard. The Registered Nurses’ Association of Ontario’s Best Practice Guideline Integrating Tobacco Interventions into Daily Practice recommends that nurses advocate for patients and provide or refer them to intensive interventions and counselling as patients contemplate smoking cessation (RNAO, 2017). The six stages of change identified among smokers attempting to quit include precontemplation, contemplation, preparation, action, maintenance, and termination. (The stages of change in relationship to patient teaching [transtheoretical model] are discussed in Chapter 4, Table 4.3.) Each stage requires specific actions to progress to the next stage. Nurses working with patients at their individual stage of change can help them progress to the next stage. For patients unwilling to quit, motivational interviewing is recommended (discussed in Chapter 11). The Canadian Lung Association (2021) provides information on access to counselling, medications, and supports to help Canadians quit smoking. Tobacco use and dependence and strategies to assist patients to stop smoking are discussed in Chapter 11. Nicotine’s addictive properties make quitting a difficult task that requires much support. Nicotine replacement significantly lessens the urge to smoke and increases the percentage of smokers who successfully quit smoking. There is no evidence that one product has better results than another, so the choice of agent is dependent on the health care provider and patient preferences. The advice and motivation of health care providers can be a powerful force in smoking cessation. Nurses are in a unique position to promote smoking cessation because they see large numbers of smokers who may be reluctant to seek help. Support for the smoker includes education that smoking a few cigarettes during a cessation attempt (a slip) is much different from resuming the full smoking habit (a relapse). Despite the slip, smokers should be encouraged to continue the attempt at cessation without viewing the effort as a failure. Measures to assist an individual in quitting should be directed toward the meaning that smoking has to that individual. The nurse needs to be aware of resources in the community to assist the individual who is interested in quitting.  ACUTE INTERVENTION.  Care of the patient with lung cancer will initially involve support and reassurance during the diagnostic evaluation. (Specific nursing measures related to the diagnostic studies are outlined in Chapter 28.) Another major responsibility of the nurse is to help the patient and the family cope with the diagnosis of lung cancer. The patient may feel guilty about cigarette smoking having caused the cancer and need to discuss this feeling with someone who has a nonjudgemental attitude. Questions regarding the patient’s condition should be answered honestly. Additional counselling from a social worker, psychologist, or member of the clergy may be needed. Specific care of the patient will depend on the treatment plan. Postoperative care for the patient having surgery is discussed later in this chapter. Care of the patient undergoing radiation therapy and chemotherapy is discussed in Chapter 18 and in NCP 18.1 and NCP 18.2, on the Evolve website. The nurse has a major role in providing patient

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comfort, teaching methods to reduce pain, assessing for signs and symptoms of progressive or recurrent disease, and assessing indications for hospitalization.  AMBULATORY AND HOME CARE.  Patient teaching needs to include signs and symptoms to report, such as hemoptysis, dysphagia, chest pain, and hoarseness. The patient and caregivers should be encouraged to provide a smoke-­free environment, which may include smoking cessation for multiple family members. If the treatment plan includes the use of home oxygen, teaching must include the safe use of oxygen. The patient who has had a surgical resection with intent to cure should be followed up with carefully, to watch for manifestations of metastasis. The patient and family should be told to contact the physician if symptoms such as hemoptysis, dysphagia, chest pain, and hoarseness develop. For many individuals who have lung cancer, little can be done to significantly prolong their lives. Radiation therapy and chemotherapy can be used to provide palliative relief from distressing symptoms. Constant pain can become a major issue. (Measures used to relieve pain are discussed in Chapter 10. Care of the patient with cancer is discussed in Chapter 18.) The patient and family or caregivers may need information about palliative care options in the community.  EVALUATION The following are the expected outcomes for the patient with lung cancer: • Patient will have adequate breathing patterns. • Patient will have adequate airway clearance. • Patient will have adequate tissue oxygenation. • Patient will have minimal to no pain. • Patient will have a realistic attitude about prognosis. 

OTHER TYPES OF LUNG TUMOURS Other types of primary lung tumours include sarcomas, lymphomas, and bronchial adenomas. Bronchial adenomas are small tumours that arise from the lower trachea or major bronchi and are considered malignant because they are locally invasive and frequently metastasize. Clinical manifestations of bronchial adenomas include hemoptysis, persistent cough, localized obstructive wheezing, and pneumonia. Bronchial adenomas can usually be treated successfully with surgical resection. The lungs are a common site for secondary metastases and are more often affected by metastatic growth than by primary lung tumours. The pulmonary capillaries, with their extensive network, are ideal sites for tumour emboli. In addition, the lungs have an extensive lymphatic network. The primary malignancies that spread to the lungs often originate in the GI or genitourinary tracts and in the breast. General symptoms of lung metastases are chest pain and nonproductive cough. Benign tumours of the lung are generally classified as mesenchymal. Their occurrence is rare and they have the potential to become malignant. The most common mesenchymal tumours are chondromas, which arise in the bronchial cartilage, and leiomyomas, which are myomas of smooth, nonstriated muscle fibres. Mesotheliomas may be malignant or benign and originate from the visceral pleura. Benign mesotheliomas are localized lesions. Hamartomas of the lung are the most common benign tumour. These tumours, composed of fibrous tissue, fat, and

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SECTION 5  Conditions of Oxygenation: Ventilation

EVIDENCE-­INFORMED PRACTICE

TABLE 30.15    COMMON TRAUMATIC CHEST

INJURIES AND MECHANISMS OF INJURY

Research Highlight Do Noninvasive Interventions Improve Quality of Life in Patients With Lung Cancer? Clinical Question In small cell lung cancer patients (P), what are the effects of preoperative exercise interventions in patients after surgery (I) compared to usual rehabilitation interventions (C) on outcomes related to functional capacity, mental wellness, and medical care (O)? 

Best Available Evidence • Systematic review of randomized controlled trials (RCTs) 

Critical Appraisal and Synthesis of Evidence • M  eta-­analysis of 10 clinical trials • Interventions studied included combinations of interventions to manage breathlessness, including aerobic training, inspiratory muscle training, and strength training, inspiratory muscle training, and/or multicomponent training. 

Conclusions • T  here was a significant beneficial effect of a 6-­minute walk distance on dyspnea, postoperative hospitalizations, and postoperative pulmonary complications. • Physical exercise is an effective treatment to improve exercise tolerance, reduce dyspnea, and improve quality of life in patients with cancer. • Preoperative exercise is effective in reducing postoperative complications and length of hospital stay in patients undergoing lung cancer surgery. • Exercise training improves dyspnea in postoperative patients, in particular when aerobic training is part of a postoperative pulmonary rehabilitation program. 

Implications for Nursing Practice • P  hysical exercise should be considered a standard of preoperative care. • These interventions may decrease the cost of medical care, which would be beneficial both for patients and for the public. • Future studies should clearly describe the content of the exercise intervention, as well as the adherence rates to interventions, and they should also report potential adverse events associated with the exercise session.

Reference for Evidence Rosero, I. D., Ramírez-­Vélez, R., Lucía, A., et al. (2019). Systematic review and meta-­analysis of randomized, controlled trials on preoperative physical exercise interventions in patients with non-­small-­cell lung cancer. Cancers, 11(7), 944. https://doi.org/10.3390/cancers11070944 P, patient population of interest; I, intervention or area of interest; C, comparison of interest or comparison group; O, outcome(s) of interest (see Chapter 1).

blood vessels, are congenital malformations of the connective tissue of the bronchiolar walls. Hamartomas are slow-­growing tumours. 

  CHEST TRAUMA AND THORACIC INJURIES Traumatic injuries fall into two major categories: (1) blunt trauma and (2) penetrating trauma. Blunt trauma occurs when the body is struck by a blunt object, such as a steering wheel. The external injury may appear minor, but the impact may cause severe, life-­threatening internal injuries, such as a ruptured spleen. Contrecoup trauma, a type of blunt trauma, is caused by the impact of parts of the body against other objects. This type of injury differs from blunt trauma primarily in the velocity of the impact. Internal organs are rapidly forced back and forth

Mechanism of Injury

Common Related Injury

Blunt Trauma Blunt steering-­wheel injury to chest

Shoulder-­harness seat belt injury Crush injury (e.g., heavy equipment, crushing thorax)

Rib fractures, flail chest, pneumothorax, hemopneumothorax, cardiac contusion, pulmonary contusion, cardiac tamponade, great vessel tears Fractured clavicle, dislocated shoulder, rib fractures, pulmonary contusion, pericardial contusion, cardiac tamponade Pneumothorax and hemopneumothorax, flail chest, great vessel tears and rupture, decreased blood return to heart with decreased cardiac output

Penetrating Trauma Gunshot or stab wound to chest

Open pneumothorax, tension pneumothorax, hemopneumothorax, cardiac tamponade, esophageal damage, tracheal tear, great vessel tears

within the bony structures that surround them so that internal injury is sustained not only on the side of the impact but also on the opposite side, where the organ or organs hit bony structures. If the velocity of impact is great enough, organs and blood vessels can literally be torn from their points of origin. This is the shearing injury that can cause transection of the aorta, hemothorax, and diaphragmatic rupture injuries. Compression injury occurs when the body cannot handle the degree of external pressure during blunt trauma, resulting in contusions, crush injuries, and organ rupture. Penetrating trauma occurs when a foreign body impales or passes through the body tissues (e.g., gunshot wounds, stabbings). Table 30.15 describes selective traumatic injuries as they relate to the categories of trauma and the mechanism of injury. Emergency care of the patient with a chest injury is presented in Table 30.16. Thoracic injuries range from simple rib fractures to life-­ threatening tears of the aorta, vena cava, and other major vessels. The most common thoracic emergencies and their management are described in Table 30.17.

PNEUMOTHORAX A pneumothorax is the presence of air in the pleural space. A complete or partial collapse of a lung results from this accumulation of air. This condition should be suspected after any blunt trauma to the chest wall. Pneumothorax may be closed or open. Pneumothorax associated with trauma may be accompanied by hemothorax, a condition called hemopneumothorax.

Types of Pneumothorax Closed Pneumothorax.  Closed pneumothorax has no associated external wound. The most common form is a spontaneous pneumothorax, which is accumulation of air in the pleural space without an apparent antecedent event. It is caused by the rupture of small blebs (air-­filled alveolar dilations less than 1 cm in diameter on the edge of the lung at the apex of the upper lobe or superior segment of the lower lobe) on the visceral pleural space. The cause of the blebs is unknown. This condition

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  TABLE 30.16  EMERGENCY MANAGEMENT Chest Trauma Etiology

Assessment Findings

Interventions

Blunt

Respiratory

Initial

• Motor vehicle collision • Pedestrian accident • Fall • Assault with blunt object • Crush injury • Explosion

• Dyspnea, respiratory distress • Cough with or without hemoptysis • Cyanosis of mouth, face, nail beds, mucous membranes • Tracheal deviation • Audible air escaping from chest wound • Decreased breath sounds on side of injury • Decreased O2 saturation • Frothy secretions

• Ensure patent airway. • Administer high-­flow O2 with nonrebreather mask. • Establish IV access with two large-­bore catheters. Begin fluid resuscitation as appropriate. • Remove clothing to assess injury. • Cover sucking chest wound with nonporous dressing taped on three sides. • Stabilize impaling objects with bulky dressings. Do not remove. • Assess for other significant injuries and treat appropriately. • Stabilize flail rib segment first with hand and then by application of large pieces of tape horizontal across the flail segment. • After cervical spine injury has been ruled out, place patient in semi-­Fowler’s position or position patient on the injured side if breathing is easier.

Penetrating • Knife • Gunshot • Stick • Arrow • Other missiles

Cardiovascular • Rapid, thready pulse • Decreased blood pressure • Narrowed pulse pressure • Asymmetrical blood pressure values in arms • Distended neck veins • Muffled heart sounds • Chest pain • Crunching sound synchronous with heart sounds • Dysrhythmias

Surface Findings • Bruising • Abrasions • Open chest wound • Asymmetrical chest movement • Subcutaneous emphysema

Ongoing Monitoring • Monitor vital signs, level of consciousness, O2 saturation, cardiac rhythm, respiratory status, and urinary output. • Anticipate intubation for respiratory distress. • Release dressing if tension pneumothorax develops after sucking chest wound is covered.

IV, intravenous; O2, oxygen.

  TABLE 30.17  EMERGENCY MANAGEMENT Thoracic Injuries Definition

Clinical Manifestations

Emergency Management

Dyspnea, decreased movement of involved chest wall, diminished or absent breath sounds on the affected side, hyper-­resonance to percussion

Chest tube insertion with chest drainage system; Heimlich (flutter) valve

Dyspnea, diminished or absent breath sounds, dullness to percussion, shock

Chest tube insertion with chest drainage system; autotransfusion of collected blood, treatment of hypovolemia as necessary

Cyanosis, air hunger, violent agitation, tracheal deviation away from affected side, subcutaneous emphysema, neck vein distension, hyper-­ resonance to percussion

Medical emergency: needle decompression followed by chest tube insertion with chest drainage system

Paradoxical movement of chest wall, respiratory distress, associated hemothorax, pneumothorax, pulmonary contusion

Stabilization of flail segment with intubation in some patients and taping in others; oxygen therapy; treatment of associated injuries; analgesia

Muffled, distant heart sounds, hypotension, neck vein distension, increased central venous pressure

Medical emergency: pericardiocentesis with surgical repair as appropriate

Pneumothorax Air in pleural space (see Figure 30.5)

Hemothorax Blood in the pleural space, usually occurs in conjunction with pneumothorax

Tension Pneumothorax Air in pleural space that does not escape Continued increase in amount of air shifts intrathoracic organs and increases intrathoracic pressure (see Figure 30.6)

Flail Chest Fracture of two or more adjacent ribs in two or more places with loss of chest-­wall stability (see Figure 30.7)

Cardiac Tamponade Blood rapidly collects in pericardial sac, compresses myocardium because the pericardium does not stretch, and prevents heart from pumping effectively

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SECTION 5  Conditions of Oxygenation: Ventilation

occurs most commonly in underweight male cigarette smokers between 20 and 40 years of age. There is a tendency for this condition to recur. Other causes of closed pneumothorax include the following: • Injury to the lungs from mechanical ventilation • Injury to the lungs from insertion of a subclavian catheter • Perforation of the esophagus • Injury to the lungs from broken ribs • Ruptured blebs or bullae in a patient with COPD  Open Pneumothorax.  Open pneumothorax occurs when air enters the pleural space through an opening in the chest wall (Figure 30.5, B). Examples include stab or gunshot wounds and surgical thoracotomies. A penetrating chest wound is often referred to as a sucking chest wound. An open pneumothorax should be covered with a vented dressing. (A vented dressing is one secured on three sides with the fourth side left untaped.) This allows air to escape from the vent and decreases the likelihood of tension pneumothorax developing. If the object that caused the open chest wound is still in place, it should not be removed until a health care provider is present. The impaling object should be stabilized with a bulky dressing.  Tension Pneumothorax.  Tension pneumothorax is a pneumothorax with rapid accumulation of air in the pleural space, causing severely high intrapleural pressures with resultant tension on the heart and great vessels. It may result from either an open or a closed pneumothorax (Figure 30.6). In an open chest wound, a flap may act as a one-­way valve; thus, air can enter on inspiration but cannot escape. The intrathoracic pressure increases, the lung collapses, and the mediastinum shifts toward the unaffected side, which is subsequently compressed. As the pressure increases, cardiac output is altered because of decreased venous return and compression of the vena cava and aorta. Tension pneumothorax can occur with mechanical ventilation and resuscitative efforts. It can also occur if chest tubes are clamped or become blocked in a patient with a pneumothorax. Unclamping the tube or relieving the obstruction will remedy this situation. Tension pneumothorax is a medical emergency with both the respiratory and the circulatory systems affected. If the tension in the pleural space is not relieved, the patient is likely to die from inadequate cardiac output or marked hypoxemia. Nurses and paramedics are now being trained to insert large-­bore needles and chest tubes into the chest wall to release the trapped air.  Hemothorax.  Hemothorax is an accumulation of blood in the intrapleural space. It is frequently found in association with open pneumothorax and is then a hemopneumothorax. Causes of hemothorax include chest trauma, lung malignancy, complications of anticoagulant therapy, pulmonary embolus, and tearing of pleural adhesions.  Chylothorax.  Chylothorax is the presence of lymphatic fluid in the pleural space because of a leak in the thoracic duct. Causes include trauma, surgical procedures, and malignancy. The thoracic duct is disrupted, and the chylous fluid, milky white with high lipid content, fills the pleural space. Total lymphatic flow through the thoracic duct is 1 500 to 2 400 mL/day. Fifty percent of those affected will heal with conservative treatment (chest drainage, bowel rest, and total parenteral nutrition). Surgery and pleurodesis are options if conservative therapy fails. Pleurodesis is the artificial production of adhesions between the parietal and the visceral pleurae, usually done with a chemical sclerosing agent. 

Fibrothorax

Collapsed lung Air

Pleural effusion

A

B

FIG. 30.5  Disorders of the pleura. A, Fibrothorax resulting from an organiza-

tion of inflammatory exudate and pleural effusion. B, Open pneumothorax resulting from collapse of the lung caused by disruption of the chest wall and outside air entering.

Midline

Superior vena cava

Tracheal deviation

Inferior vena cava Pneumothorax Mediastinal shift FIG. 30.6  Tension pneumothorax. As pleural pressure on the affected side

increases, mediastinal displacement ensues with resultant respiratory and cardiovascular compromise.

Clinical Manifestations If the pneumothorax is small, mild tachycardia and dyspnea may be the only manifestations. If the pneumothorax is large, respiratory distress may be present, including shallow, rapid respirations; dyspnea; air hunger; and decreased oxygen saturation. Chest pain and a cough with or without hemoptysis may be present. On auscultation, there are no breath sounds over the affected area, and hyper-­resonance may be present. A chest radiograph shows the presence of air or fluid in the pleural space. If a tension pneumothorax develops, the patient experiences severe respiratory distress, tachycardia, and hypotension. Mediastinal displacement occurs, and the trachea shifts to the unaffected side. The patient is hemodynamically unstable.  Interprofessional Care Treatment depends on the severity of the pneumothorax and the nature of the underlying disease. If the patient is stable and the amount of air and fluid accumulated in the intrapleural space is minimal, no treatment may be needed as the pneumothorax resolves spontaneously. If the amount of air or fluid is minimal, the pleural space can be aspirated with a large-­bore needle. As a life-­saving measure, needle venting (using a large-­bore needle) of the pleural space may be used. A Heimlich valve may also be used to evacuate air from the pleural space. The most definitive and common form of treatment of pneumothorax and hemothorax is the insertion of a chest tube that is connected to water-­ seal drainage. Repeated spontaneous pneumothorax may have

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to be treated surgically by a partial pleurectomy, stapling, or pleurodesis to promote adherence of the pleurae to one another. 

FRACTURED RIBS Rib fractures are the most common type of chest injury resulting from trauma. Ribs 5 through 10 are most commonly fractured because they are least protected by chest muscles. If the fractured rib is splintered or displaced, it may damage the pleura and the lungs. Clinical manifestations of fractured ribs include pain (especially on inspiration) at the site of injury. The individual splints the affected area and takes shallow breaths to try to decrease the pain. The person is reluctant to take deep breaths, and the decreased ventilation may cause atelectasis to develop. The main goal of treatment is to decrease pain so that the patient can breathe adequately to promote good chest expansion. Intercostal nerve blocks with local anaesthesia may be used to provide pain relief. The effect of the anaesthesia lasts for a period of hours to days. It must be repeated as necessary to provide pain relief. Opioid medication therapy must be individualized and used with caution because these medications can depress respirations. Nonsteroidal anti-­inflammatory medications are used to reduce pain and aid with deep breathing and coughing. Patient teaching should emphasize deep breathing, coughing, use of incentive spirometry, and use of pain medications. Strapping the chest with tape or using a binder is not common practice. Most health care providers believe that these measures should be avoided because they reduce lung expansion and predispose the individual to atelectasis. 

flail section sinks in with the mediastinal shift to the uninjured side. On expiration, the flail section bulges outward with the mediastinal shift to the injured side.

FLAIL CHEST

CHEST TUBES AND PLEURAL DRAINAGE

Flail chest results from multiple rib fractures, causing instability of the chest wall (Figure 30.7). The chest wall cannot provide the bony structure necessary to maintain bellows action and ventilation. The affected (flail) area will move paradoxically to the intact portion of the chest during respiration. During inspiration, the affected portion is sucked in, and during expiration, it bulges out. This paradoxical chest movement prevents adequate ventilation of the lung in the injured area. The underlying lung may or may not have a serious injury. Associated pain and any lung injury giving rise to loss of compliance will contribute to an alteration in breathing patterns and lead to hypoxemia. A flail chest is usually apparent on visual examination of the unconscious patient. The patient manifests rapid, shallow respirations and tachycardia. A flail chest may not be initially apparent in the conscious patient as a result of splinting of the chest wall. The patient moves air poorly, and movement of the thorax is asymmetrical and uncoordinated. Palpation of abnormal respiratory movements, crepitus of the rib, chest radiography, and ABG assessment assist in the diagnosis. Initial therapy consists of adequate ventilation, administration of humidified oxygen, careful administration of crystalloid IV solutions, and pain control. The definitive therapy is to re-­ expand the lung and ensure adequate oxygenation. Although many patients can be managed without the use of mechanical ventilation, a short period of intubation and ventilation may be necessary until the diagnosis of the lung injury is complete. The lung parenchyma and fractured ribs will heal with time. Some patients continue to experience intercostal pain after the flail chest has resolved. 

The purpose of chest tubes and pleural drainage is to remove the air and fluid from the pleural space and to restore normal intrapleural pressure so that the lungs can re-­expand. (Intrapleural pressure, also known as intrathoracic pressure, and the intrapleural space are described in Chapter 28.) Small accumulations of air or fluid in the pleural space may not require removal by thoracentesis or chest tube insertion. Instead, the air and fluid may be reabsorbed over time.

Inspiration

Expiration FIG. 30.7  Flail chest produces paradoxical respiration. On inspiration, the

Chest Tube Insertion Chest tubes can be inserted in the emergency department, at the patient’s bedside, or in the operating room, depending on the situation. In the operating room, the chest tube is inserted via the thoracotomy incision. In the emergency department or at the bedside, the patient is placed in a sitting position or is lying down with the affected side elevated. Prior to the procedure it is important to have airway, oxygen, suction, and defibrillation equipment available at the bedside in case emergency resuscitation is required. The area is prepared with antiseptic solution, and the site is infiltrated with a local anaesthetic agent. After a small incision is made, one or two chest tubes are inserted into the pleural space. One catheter is placed anteriorly through the second intercostal space to remove air (Figure 30.8). The other is placed posteriorly through the eighth or ninth intercostal space to drain fluid and blood. The tubes are sutured to the chest wall, and the puncture wound is covered with an airtight dressing. During insertion, the tubes are kept clamped. After the tubes are in place in the pleural space, they are connected to drainage tubing and pleural drainage, and the clamp is removed.

614

SECTION 5  Conditions of Oxygenation: Ventilation Parietal pleura Visceral pleura Chest tube Lung Pleural space Rib cage Chest tube

Diaphragm

Water-seal chamber Suction control chamber Collection chamber Air leak monitor

A

Second intercostal space Thoracotomy incision To remove air Rib cage To drain fluid and blood FIG. 30.8  Placement of chest tubes.

Each tube may be connected to a separate drainage system and suction. More commonly, a Y-­connector is used to attach both chest tubes to the same drainage system. 

Pleural Drainage Most pleural drainage systems have three basic compartments, each with its own separate function. The first compartment, the collection chamber, receives fluid and air from the chest cavity. The fluid stays in this chamber while the air vents to the second compartment (Figure 30.9). The second compartment, called the water-­seal chamber, contains 2 cm of water, which acts as a one-­way valve. The incoming air enters from the collection chamber and bubbles up through the water. (The water acts as a one-­way valve to prevent backflow of air into the patient from the system.) Initial bubbling of air is seen in this chamber when a pneumothorax is evacuated. Intermittent bubbling can also be seen during exhalation, coughing, or sneezing because of an increase in the patient’s intrathoracic pressure. In this chamber, fluctuations, or “tidalling,” will be seen and reflect the pressures in the pleural space. If tidalling is not seen, either the lungs have re-­expanded or there is a kink or obstruction in the tubing. The air then exits the water seal and enters the suction chamber. A third compartment, the suction control chamber, applies controlled suction to the chest drainage system. The classic suction control chamber uses tubing with one end submerged in a column of water and the other end vented to the atmosphere. It is typically filled with 20 cm of water. When the negative pressure generated by the suction source exceeds 20 cm, the air from the atmosphere enters the chamber through a vent and begins bubbling up through the water. As a result, excess pressure is

Dry suction regulator Water-seal chamber Suction monitor bellows Collection chamber Air leak monitor

B FIG. 30.9  Chest drainage unit. Both units have three chambers: (1) collec-

tion chamber; (2) water-­seal chamber; and (3) suction control chamber. The suction control chamber requires a connection to a wall suction source that is dialed up higher than prescribed so that the suction will work. A, Water suction. This unit uses water in the suction control chamber to control the wall suction pressure. B, Dry suction. This unit controls wall suction by using a regulator control dial. Source: Getinge Group, Merrimack, NH.

relieved. The amount of suction applied is regulated by the depth of the suction control tube in the water and not by the amount of suction applied to the system. An increase in suction does not result in an increase in negative pressure to the system because any excess suction merely draws in air through the vented tubing. The suction pressure is usually ordered to be −20 cm H2O. Two types of suction control chambers are available on the market: wet and dry. The wet suction control chamber system is the classic system outlined previously. Bubbling is one way to tell that suction is functioning. Suction is started by turning up the vacuum source until gentle bubbling appears. Turning the vacuum source higher just makes the bubbling more vigorous and makes the water evaporate faster. Even with gentle bubbling, water evaporates in this chamber, and water must be added periodically. The dry suction control chamber system, by contrast, contains no water. It uses either a restrictive device or a regulator, internal to the chest drainage system, to dial the desired negative pressure. The dry system has a visual alert that

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provider using sterile water. Chemical pleurodesis can also be performed through this catheter. This system is not suitable for trauma or for drainage of blood. Because of the smaller size, the tube can become kinked, occluded, or dislodged more easily. Small-­bore chest tubes and Heimlich valves should be used with caution in patients on mechanical ventilators because there is a potential for rapid accumulation of air and a tension pneumothorax. 

A

NURSING MANAGEMENT CHEST DRAINAGE Chest tube Heimlich valve

Drainage bag

B FIG. 30.10  A, The Heimlich chest drain valve is a specially designed flutter

valve that is used in place of a chest drainage unit for small, uncomplicated pneumothorax with little or no drainage and no need for suction. The valve allows for escape of air but prevents the re-­entry of air into the pleural space. B, The valve is placed between the chest tube and the drainage bag, which can be worn under a person’s clothes.

indicates if the suction is working, so bubbling is not seen in a third chamber. The suction pressures are increased by turning the dial on the drainage system. Increasing the vacuum suction source will not increase the pressure (see Figure 30.9). A variety of commercial disposable plastic chest drainage systems are available. The manufacturer’s suggestions for use are included with the equipment. The plastic units allow the patient mobility and decrease the risk of breaking or spilling the drainage system.

INFORMATICS IN PRACTICE Chest Drainage System • A  nurse needs to set up a chest drainage system but has not done so since being in a simulation lab in nursing school. • On the Internet, find a procedure manual, watch a video, or listen to a podcast of the procedure that would aid the nurse in this situation.

Heimlich Valves.  Another device that may be used to evacuate air from the pleural space is the Heimlich valve (Figure 30.10). This device consists of a rubber flutter one-­way valve within a rigid plastic tube. It is attached to the external end of the chest tube. The valve opens whenever the pressure is greater than the atmospheric pressure and closes when the reverse occurs. The Heimlich valve functions like a water seal and is usually used for emergency transport or in special home care situations.  Small Chest Tubes.  Small chest tubes (“pigtail catheters”) are used in selected patients because they are less traumatic. The drains may be straight catheters or “pigtail” catheters (curled at the distal end, resembling a pig’s tail). Curled catheters are considered to be less traumatic than straight catheters. These catheters, if occluded, can be irrigated by the health care

Some general guidelines for nursing care of the patient with chest tubes and water-­seal drainage systems are presented in Table 30.18. The traditional practice of routine milking or stripping of chest tubes to maintain patency is no longer recommended because it can cause dangerously high intrapleural pressure and damage to pleural tissue. Drainage and blood are not likely to clot inside chest tubes because the newer chest tubes are made with a coating that makes them nonthrombogenic. The nurse should remember that insertion of the chest tube, as well as its continued presence, can be painful to the patient. Dislodgement of the tube may occur if the tube is not stabilized. Clamping of chest tubes during transport or when the tube is accidentally disconnected is no longer advocated. The danger of rapid accumulation of air in the pleural space causing tension pneumothorax is far greater than that of a small amount of atmospheric air entering the pleural space. Chest tubes may be momentarily clamped to change the drainage apparatus or to check for air leaks. Clamping for more than a few moments is indicated only for assessing how the patient will tolerate chest tube removal. It is done to simulate chest tube removal and identify if there will be negative clinical repercussions with tube removal. Generally, this is done 4 to 6 hours before the tube is removed, and the patient is monitored closely. If a chest tube becomes disconnected, the most important intervention is immediate re-­establishment of the water-­seal system and attachment of a new drainage system as soon as possible. In some hospitals, when disconnection occurs, the chest tube is immersed in sterile water (≈2 cm) until the system can be re-­established. It is important for the nurse to know the unit policies, individual clinical situation (e.g., whether an air leak exists), and physician preference before resorting to prolonged chest tube clamping. As with many procedures, the hospital may have policies and procedures referring to the care of chest tubes. The nurse needs to ensure that these are reviewed and followed. COMPLICATIONS Chest tube malposition is the most common complication. The nurse does routine monitoring to evaluate whether the chest drainage is successful by observing for tidalling in the water-­ seal chamber, listening for breath sounds over the lung fields, and measuring the amount of fluid drainage. Re-­expansion pulmonary edema can occur after rapid expansion of a collapsed lung in patients with a pneumothorax or with evacuation of large volumes of pleural fluid (>1 to 1.5 L). A vasovagal response with symptomatic hypotension can occur from toorapid removal of fluid. Infection at the skin site is also a concern. Meticulous sterile technique during dressing changes can reduce the incidence of infected sites. Other complications include (a) pneumonia from not taking deep breaths, from not using an incentive spirometer,

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SECTION 5  Conditions of Oxygenation: Ventilation

TABLE 30.18    CLINICAL GUIDELINES FOR CARE OF PATIENT WITH CHEST TUBES AND WATER-­SEAL

DRAINAGE SYSTEM

1. Keep all tubing loosely coiled below chest level. Tubing should drop straight from bed or chair to drainage unit. Do not let it be compressed. 2. Keep all connections between chest tubes, drainage tubing, and drainage collector tight, and tape at connections. 3. Observe for air fluctuations (tidalling) and bubbling in the water-­seal chamber. • If no tidalling is observed (rising with inspiration and falling with expiration in the spontaneously breathing patient), the drainage system is blocked, the lungs are re-­expanded, or the system is attached to suction. • If bubbling increases, there may be an air leak in the drainage system or a leak from the patient (bronchopleural leak). 4. If the chest tube is connected to suction, disconnect from wall suction to check for tidalling. 5. Suspect a system leak when bubbling is continuous. • To determine the source of the air leak, momentarily clamp the tubing successively from the chest tube insertion site to the drainage set, observing for the bubbling to cease. When bubbling ceases, the leak is above the clamp. • Retape tubing connections. • If leak continues, notify physician. It may be necessary to replace the drainage apparatus or to secure the chest tube with an air-­ occlusive dressing. 6. High fluid levels in the water seal indicate residual negative pressure. • The chest system may need to be vented by using the high negativity release valve available on the drainage system to release residual pressure from the system. • Do not lower water-­seal column when wall suction is not operating or when patient is on gravity drainage.

Patient’s Clinical Status 1. Monitor patient’s clinical status. Assess vital signs, lung sounds, pain. 2. Assess for manifestations of re-­accumulation of air and fluid in the chest (↓ or absent breath sounds), significant bleeding (>100 mL/hr), chest drainage site infection (drainage, erythema, fever, ↑ white blood cell count), or poor wound healing. Notify physician for management plan. Evaluate for subcutaneous emphysema at chest tube site. 3. Encourage patient to breathe deeply periodically to facilitate lung expansion and encourage range-­of-­motion exercises to the shoulder on the affected side. Incentive spirometry every hour while awake may be necessary to prevent atelectasis or pneumonia. 4. Chest tubes are not routinely clamped. A physician order is required. A physician may order clamping for 24 hours to evaluate for re-­ accumulation of fluid or air before discontinuing the chest tube.

Chest Drainage 1. Never elevate the drainage system to the level of the patient’s chest because doing so will cause fluid to drain back into the lungs. Secure the unit to the drainage stand. If the drainage chambers are full, notify the physician and anticipate changing the system. Do not try to empty it. 2. Mark the time of measurement and the fluid level on the drainage unit according to the unit standards. Report any change in the quantity or characteristics of drainage (e.g., clear yellow to bloody) to the physician and record the change. Notify physician if >100 mL/ hr drainage.

and from splinting on the affected side, and (b) shoulder disuse (“frozen shoulder”) from lack of range-­of-­motion exercises. Poor patient adherence or lack of patient teaching can contribute to these complications. Nurses have a key role in preventing these complications. 

3. Check position of the chest drainage container. If the drainage system is overturned and the water seal is disrupted, return it to an upright position and encourage patient to take a few deep breaths, followed by forced exhalations and cough manoeuvres. 4. If the drainage system breaks, place the distal end of the chest tubing connection in a sterile water container at a 2-­cm level as an emergency water seal. 5. Do not strip chest tubes. Doing so dangerously increases intrapleural pressures. Drainage tubes may be milked (alternately folded or squeezed and then released) on physician order. Milk only if drainage has evidence of clots or obstruction. Take 15-­cm strips of the chest tube and squeeze and release starting close to the chest and repeating down the tube distally.

Monitoring Wet Versus Dry Suction Chest Drainage Systems Suction Control Chamber in Wet Suction System 1. Keep the suction control chamber at the appropriate water level by adding sterile water as needed to replace water lost to evaporation. 2. Keep the muffler covering the suction control chamber in place to prevent more rapid evaporation of water and to decrease noise of the bubbling. 3. After filling the suction control chamber to the ordered suction amount (generally −20 cm water suction), connect the suction tubing to the wall suction. 4. Dial the wall suction regulator until continuous gentle bubbling is seen in the suction control chamber (generally 80–120 mm Hg). Vigorous bubbling is not necessary and will increase the rate of evaporation. 5. If no bubbling is seen in the suction control chamber, (a) there is no suction, (b) the suction is not set high enough, or (c) the pleural air leak is so large that suction is not high enough to evacuate it.

Suction Control Chamber in Dry Suction System (See Manufacturer’s Directions) 1. After connecting patient to system, turn the dial on the chest drainage system to amount ordered (generally −20 cm pressure), connect suction tubing to wall suction source, and increase the suction until the correct amount of negative pressure is indicated. There will be a high negative-­pressure release valve in the system.

Chest Tube Dressings 1. Dressings are not routinely changed. If there is visible drainage, notify physician for instructions. 2. If ordered to change dressings, remove old dressing carefully to avoid removing unsecured chest tube. Assess the site, and culture site as indicated. 3. Cleanse the site with sterile normal saline. Apply sterile gauze and tape to secure the dressing. Some physicians may prefer use of petroleum gauze dressing around the tube to prevent air leak. Date the dressing and document dressing change.

Obtaining a Sample From the Chest Tube 1. Form a loop in the tubing in an area to get the most recently drained fluid. 2. Swab the sampling site of the tubing with antiseptic and allow to air-­dry. 3. Aspirate from the sampling site with a syringe; cap syringe; label with patient name, date, time, and source of specimen. 4. Send to laboratory.

CHEST TUBE REMOVAL The patient with chest tubes may have chest radiographic studies to follow the course of lung expansion. The chest tubes are removed when the lungs are re-­expanded and fluid drainage has ceased. Generally, suction is discontinued, and the patient is

CHAPTER 30  Nursing Management: Lower Respiratory Conditions

617

TABLE 30.19    CHEST SURGERIES Type and Description

Indication

Comments

Lung cancer, bronchiectasis, TB, emphysematous bullae, benign lung tumours, fungal infections

Most common lung surgery; postoperative insertion of chest tubes; expansion of remaining lung tissue to fill up space

Lung cancer (most common), extensive TB, bronchiectasis, lung abscess

Done only when lobectomy or segmental resection will not remove all diseased lung; no drainage tubes (generally), fluid gradually fills space where lung was; patient positioned on operative side to facilitate expansion of remaining lung

Lung cancer, bronchiectasis, TB

Technically difficult; done to remove lung segment; insertion of chest tubes; expansion of remaining lung tissue to fill space

Lung biopsy, excision of small nodules

Need for chest tubes after surgery

Empyema

Use of chest tubes and drainage after surgery

Chest trauma

Use of chest tubes and drainage after surgery

Lobectomy Removal of one lobe of lung

Pneumonectomy Removal of entire lung

Segmental Resection Removal of one or more lung segments

Wedge Resection Removal of small, localized lesion that occupies only part of a segment

Decortication Removal of thick, fibrous membrane from visceral pleura

Exploratory Thoracotomy Incision into thorax to look for injured or bleeding tissues

Thoracotomy Not Involving Lungs* Incision into thorax for surgery on other organs

Hiatal hernia repair, open-­heart surgery, esophageal surgery, tracheal resection, aortic aneurysm repair

Video-­Assisted Thoracoscopic Surgery (VATS) VATS under general anaesthesia in OR

Procedures performed using VATS include lung biopsy, lobectomy, resection of nodules, repair of fistulas

Video-­assisted technique involving insertion of a rigid scope with a distal lens into the pleura with image shown on a monitor screen, allowing surgeon to manipulate instruments passed into the pleural space through separate small intercostal incisions

Lung Volume Reduction Surgery (LVRS) Advanced bullous emphysema, α1-­antitrypsin emphysema

Involves reducing lung volume by multiple wedge excisions or VATS (see Video-­Assisted Thoracoscopic Surgery)

OR, operating room; TB, tuberculosis. *For comments on thoracotomy not involving the lungs, see discussion of individual diseases in text.

placed on gravity drainage for a period of time before the tubes are removed. The tube is removed by cutting the sutures; applying a sterile petroleum jelly gauze dressing; having the patient take a deep breath, exhale, and bear down (Valsalva manoeuvre); and then removing the tube. Pain medication is generally given before chest tube removal. The site is covered with an airtight dressing, the pleura seals itself off, and the wound heals in several days. A chest radiograph is obtained after chest tube removal to evaluate for pneumothorax, re-­accumulation of fluid, or both. The wound should be observed for drainage and should be reinforced if necessary. The patient should be observed for respiratory distress, which may signify a recurrent or new pneumothorax. 

CHEST SURGERY Chest surgery is performed for a variety of reasons, some of which are unrelated to primary lung conditions. For example,

a thoracotomy may be performed for heart and esophageal surgery. The types of chest surgery are compared in Table 30.19.

Preoperative Care Before chest surgery, baseline data are obtained on the respiratory and cardiovascular systems. Diagnostic studies performed are pulmonary function, chest radiography, electrocardiogram (ECG), ABGs, blood urea nitrogen (serum urea [nitrogen]), serum creatinine, blood glucose, serum electrolytes, and complete blood cell count. Additional studies of cardiac function such as cardiac catheterization may be done for the patient who is to undergo a pneumonectomy. A careful physical assessment of the lungs, including percussion and auscultation, should be done. This will allow the nurse to compare preoperative and postoperative findings. The patient should be encouraged to stop smoking before surgery to decrease secretions and increase oxygen saturation.

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SECTION 5  Conditions of Oxygenation: Ventilation

In the anxious period before surgery, refraining from smoking is not easy for the habitual smoker to do. Chest physiotherapy may be indicated to help drain the lungs of accumulated secretions. This is especially indicated for the patient with a lung abscess or bronchiectasis. Preoperative teaching should include exercises for effective deep breathing and incentive spirometry. If the patient practises these techniques before surgery, the techniques will be easier to perform after surgery. The patient should be told that adequate medication will be given to reduce the pain and should be helped to splint the incision with a pillow to facilitate deep breathing. For most types of chest surgery, chest tubes are inserted and connected to water-­sealed drainage systems. The purpose of these tubes should be explained to the patient. In addition, oxygen is frequently given the first 24 hours after surgery. Range-­ of-­motion exercises on the surgical side, similar to those for the mastectomy patient, should be taught (see Chapter 54). The thought of losing part of a vital organ is frequently frightening. The patient should be reassured that the lungs have a large degree of functional reserve. Even after the removal of one lung, there is enough lung tissue to maintain adequate oxygenation. The nurse should be available to answer questions asked by the patient and the family, and questions should be answered honestly. The nurse should try to facilitate expression of concerns, feelings, and questions. (General preoperative care and teaching are discussed in Chapter 20.) 

Surgical Therapy Thoracotomy (surgical opening into the thoracic cavity) surgery is considered major surgery because the incision is large and cuts into bone, muscle, and cartilage. The two types of thoracic incisions are median sternotomy, performed by splitting the sternum, and lateral thoracotomy. The median sternotomy is primarily used for surgery involving the heart. The two types of lateral thoracotomy are posterolateral and anterolateral. The posterolateral thoracotomy is used for most surgeries involving the lung. The incision is made from the anterior axillary line below the nipple level posteriorly at the fourth, fifth, or sixth intercostal space. It is rarely necessary to remove the ribs. Strong mechanical retractors are used to gain access to the lung. The anterolateral incision is made in the fourth or fifth intercostal space from the sternal border to the midaxillary line. This procedure is commonly used for surgery or trauma victims, mediastinal operations, and wedge resections of the upper and middle lobes of the lung. The extensiveness of the thoracotomy incision often results in severe pain for the patient after surgery. Because muscles have been severed, the patient is reluctant to move their shoulder and arm on the surgical side. Chest tubes are placed in the pleural space except in pneumonectomy surgery. In a pneumonectomy, the space from which the lung was removed gradually fills with serosanguinous fluid. Video-­Assisted Thoracoscopic Surgery.  Video-­assisted thoracoscopic surgery (VATS) is a thoracoscopic surgical procedure that, in many cases, can be done instead of a full thoracotomy. The procedure involves three or four 2.5-­cm incisions made on the chest that allow the thoracoscope (a special fibre-­ optic camera) and instruments to be inserted and manipulated. Video-­assisted thoracoscopes improve visualization because the surgeon can view the thoracic cavity from the video monitor. The thoracoscope is equipped with a camera that magnifies the

image on the monitor. Thoracoscopy can be used to diagnose and treat a variety of conditions of the lung, the pleura, and the mediastinum. The candidate for this type of procedure should not have a prior history of conventional thoracic surgery, because of the probability of adhesion formation, which would make access more difficult. The patient whose lesions are in the lung periphery or the mediastinum is a better candidate because of better accessibility. The patient considered for thoracoscopic surgery should have sufficient pulmonary function before surgery to allow the surgeon to perform conventional thoracotomy if complications occur. Complications that may occur are bleeding, diaphragmatic perforation, air emboli, persistent pleural air leaks, and tension pneumothorax. There are many benefits of thoracoscopic surgery when compared with a conventional thoracotomy procedure. These include less adhesion formation, minimal blood loss, less time under anaesthesia, shorter hospitalization, faster recovery, less pain, and no need for postoperative rehabilitation therapy because of minimal disruption of thoracic structures. Chest tubes are placed at the end of the procedure through one of the incisions. The incisions are closed with sutures or a wound-­approximating adhesive bandage. Nursing assessment and care after surgery include monitoring respiratory status and lung re-­expansion with the chest tubes and checking the incisions for drainage or dehiscence. The most common complication is prolonged air leak. A return to prior activities should be encouraged as quickly as possible. The hospital stay averages from 1 to 5 days, depending on the type of surgery. 

Postoperative Care Specific measures related to nursing care after a thoracotomy are presented in NCP 30.2, available on the Evolve website. The specific follow-­up care depends on the type of surgical procedure. General postoperative care is discussed in Chapter 22. 

  RESTRICTIVE RESPIRATORY DISORDERS Restrictive respiratory disorders are characterized by a restriction in lung volume (caused by decreased compliance of the lungs or chest wall). This is in contrast to obstructive disorders, which are characterized by increased resistance to airflow (see Chapter 31). Pulmonary function tests are the best means of differentiating between restrictive and obstructive respiratory disorders (Table 30.20). Mixed obstructive and restrictive disorders are often manifested. For example, a patient may have both chronic bronchitis (an obstructive condition) and pulmonary fibrosis (a restrictive condition). Restrictive problems are generally categorized into extrapulmonary and intrapulmonary disorders. Extrapulmonary causes of restrictive lung disease include disorders involving the central nervous system, neuromuscular system, and chest wall (Table 30.21). In these disorders, the lung tissue is normal. Intrapulmonary causes of restrictive lung disease involve the pleura or the lung tissue (Table 30.22).

PLEURAL EFFUSION Types The pleural space lies between the lung and the chest wall and normally contains a very thin layer of fluid. Pleural effusion is a collection of fluid in the pleural space (see Figure 30.5, A). It is

CHAPTER 30  Nursing Management: Lower Respiratory Conditions not a disease but rather a sign of a serious disease. Pleural effusion is frequently classified as transudative or exudative according to whether the protein content of the effusion is low or high, TABLE 30.20    RELATIONSHIP OF LUNG

VOLUMES TO TYPE OF VENTILATORY DISORDER

Lung Volumes

Restrictive

Obstructive

Restrictive and Obstructive

Vital capacity (VC) Total lung capacity (TLC) Residual volume (RV) Forced expiratory volume in 1 sec (FEV1) FEV1/Functional vital capacity (FVC)

↓ ↓

Normal or ↓ ↑

↓ Variable

Normal or ↓ Normal or ↓

↑ ↓

Variable ↓

Normal or ↑

↓

↓

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respectively. A transudate occurs primarily in noninflammatory conditions and is an accumulation of protein-­and cell-­poor fluid. Transudative pleural effusions (also called hydrothorax) are caused by (1) increased hydrostatic pressure found in heart failure, which is the most common cause of pleural effusion, or (2) decreased oncotic pressure (from hypoalbuminemia) found in chronic liver or renal disease. In these situations, fluid movement is facilitated out of the capillaries and into the pleural space. An exudative effusion is an accumulation of fluid and cells in an area of inflammation. An exudative pleural effusion results from the increased capillary permeability characteristic of the inflammatory reaction. This type of effusion occurs secondary to conditions such as pulmonary malignancies, pulmonary infections, pulmonary embolization, and GI disease (e.g., pancreatic disease, esophageal perforation). The type of pleural effusion can be determined from a sample of pleural fluid obtained via thoracentesis (a procedure to remove fluid from the pleural space). Exudates have a high

TABLE 30.21    EXTRAPULMONARY CAUSES OF RESTRICTIVE LUNG DISEASE Disease or Alteration

Description

Comments

Injury to or impingement on respiratory centre, causing hypoventilation or hyperventilation; relationship of manifestations to increased intracranial pressure (see Chapters 59 and 60) Depression of respiratory centre, respiratory rate of 2 mm in diameter), (b) insufficient collateral blood flow from the bronchial circulation, or (c) pre-­existing lung disease. Infarction results in alveolar necrosis and hemorrhage. Occasionally, the necrotic tissue becomes infected and an abscess may develop. Concomitant pleural effusion is frequent. Pulmonary hypertension results from hypoxemia or from involvement of more than 50% of the area of the normal pulmonary bed. As a single event, an embolus does not cause pulmonary hypertension unless it is massive. Recurrent emboli may result in chronic pulmonary hypertension.  Diagnostic Studies A spiral (helical) CT scan is the most frequently used test to diagnose PE (Table 30.24). An IV injection of contrast media is required to view the blood vessels. The scanner continuously rotates while obtaining slices and does not start and stop between each slice. This allows visualization of all anatomical regions of the lungs. The computer reconstructs the data to provide a three-­dimensional picture and assist in emboli visualization. If a patient cannot have contrast media, a ventilation– perfusion (VQ) scan is done. The VQ scan has two components and is most accurate when both are performed: 1. Perfusion scanning involves IV injection of a radioisotope. A scanning device images the pulmonary circulation.

CHAPTER 30  Nursing Management: Lower Respiratory Conditions TABLE 30.24    INTERPROFESSIONAL CARE Acute Pulmonary Embolism Diagnostic

Interprofessional Therapy

• History and physical examination • Chest radiographic study • Continuous ECG monitoring • ABGs • Venous ultrasound • CBC count with WBC differential • Spiral (helical) CT scan • Ventilation–perfusion (VQ) scan • Lung scan • D-­dimer level • Troponin level, BNP level • Pulmonary angiography

• Supplemental oxygen, intubation may be necessary • Fibrinolytic agent • Unfractionated heparin IV infusion • Low-­molecular-­weight heparin (e.g., enoxaparin [Lovenox]) • Warfarin (Coumadin) for long-­ term therapy • Monitoring of aPTT and INR levels • Limited activity • Opioids for pain relief • Inferior vena cava filter • Pulmonary embolectomy in life-­threatening situation

ABGs, arterial blood gases; aPTT, activated partial thromboplastin time; BNP, B-­type natriuretic peptide; CBC, complete blood cell; CT, computed tomography; ECG, electrocardiogram; INR, international normalized ratio; IV, intravenous; WBC, white blood cell.

2.  Ventilation scanning involves inhalation of a radioactive gas such as xenon. Scanning reflects the distribution of gas through the lung. The ventilation component requires the cooperation of the patient and may be impossible to perform in a critically ill patient, particularly if the patient is intubated. D-­dimer is a laboratory test that measures the amount of cross-­linked fibrin fragments. These fragments are found in the circulation after clotting events such as VTE, acute myocardial infarction, unstable angina, and acute stroke. This degradation product is rarely found in healthy individuals. The disadvantage of D-­dimer is that it is neither specific (other conditions cause elevation) nor sensitive, because up to 50% of patients with small PEs have normal results. Patients with suspected PE and an elevated D-­dimer level but normal venous ultrasound may need a lung scan or spiral CT. Pulmonary angiography is a sensitive and specific test for PE. However, it is an invasive procedure that involves the insertion of a catheter through the antecubital or femoral vein, advancement to the pulmonary artery, and injection of contrast medium. It allows visualization of the pulmonary vascular system and location of the embolus. However, with spiral CT, pulmonary angiography is now used less frequently. ABG analysis is important, but not diagnostic. The partial pressure of oxygen in arterial blood (PaO2) is low because of inadequate oxygenation secondary to an occluded pulmonary vasculature preventing matching of perfusion to ventilation. The pH remains normal unless respiratory alkalosis develops as a result of prolonged hyperventilation or to compensate for lactic acidosis caused by shock. Abnormal findings are usually reported on the chest radiograph (atelectasis, pleural effusion) and on the ECG (ST-­segment and T-­wave changes), but they are not diagnostic for PE. Serum troponin levels are elevated in 30 to 50% of patients with PE, and, although not diagnostic, they are predictive of an adverse prognosis. Serum B-­type natriuretic peptide levels, although not diagnostic, may be helpful in identifying the severity of the clinical course. 

Interprofessional Care Prevention of PE begins with prevention of VTE. VTE prophylaxis includes the use of sequential compression devices, early

623

ambulation, and prophylactic use of anticoagulant medications. To reduce mortality risk, treatment is begun as soon as PE is suspected (see Table 30.24). The objectives are to (a) prevent further growth or multiplication of thrombi in the lower extremities, (b) prevent embolization from the upper or lower extremities to the pulmonary vascular system, and (c) provide cardiopulmonary support if indicated. Supportive therapy for the patient’s cardiopulmonary status varies according to the severity of the PE. The administration of supplemental oxygen by mask or cannula is adequate for some patients. Oxygen is given in a concentration determined by ABG analysis. In some situations, endotracheal intubation and mechanical ventilation are necessary to maintain adequate oxygenation. Respiratory measures such as turning, coughing, deep breathing, and incentive spirometry are important to help prevent or treat atelectasis. If symptoms of shock are present, IV fluids are administered followed by vasopressor agents, as needed, to support perfusion (see Chapter 69). If heart failure is present, diuretics are used. (Heart failure is discussed in Chapter 37.) Pain resulting from pleural irritation or reduced coronary blood flow is treated with opioids, usually morphine. Medication Therapy.  Fibrinolytic medications, such as tissue plasminogen activator (tPA) or alteplase (Activase), dissolve the PE and the source of the thrombus in the pelvis or deep leg veins, thereby decreasing the likelihood of recurrent emboli. Indications for thrombolytic therapy in PE include hemodynamic instability and right ventricular dysfunction. (Thrombolytic therapy is discussed in Chapter 40; see Table 40.10.) Because most deaths are caused by recurrent PEs, treatment should begin immediately. Properly managed anticoagulant therapy is effective in the prevention of further emboli. Heparin works to prevent future clots but does not dissolve existing clots. Although unfractionated heparin IV has traditionally been used, low-­ molecular-­ weight heparin (e.g., enoxaparin [Lovenox]) is becoming more common. Warfarin (Coumadin) should be initiated within the first 24 hours and is typically administered for 3 to 6 months. Some health care providers use factor Xa inhibitors and direct thrombin inhibitors in the treatment of PEs. The dosage of heparin is adjusted according to the activated partial thromboplastin time (aPTT), and the dosage of warfarin is determined by the international normalized ratio (INR). Frequent changes and titrations of heparin doses are needed initially in order to obtain a therapeutic aPTT level. Anticoagulant therapy may be contraindicated if the patient has complicating factors such as blood dyscrasias, hepatic dysfunction causing alteration in the clotting mechanism, injury to the intestine, overt bleeding, a history of hemorrhagic stroke, or neurological conditions.  Surgical Therapy.  If the degree of pulmonary arterial obstruction is severe and the patient does not respond to conservative therapy, an immediate embolectomy may be indicated. Pulmonary embolectomy, a rare procedure, has a 50% mortality rate. Preoperative pulmonary angiography is necessary to identify and locate the site of the embolus. When a pulmonary embolectomy is performed, the patient also has placement of a vena cava filter. To prevent further emboli, an inferior vena cava filter may be the treatment of choice in patients who remain at high risk and for patients for whom anticoagulation is contraindicated. This device is placed at the level of the diaphragm in the inferior vena cava via the femoral vein. It prevents migration of

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SECTION 5  Conditions of Oxygenation: Ventilation

large clots into the pulmonary system. Potential complications associated with this device include recurrent VTEs and post-­ thrombotic syndrome, in addition to misplacement, migration, and perforation. 

NURSING MANAGEMENT PULMONARY EMBOLISM NURSING IMPLEMENTATION HEALTH PROMOTION.  Nursing measures aimed at prevention of PEs are similar to those for prophylaxis of VTEs; see the discussion of venous thrombosis in Chapter 40).  ACUTE INTERVENTION.  The prognosis of a patient with PE is good if therapy is promptly instituted. The patient should be kept on bed rest in a semi-­Fowler’s position to facilitate breathing. An IV line should be maintained for medications and fluid therapy. The nurse should know the adverse effects of medications and observe for them. Oxygen therapy should be administered as ordered. Careful continuous monitoring of vital signs, cardiac dysrhythmia, pulse oximetry (oxygen saturation), ABGs, and lung sounds is critical to assess the patient’s status. Laboratory results should be monitored to ensure normal ranges of aPTT and INR. Nursing care includes assessing for the complications of anticoagulant therapy (e.g., bleeding, hematomas, bruising) and for PEs (e.g., hypoxia, hypotension). The nurse should perform appropriate interventions related to immobility and fall precautions. Patients are usually anxious because of pain, a sense of doom, inability to breathe, and fear of death. Explaining the situation and providing emotional support and reassurance can help relieve this anxiety.  AMBULATORY AND HOME CARE.  The patient affected by thromboembolic processes may require emotional support. In addition, some patients may have an underlying chronic illness requiring long-­term treatment. To provide supportive therapy, the nurse needs to understand and differentiate between the various conditions caused by the underlying disease and those related to thromboembolic disease. Patient teaching regarding long-­term anticoagulant therapy is critical. Anticoagulant therapy continues for at least 3 to 6 months; patients with recurrent emboli are treated indefinitely. INR levels are drawn at intervals and warfarin dosage is adjusted. Some patients are monitored by nurses in an anticoagulation clinic. Long-­term management is similar to that for the patient with VTE (see the discussion of VTE in Chapter 40). Discharge planning is aimed at limiting progression of the condition and preventing complications and recurrence. The need for the patient to return to the health care provider for regular follow-­up examinations should be reinforced.  EVALUATION The expected outcomes are that the patient who has a PE will have • Adequate tissue perfusion and respiratory function • Adequate cardiac output • Increased level of comfort • No recurrence of PE 

  PULMONARY HYPERTENSION Pulmonary hypertension comprises a variety of disorders occurring as a primary disease (primary pulmonary hypertension) or as a complication of a large number of respiratory and cardiac disorders (secondary pulmonary hypertension).

Pulmonary hypertension is elevated pulmonary pressure resulting from an increase in pulmonary vascular resistance to blood flow through small arteries and arterioles.

PRIMARY PULMONARY HYPERTENSION Primary pulmonary hypertension (PPH) is a rare, severe, and progressive disease. PPH is characterized by mean pulmonary arterial pressure greater than 25 mm Hg at rest or greater than 30 mm Hg with exercise, in the absence of a demonstrable cause. PPH is associated with a poor prognosis because there is no definitive therapy.

Etiology and Pathophysiology The exact etiology of PPH is unknown. PPH has been linked to the use of fenfluramine in the drug Fen-­Phen, which was used as an appetite suppressant to treat obesity. The drug was withdrawn from the market in 1996. PPH affects more women than men. It may have a genetic component because the incidence is higher in families. It is a rare and potentially fatal disease; the mean age at diagnosis is 36 years. Normally, the pulmonary circulation is characterized by low resistance and low pressure. In pulmonary hypertension, the pulmonary pressures are elevated. Until recently, the pathophysiology of PPH was poorly understood. It has been discovered that a key mechanism involved in PPH is a deficient release of vasodilator mediators from the pulmonary epithelium with a resultant cascade of injury (Figure 30.12).  Clinical Manifestations Classic symptoms of pulmonary hypertension are dyspnea on exertion and fatigue. Exertional chest pain, dizziness, and exertional syncope are other symptoms. These symptoms are related to the inability of cardiac output to increase in response to increased oxygen demand. Eventually, as the disease progresses, dyspnea occurs at rest. Pulmonary hypertension increases the workload of the right ventricle and causes right ventricular hypertrophy (a condition called cor pulmonale) and eventually heart failure. A chest radiograph generally shows enlarged central pulmonary arteries and clear lung fields. A heart enlarged on the right may be seen. An echocardiogram usually reveals right ventricular hypertrophy.  Interprofessional Care Diagnostic evaluation includes an ECG, a chest radiographic study, and an echocardiogram. CT and cardiac catheterization to measure pulmonary artery pressures can be used. Additional tests may be done to exclude secondary factors. Early recognition of pulmonary hypertension is essential to interrupt the self-­perpetuation cycle responsible for the progression of this condition (see Figure 30.12). The mean time between onset of symptoms and diagnosis is 2 years. By the time patients become symptomatic, the disease is already in the advanced stages and the size of pulmonary artery pressure is two to three times normal. Although there is no cure for PPH, treatment can relieve symptoms, improve quality of life, and prolong life. Diuretic therapy relieves dyspnea and peripheral edema and may be useful in reducing right ventricular volume overload. Anticoagulation therapy is recommended for patients with severe pulmonary hypertension to prevent in situ thrombus formation and venous thrombosis.

CHAPTER 30  Nursing Management: Lower Respiratory Conditions PATHOPHYSIOLOGY MAP Genetic causes

Unknown causes

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transplantation. A patient education and support site for pulmonary hypertension is located on the Pulmonary Hypertension Association’s website (see the Resources at the end of this chapter). 

SECONDARY PULMONARY HYPERTENSION Pulmonary endothelial injury ↑ Vasoactive mediators Vasoconstriction ↑ Growth factors Remodelling (vessel wall thickening) ↑ Coagulation and fibrinolytic defects can precipitate thrombosis in situ Sustained pulmonary hypertension

Right ventricular hypertrophy

Cor pulmonale

Right-sided heart failure FIG. 30.12  Pathogenesis of pulmonary hypertension and cor pulmonale.

Vasodilator therapy is used to reduce right ventricular overload by dilating pulmonary vessels and reversing remodelling. Many patients with pulmonary hypertension can be effectively managed with calcium channel blocker therapy, such as nifedipine (Adalat) and diltiazem (Cardizem). Synthetic prostacyclins promote pulmonary vasodilation and reduce pulmonary vascular resistance and have revolutionized the management of PPH. They are now the treatment of choice for select patients unresponsive to calcium channel blockers. They can be administered orally (e.g., bosentan), subcutaneously (e.g., treprostinil), or intravenously (e.g., epoprostenol). Aerosolized forms are not yet available in Canada. Bosentan (Tracleer) is an oral form of prostacyclin used to treat PPH. It is an active endothelin receptor antagonist. This medication works by blocking the hormone endothelin, which causes blood vessels to constrict. Treprostinil (Remodulin), a prostacyclin, is used as a continuous subcutaneous injection. It causes vasodilation of the pulmonary arterial system and inhibits platelet aggregation. Surgical interventions include atrial septostomy, pulmonary thromboendarterectomy, and lung transplantation. Lung transplantation is the mainstay of treatment for those patients who do not respond to prostacyclins and progress to severe right-­sided heart failure. Recurrence of the disease has not been reported in individuals who have undergone

Secondary pulmonary hypertension (SPH) occurs when a primary disease causes a chronic increase in pulmonary artery pressures. It can develop as a result of parenchymal lung disease, left ventricular dysfunction, intracardiac shunts, chronic pulmonary thromboembolism, or systemic connective tissue disease. The specific primary disease pathology may result in anatomical or vascular changes causing the pulmonary hypertension. Anatomical changes causing increased vascular resistance include (1) loss of capillaries as a result of alveolar wall damage (e.g., COPD), (2) stiffening of the pulmonary vasculature (e.g., pulmonary fibrosis connective tissue disorders), and (3) obstruction of blood flow (chronic emboli). Vasomotor increases in pulmonary vascular resistance are found in conditions characterized by alveolar hypoxia. Hypoxia causes localized vasoconstriction and shunting of blood away from poorly ventilated alveoli. Alveolar hypoxia can be caused by a wide variety of conditions. It is possible to have a combination of anatomical restriction and vasomotor constriction. This combination is found in the patient with long-­standing chronic bronchitis who has chronic hypoxia in addition to loss of lung tissue. Symptoms can reflect the underlying disease, but some, such as dyspnea, fatigue, lethargy, and chest pain, are directly attributable to the SPH. Physical findings include right ventricular hypertrophy and signs of right ventricular failure (increased pulmonic heart sound, right-­sided fourth heart sound, peripheral edema, hepatomegaly). Treatment of pulmonary hypertension caused primarily by pulmonary or cardiac disorders consists mainly of treating the underlying disorder. Treatment of SPH is similar to treatment of PPH. 

COR PULMONALE Cor pulmonale is a hypertrophy of the right side of the heart, with or without heart failure, resulting from pulmonary hypertension. Diseases of the lung or thorax or changes in pulmonary circulation can lead to pulmonary hypertension. Pulmonary hypertension is usually a pre-­existing condition in the individual with cor pulmonale. Cor pulmonale may be present with or without overt cardiac failure. The most common cause of cor pulmonale is COPD; however, almost any disorder that affects the respiratory system can cause cor pulmonale. The etiology and pathogenesis of pulmonary hypertension and cor pulmonale are outlined in Figure 30.12.

Clinical Manifestations Clinical manifestations of cor pulmonale include dyspnea, chronic productive cough, wheezing respirations, retrosternal or substernal pain, and fatigue. Chronic hypoxemia leads to polycythemia and increased total blood volume and viscosity of the blood. (Polycythemia is often present in cor pulmonale secondary to COPD.) Compensatory mechanisms that are secondary to hypoxemia can aggravate the pulmonary hypertension. Episodes of cor pulmonale in a person with underlying

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SECTION 5  Conditions of Oxygenation: Ventilation

TABLE 30.25    INTERPROFESSIONAL CARE Cor Pulmonale Diagnostic

Interprofessional Therapy

• History and physical examination • ABGs • Serum and urine electrolytes • Monitoring with ECG • Chest radiographic study

• O2 therapy • Bronchodilators • Diuretics • Low-­sodium diet • Fluid restriction • Antibiotics (if indicated) • Digitalis (if left-­sided heart failure) • Vasodilators (if indicated) • Calcium channel blockers (if indicated)

ABGs, arterial blood gases; ECG, electrocardiogram; O2, oxygen.

chronic respiratory conditions are frequently triggered by an acute respiratory tract infection. If heart failure accompanies cor pulmonale, additional manifestations such as peripheral edema, weight gain, distended neck veins, full, bounding pulse, and enlarged liver will also be found. (Heart failure is discussed in Chapter 37.) A chest radiograph will show an enlarged right ventricle and pulmonary artery. 

Interprofessional Care The primary management of cor pulmonale is directed at treating the underlying pulmonary condition that precipitated the heart condition (Table 30.25). Long-­ term low-­ flow oxygen therapy is used to correct the hypoxemia and reduce vasoconstriction in chronic states of respiratory disorders. If fluid, electrolyte, and acid–base imbalances are present, they must be corrected. Diuretics and a low-­sodium diet will help decrease the plasma volume and the load on the heart. Bronchodilator therapy is indicated if the underlying respiratory condition is caused by an obstructive disorder. Digitalis may be used if there is left-­sided heart failure. Other treatments include those for pulmonary hypertension and comprise vasodilator therapy, calcium channel blockers, and anticoagulants. Theophylline may help because of its weak inotropic effect on the heart. When medical treatment fails, lung transplantation is an option for some patients. Management of cor pulmonale resulting from COPD is similar to that described for COPD (see Chapter 31). Continuous low-­flow oxygen during sleep, exercise, and small, frequent meals may allow the patient to feel better and be more active. 

  LUNG TRANSPLANTATION Lung transplantation has evolved as a viable therapy for patients with end-­stage lung disease. A variety of pulmonary disorders are potentially treatable with some type of lung transplantation (Table 30.26). Improved selection criteria, technical advances, and better methods of immunosuppression have resulted in improved survival rates. Various transplant options are available, including single-­lung transplant, bilateral-­lung transplant, heart–lung transplant, and transplantation of lobes from a living related donor.

TABLE 30.26    INDICATIONS FOR LUNG

TRANSPLANTATION

• α  1-­Antitrypsin deficiency • Bronchiectasis • Cystic fibrosis • Emphysema • Idiopathic pulmonary fibrosis • Interstitial lung disease • Pulmonary fibrosis secondary to other diseases (e.g., sarcoidosis) • Pulmonary hypertension

Patients being considered for a lung transplant need to undergo extensive evaluation. The candidate for lung transplantation should not have a malignancy or recent history of malignancy (within the past 2 years), renal or liver insufficiency, or HIV. The typical wait for a lung transplant is longer than 1 year. The candidate and the family must undergo psychological screening to determine the ability to cope with a postoperative regimen that requires strict adherence to immunosuppressive therapy, continuous monitoring for early signs of infection, and prompt reporting of manifestations of infection for medical evaluation. Postoperative care includes ventilatory support, pulmonary clearance measures (bronchodilators, chest physiotherapy, and deep breathing and coughing), fluid and hemodynamic management, immunosuppression, detection of early rejection, and prevention or treatment of infection. Infection is the leading cause of morbidity and mortality. Gram-­negative bacterial pneumonia is common. Viral infection with CMV and herpes simplex occur frequently. CMV is a leading cause of mortality, which, if it is going to occur, usually happens 4 to 8 weeks after surgery. Fungal infections are also seen. An empirical antibiotic regimen is routine perioperatively for potential pathogens isolated from the donor or recipient. Immunosuppressive therapy usually includes a triple-­ medication regimen of cyclosporine, azathioprine (Imuran), and prednisone. Immunosuppressive medications are discussed in Chapter 16 and Table 16.16. Acute rejection can be seen as soon as 5 to 7 days after surgery. It is characterized by low-­grade fever, fatigue, and oxygen desaturation with exercise. Accurate diagnosis is by transtracheal biopsy. Treatment with bolus corticosteroids results in remission of symptoms. Bronchiolitis obliterans (an obstructive airway disease causing progressive occlusion) is considered to represent chronic rejection in lung transplant patients. The onset is often subacute, with gradual, progressive obstructive airflow defect, including cough, dyspnea, and recurrent lower respiratory tract infection. Treatment involves optimum maintenance immunosuppression. Discharge planning begins in the preoperative phase. Patients are placed in an outpatient rehabilitation program to improve physical endurance. The use of home spirometry has been useful in monitoring trends in lung function. Patients are taught to keep logs of medications, laboratory results, and spirometry. Patients need to be able to perform self-­care activities, including medication management and ability to identify when to call the health care provider. Over the past decade, lung transplantation has become an increasingly important mode of therapy for patients with a variety of end-­stage lung diseases.

CHAPTER 30  Nursing Management: Lower Respiratory Conditions

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CASE STUDY Pneumonia and Lung Cancer Patient Profile

Interprofessional Care

J. H. (pronouns he/him), 52 years old, comes to the emergency department reporting shortness of breath. He has not seen a health care provider for many years. 

• D  iagnosis: pneumonia with small cell lung cancer • Follow-­up with patient and family to consider treatment options 

Subjective Data

1. H  ow would J. H.’s pneumonia be classified? Why is classification important? 2. What would the nurse’s analysis of J. H.’s arterial blood gas results be? 3. Priority decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any interprofessional issues? 4. Priority decision: What are the priority nursing interventions for J. H.? 5. The nurse is planning a meeting with J. H. and his family to discuss their needs. The physician tells the nurse that J. H. is terminally ill. Who should be included in this meeting? 6. Evidence-­informed practice: J. H.’s children tell the nurse that they are worried they will get lung cancer because their father has it and they grew up around secondhand smoke. They want to know what kind of screening is available for them. How should the nurse respond? 7. What is the goal if radiation therapy is used for J. H.? 8. What issues should be addressed in the nurse’s teaching of J. H. and his partner as J. H. is prepared for discharge and care at home?

• Has a 38 pack-­year history of cigarette smoking • States he has always been slender but has had 11-­kg weight loss despite a normal appetite in the past few months • Admits to a “smoker’s cough” for the past 2 to 3 years; recently coughing up blood • Is married and is the parent of three adult children 

Objective Data Physical Examination • • • • •

 hin, pale, looking older than stated age T Height 182 cm; weight 61.2 kg Intermittently confused and anxious with rapid shallow respirations Vital signs: temperature 39.2°C, heart rate 120, respiratory rate 36 Chest wall has limited excursion on right side; auscultation of left side reveals coarse crackles but clear with cough; right side has diminished breath sounds 

Diagnostic Studies • A  rterial blood gases: pH 7.51, PaO2 58 mm Hg, PaCO2 30 mm Hg, HCO3− 22 mmol/L, O2 saturation 84% (room air) • Chest radiograph: consolidation of the right lung, especially in the base with possible mass in the area of right bronchus; pleural effusion on the right side • Bronchoscopy with biopsy of mass: small cell lung carcinoma 

Discussion Questions

Answers are available at http://evolve.elsevier.com/Canada/Lewis/medsurg

 REVIEW QUESTIONS The number of the question corresponds to the same-­numbered objective at the beginning of the chapter. 1. What clinical manifestations should the nurse expect when assessing a client with pneumococcal pneumonia? a. Fever, chills, and a productive cough with purulent sputum b. Nonproductive cough and night sweats that are usually self-­ limiting c. Gradual onset of nasal stuffiness, sore throat, and purulent productive cough d. Abrupt onset of fever, nonproductive cough, and formation of lung abscesses 2. A client with pneumonia has the nursing diagnosis of inadequate airway clearance from an excessive amount of mucus and retained secretions. What would be an appropriate nursing intervention? a. Promote fluid hydration, as appropriate, to help liquefy secretions. b. Provide analgesics as ordered to promote client comfort. c. Administer oxygen as prescribed to maintain optimal oxygen levels. d. Teach the client how to cough effectively to bring secretions to the mouth. 3. A client with tuberculosis (TB) has a history of nonadherence to the medication regimen. What is the most common cause of this behaviour in clients with TB? a. Fatigue and lack of energy to manage self-­care b. Lack of knowledge about how the disease is transmitted c. Lack of social support systems for the client and family

d. Feelings of shame and the response to the social stigma associated with TB 4. A client has been receiving high-­dose corticosteroids and broad-­ spectrum antibiotics for treatment of serious trauma and infection. Which of the following infections is the client most susceptible to? a. Aspergillosis b. Candidiasis c. Coccidioidomycosis d. Histoplasmosis 5. Which of the following statements best describes the treatment of lung abscess? a. It is best treated with surgical excision and drainage. b. Antibiotics for a prolonged period is the treatment of choice. c. Abscesses are difficult to treat and usually result in pulmonary fibrosis. d. Penicillin can effectively eradicate anaerobic organisms. 6. What is a common complication of many types of environmental lung diseases? a. Benign tumour growth b. Diffuse airway obstruction c. Liquefactive necrosis d. Pulmonary fibrosis 7. What type of lung cancer is generally associated with the best prognosis because it is potentially surgically resectable? a. Adenocarcinoma b. Small cell carcinoma

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SECTION 5  Conditions of Oxygenation: Ventilation

c. Squamous cell carcinoma d. Undifferentiated large cell carcinoma 8. How does the nurse identify in a client a flail chest caused by trauma? a. Multiple rib fractures are determined by radiographic study. b. Tracheal deviation to the unaffected side is present. c. Paradoxical chest movement occurs during respiration. d. Decreased movement of the involved chest wall is apparent. 9. The nurse notes tidalling of the water level in the tube submerged in the water-­seal chamber in a client with closed chest tube drainage. What should the nurse do? a. Continue to monitor this normal finding. b. Check all connections for a leak in the system. c. Lower the drainage collector further from the chest. d. Clamp the tubing at progressively more distal points from the client until the tidalling stops. 10. Which nursing measure should be instituted after a pneumonectomy? a. Monitor chest tube drainage and functioning. b. Position the client on the operative side or their back. c. Perform range-­of-­motion exercises on the affected upper extremity. d. Auscultate frequently for lung sounds on the affected side. 11. What is the cause of respiratory symptoms in clients with Guillain-­ Barré syndrome? a. Central nervous system depression b. Deformed chest-­wall muscles c. Paralysis of the diaphragm secondary to trauma d. Interruption of nerve transmission to respiratory muscles 12. A client with chronic obstructive pulmonary disease asks why the heart is affected by the respiratory disease. Which of the following statements regarding cor pulmonale is the basis for the nurse’s response to the client? a. Pulmonary congestion secondary to left ventricular failure b. Excess serous fluid collection in the alveoli caused by retained respiratory secretions c. Right ventricular hypertrophy secondary to increased pulmonary vascular resistance d. Right ventricular failure secondary to compression of the heart by hyperinflated lungs 13. Which statement(s) describe(s) the management of a client following lung transplantation? (Select all that apply.) a. High doses of oxygen are administered around the clock. b. The use of a home spirometer will help to monitor lung function. c. Immunosuppressant therapy usually involves a three-­ medication regimen. d. Most clients experience an acute rejection episode in the first 2 days. e. The lung is biopsied using a transtracheal method if rejection is suspected. 1. a; 2. a; 3. d; 4. b; 5. b; 6. d; 7. c; 8. c; 9. a; 10. b; 11. d; 12. c; 13. b, c, e. For even more review questions, visit http://evolve.elsevier.com/ Canada/Lewis/medsurg.

REFERENCES BC Centre for Disease Control. (2019). Communicable disease control manual. Chapter 4: tuberculosis. http://www.bccdc.ca/resource-gallery/Documents/Communicable-Disease-Manual/Chapter%204%20 -%20TB/5.0%20Treatment%20and%20Active%20TB%20Disease.pdf.

Canadian Cancer Society. (2021a). Cancer statistics at a glance. https://www.cancer.ca/en/cancer-­information/cancer-­101/cancer-­ statistics-­at-­a-­glance/?region=ab Canadian Cancer Society. (2021b). Lung cancer: Malignant tumours of the lung. http://www.cancer.ca/en/cancer-­information/cancer-­ type/lung/lung-­cancer/cancerous-­tumours/?region=on Canadian Cancer Society. (2021c). Risk factors for lung cancer. https://www.cancer.ca/en/cancer-­information/cancer-­type/lung/ri sks/?region=ab Canadian Cancer Society. (2021d). What is second-­hand smoke and how does it affect you?. https://www.cancer.ca/en/prevention-­and-­ screening/reduce-­cancer-­risk/make-­healthy-­choices/live-­smoke-­free/what-­is-­second-­hand-­smoke/?region=on Canadian Cancer Society. (2021e). What you need to know about e-­cigarettes. https://www.cancer.ca/en/prevention-­and-­ screening/reduce-­cancer-­risk/make-­healthy-­choices/live-­smoke-­free/what-­you-­need-­to-­know-­about-­e-­cigarettes/?region=on Canadian Centre for Occupational Health and Safety (CCOHS). (2021a). OSH Answers fact sheets: Asthma, work related. https:// www.ccohs.ca/oshanswers/diseases/asthma.html Canadian Centre for Occupational Health and Safety (CCOHS). (2021b). OSH Answers fact sheets: OH&S Legislation in Canada—Basic responsibilities. https://www.ccohs.ca/oshanswers/legisl/responsi.html Canadian Institute for Health Information. (2021). Hospital stays in Canada. https://www.cihi.ca/en/hospital-­stays-­in-­canada Canadian Lung Association. (2016). Smoking and tobacco: Benefits of quitting smoking. https://www.lung.ca/lung-­health/smoking-­and-­ tobacco/benefits-­quitting Canadian Lung Association. (2021). Smoking and tobacco. https://www.lung.ca/lung-­health/smoking-­and-­tobacco Canadian Task Force on Preventive Health Care. (2016). Recommendations on screening for lung cancer. Canadian Medical Association Journal, 188(6), 425–432. https://doi.org/10.1503/ cmaj.151421 Dalcin, D., Sieswerda, L., Dubois, S., et al. (2018). Epidemiology of invasive pneumococcal disease in Indigenous and non-­Indigenous adults in northwestern Ontario, Canada 2006-­2015. BMC Infectious Diseases, 18(1), 621. https://doi.org/10.1186/s12879-­018-­3531-­9 Francesco, P. (2020). Electronic cigarettes, vaping-­related lung injury and lung cancer, where do we stand? European Journal of Cancer Prevention (Epub ahead of print). https://doi.org/10.1097/ CEJ.0000000000000630 Government of Canada. (2016). Pneumococcal vaccine: Canadian immunization guide. https://www.canada.ca/en/public-­health/service s/publications/healthy-­living/canadian-­immunization-­guide-­part-­ 4-­active-­vaccines/page-­16-­pneumococcal-­vaccine.html Government of Canada. (2020). Weekly influenza reports: Flu watch report February 16-22, 2020 Week 8. https://www.canada.ca/en/ public-health/services/publications/diseases-conditions/fluwatch/2019-2020/week-08-february-16-22-2020.html Health Quality Ontario and Ministry of Health and Long-­Term Care. (2013). Quality-­based procedures clinical handbook for community-­ acquired pneumonia. http://www.health.gov.on.ca/en/pro/program s/ecfa/docs/qbp_pnemonia.pdf. (Seminal). Hogg, K., Thomas, D., Mackway-­Jones, K., et al. (2011). Diagnosing pulmonary embolism: A comparison of clinical probability scores. British Journal of Haematology, 153(2), 253–258. https://doi. org/10.1111/j.1365-­2141.2011.08575.x. (Seminal). Human Resources and Social Development Canada. (2017). Occupational health and safety and compliance. https://www.canada.ca/co ntent/dam/esdc-­edsc/migration/documents/eng/health_safety/pu bs_hs/pdf/compliance.pdf

CHAPTER 30  Nursing Management: Lower Respiratory Conditions Indigenous Services Canada. (2020). Tuberculosis in Indigenous communities. https://www.sac-isc.gc.ca/eng/1570132922208/ 1570132959826 LaFreniere, M., Hussain, H., He, N., et al. (2019). Tuberculosis in Canada: 2017. Canadian Communicable Disease Report, 45(2/3), 68–74. https://doi.org/10.14745/ccdr.v45i23a04 Lux, M. (2018). Indian hospitals in Canada. The Canadian Encyclopedia. https://www.thecanadianencyclopedia.ca/en/article/ indian-­hospitals-­in-­canada Mandell, L. A., Marrie, T. J., Grossman, R. F., et al. (2000). Summary of the Canadian guidelines for the initial management of community-­acquired pneumonia: An evidence-­based update by the Canadian Infectious Disease Society and the Canadian Thoracic Society. Canadian Respiratory Journal, 7(5), 371–382. https:// doi.org/10.1086/313959. (Seminal). Nahid, P., Dorman, S. E., Alipanah, N., et al. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: treatment of drug-susceptible tuberculosis. Clinical Infectious Diseases, 63(7), e147–e195. Public Health Agency of Canada (PHAC) & Canadian Lung Association. (2014). Canadian tuberculosis standards (7th ed.). https://www.canada.ca/en/public-­health/services/infectious-­ diseases/canadian-­tuberculosis-­standards-­7th-­edition.html Registered Nurses’ Association of Ontario. (2017). Clinical best practice guidelines: Integrating tobacco interventions into daily practice. https://rnao.ca/sites/rnao-­ca/files/bpg/FINAL_TOBACCO_ INTERVENTION_WEB.pdf Rubin, B. K., & Williams, R. W. (2014). Aerosolized antibiotics for non-­cystic fibrosis bronchiectasis. Respiration; International Review of Thoracic Diseases, 88, 177–184. https://doi. org/10.1159/000366000. (Seminal). Thrombosis Canada. (2015). Pulmonary embolism (PE): Diagnosis. http://thrombosiscanada.ca/wp-­content/uploads/2015/11/4A_Pul monary-­Embolism-­Diagnosis-­2015Oct26-­FINAL2.pdf. (Seminal). World Health Organization (WHO). (2014). Companion handbook to the WHO guidelines for the programmatic management of drug-­ resistant tuberculosis. http://apps.who.int/iris/bitstream/10665/130 918/1/9789241548809_eng.pdf?ua=1&ua=1 World Health Organization (WHO). (2021). Fact sheets: Cancer. https://www.who.int/news-­room/fact-­sheets/detail/cancer Wu, H., Harder, C., & Culley, C. (2017). The 2016 clinical practice guidelines for management of hospital-­acquired and ventilator-­ associated pneumonia. The Canadian Journal of Hospital Pharmacy, 70(3). https://doi.org/10.4212/cjhp.v70i3.1667

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RESOURCES BC Cancer http://www.bccancer.bc.ca Canadian Cancer Society https://www.cancer.ca Canadian Cancer Society: Get Help to Quit Smoking https://www.cancer.ca/en/support-­a nd-­s er vices/support-­ services/quit-­smoking/?region=on Canadian Lung Association https://www.lung.ca Cancer Care Ontario https://www.cancercare.on.ca Cancer Care Ontario: Lung Cancer Evidence-­Based Guidelines (PEBC) https://www.cancercareontario.ca/en/cancer-­c are-­o ntario/ programs/data-­research/evidence-­based-­care Cancer Control Alberta https://www.albertahealthservices.ca/cancer/cancer.aspx Health Canada https://www.hc-­sc.gc.ca Public Health Agency of Canada https://www.phac-­aspc.gc.ca Statistics Canada https://www.statcan.ca Centers for Disease Control and Prevention, National Center for Health Statistics http://www.cdc.gov/nchs/fastats Centers for Disease Control and Prevention: Smoking & Tobacco Use https://www.cdc.gov/tobacco National Cancer Institute https://www.nci.nih.gov Pulmonary Hypertension Association (PHA) https://www.phassociation.org World Health Organization: International Standards for Tuberculosis Care (ISTC) https://www.who.int/tb/publications/ISTC_3rdEd.pdf For additional Internet resources, see the website for this book at http:// evolve.elsevier.com/Canada/Lewis/medsurg.

CHAPTER

31

Nursing Management

Obstructive Pulmonary Diseases Kimberly Hellmer Originating US chapter by Eugene Mondor

WEBSITE http://evolve.elsevier.com/Canada/Lewis/medsurg • • • •

 eview Questions (Online Only) R Key Points Answer Guidelines for Case Study Student Case Studies • Asthma • Cystic Fibrosis

• Customizable Nursing Care Plans • Patient with Asthma • Patient with Chronic Obstructive Pulmonary Disease • Conceptual Care Map Creator

• C  onceptual Care Map for Textbook Case Study • Audio Glossary • Content Updates

LEARNING OBJECTIVES 1. Explore the etiology, pathophysiology, and clinical manifestations of asthma, and describe the interprofessional care plan of patients with asthma. 2. Explain the nursing management of patients with asthma. 3. Discover the etiology, pathophysiology, and clinical manifestations of chronic obstructive pulmonary disease (COPD), and describe the interprofessional care plan of patients with COPD.

4. Explain the effects of cigarette smoking on the lungs, and formulate a discussion about the benefits of smoking cessation with patients. 5. Outline the nursing management of patients with COPD. 6. Identify the indications for oxygen therapy, the methods of delivery, and the complications of oxygen administration. 7. Determine the etiology, pathophysiology, and clinical manifestations of cystic fibrosis, and describe the interprofessional care plan of patients with cystic fibrosis.

KEY TERMS absorption atelectasis α1-­antitrypsin (AAT) deficiency asthma chest physiotherapy chronic bronchitis

  

chronic obstructive pulmonary disease (COPD) cor pulmonale cough variant asthma cystic fibrosis

Obstructive pulmonary diseases are the most common chronic lung diseases, which include conditions characterized by increased airflow resistance as a result of airway obstruction or narrowing. Airway obstruction may result from accumulated secretions, edema, inflammation of the airways, bronchospasm of smooth muscle, or destruction of lung tissue, or some combination of these conditions. Asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis are obstructive pulmonary diseases. While breathing is an unconscious effort for most people, individuals living with obstructive pulmonary disease are consciously challenged with breathing. In Canada, there are 3.8 million Canadians over the age of 1 year living with asthma, 2.0 million living with COPD (Government of Canada, 2018),

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emphysema oxygen toxicity postural drainage pursed-­lip breathing status asthmaticus

and more than 4 300 living with cystic fibrosis (Cystic Fibrosis Canada, 2020). Each of the complex disease processes are further explored in this chapter.

ASTHMA Asthma is a chronic inflammatory disorder of the airways. Inflammation causes varying degrees of obstruction in the airways, which leads to recurrent episodes of wheezing, breathlessness, sensation of chest tightness, and cough, particularly at night and in the early morning. The hyper-­responsiveness, or “twitchiness,” of the airways is directly related to the degree of airway inflammation. The more airway inflammation present, the more hyper-­responsive the airways are to endogenous

CHAPTER 31  Nursing Management: Obstructive Pulmonary Diseases or exogenous stimuli or triggers. Asthma occurs as a result of environmental (endogenous or exogenous) effects on the airways that trigger a series of events in the immune system of a genetically predisposed individual. These events lead to airway inflammation and bronchoconstriction (airway narrowing). A key characteristic of asthma is the episodic and reversible nature of the airway obstruction and its associated symptoms (cough, wheeze, sensation of chest tightness, dyspnea), so an episode may resolve spontaneously or with treatment. In 2011, the Public Health Agency of Canada (PHAC) conducted a Survey on Living with Chronic Disease in Canada (SLDC), which provided an in-­depth analysis of Canadians aged 12 years and over living with asthma. The SLDC identified that more than 2.4 million (8.4%) Canadians older than 12 years were living with asthma, which translates to 9.8% of all female Canadians and 7.0% of all male Canadians (PHAC, 2015). Asthma is 40% more prevalent among Indigenous people when compared to the general Canadian population (Asthma Canada, 2019). The morbidity associated with asthma is dramatic: The SLDC found that 11.1% of Canadians with active asthma reported a minimum of one visit to a hospital emergency room in the previous 12 months because of asthma symptoms (PHAC, 2015). The high rate of morbidity related to asthma may be attributed to practice that is inconsistent with Canadian asthma consensus guidelines, inaccurate assessment of disease severity, a delay in seeking help, inadequate medical treatment, nonadherence to prescribed therapy, an increase in allergens in the environment,

limited access to health care, and a lack of knowledge on the part of patients and health care providers.

Pathophysiology The hallmarks of asthma are airway inflammation and airway hyper-­ responsiveness. The degree of bronchoconstriction is related to the degrees of airway inflammation, airway hyper-­responsiveness, and exposure to endogenous and exogenous triggers (e.g., infections, allergens, histamine, and other cell mediators). Exposure to allergens or irritants initiates an inflammatory cascade involving multiple cell types, mediators, and chemokines. Typically, there are two possible types of asthmatic responses to stimuli: an early-­phase response and a late-­ phase response. The early-­phase response in asthma is characterized by bronchospasm (Figure 31.1). This response is triggered when an allergen or irritant attaches to immunoglobulin E (IgE) receptors on mast cells found beneath the basement membrane of the bronchial wall (Figure 31.2). The mast cells become activated and, subsequently, granules are released and the phospholipids’ cell membranes are disrupted. Both processes result in the release of inflammatory mediators, including histamine, bradykinin, leukotrienes, prostaglandins, platelet-­activating factor, chemotactic factors, and cytokines (e.g., interleukin-­4 [IL-­4] and interleukin-­5 [IL-­5]). A similar early-­phase response process can occur with exercise. These mediators cause intense inflammation in association with bronchial smooth muscle constriction,

PATHOPHYSIOLOGY MAP Triggers • Infection • Allergens • Exercise • Irritants

Immune activation (IL-4, IgE production)

Mast cell degranulation

Inflammatory mediators

Vasodilation Increased capillary permeability

• • • • • •

Bronchospasm Vascular congestion Edema formation Mucus secretion Impaired mucociliary function Thickening of airway walls

• • Bronchial hyper-responsiveness • Airway obstruction

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Cellular infiltration (neutrophils, lymphocytes, eosinophils)

Neuropeptides released with autonomic nervous system effects

Airway remodelling

FIG. 31.1  Early-­and late-­phase responses of asthma. IgE, immunoglobulin E; IL-­4, interleukin-­4.

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SECTION 5  Conditions of Oxygenation: Ventilation

Allergens Mast cell

B lymphocyte IgE antibodies

Smooth muscle Swollen mucosa Muscle Mucus in spasm

Plasma cells

Allergens

A Histamine

Mucus

Inflammatory mediators Mast cell

Mucus

B FIG. 31.3  Factors causing obstruction (especially expiratory obstruction) in

asthma. A, Cross section of a bronchiole occluded by muscle spasm, swollen mucosa, and mucus in the lumen. B, Longitudinal section of a bronchiole. Source: Asthma Society of Canada. (2016). About asthma. http://www.asth ma.ca/adults/about/whatIsAsthma.php

FIG. 31.2  The early-­phase response in asthma is triggered when an allergen or irritant attaches to immunoglobulin E (IgE) receptors on mast cells, which are then activated to release histamine and other inflammatory mediators.

increased vasodilation and permeability, and epithelial damage. Clinically, the effects are bronchospasm, increased mucus secretion, edema formation, and increased amounts of tenacious sputum (see Figure 31.1), which cause wheeze, cough, sensation of chest tightness, shortness of breath, or a combination of these symptoms. This immediate response peaks within 30 to 60 minutes after exposure to the trigger (e.g., allergen, irritant) and subsides in another 30 to 90 minutes. The late-­phase response can be more severe than the early-­ phase response. It peaks 5 to 12 hours after exposure and may last from several hours to days. Its primary characteristic is inflammation as opposed to bronchial smooth muscle contraction. Eosinophils and neutrophils, the inflammatory cells involved in asthma, infiltrate the airways. These cells can subsequently release mediators that induce further inflammation and cause mast cells to degranulate, thereby causing the release of histamine and other mediators and initiating a self-­sustaining cycle. Corticosteroids are effective in preventing this cycle and reversing it, if needed. These inflammatory characteristics of a late-­phase response increase airway reactivity, which may lower the threshold of exposure necessary to induce a future asthma attack and cause its symptoms to worsen. The affected person becomes hyper-­ responsive to allergens and nonspecific stimuli such as air pollution, cold air, and dust. In summary, prominent pathophysiological features of asthma are a reduction in airway diameter and an increase in airway resistance that are related to mucosal inflammation, constriction of bronchial smooth muscle, and excess production of mucus (Figure 31.3). Accompanying these changes are hypertrophy of bronchial smooth muscle, thickening of basement membrane, hypertrophy of mucous glands, secretion of thick and tenacious sputum, hyperinflation, and air trapping in the alveoli, all of which increase the work of breathing. As a consequence of these events, respiratory muscle function

may be altered, distribution of both ventilation and perfusion may be abnormal, and arterial blood gas (ABG) values may be altered, depending on the severity of the disease. While asthma is considered a disease of the airways, during an asthma attack, eventually all aspects of pulmonary function are compromised. If airway inflammation is not treated or does not resolve, progressive and irreversible lung damage may eventually occur. This irreversible airway obstruction is thought to be the result of inflammation-­induced structural changes called airway remodelling (Global Initiative for Asthma [GINA], 2020). 

Triggers of Asthma Attacks Although the exact mechanisms that cause airway hyper-­ responsiveness and inflammation remain unknown, multiple stimuli or triggers are involved (Table 31.1; see Figure 31.1). Numerous allergens, chemicals, and infectious pathogens can trigger airway inflammation, which leads to airway narrowing and appearance of symptoms. These triggers are discussed in the following sections. Allergens.  Some people with asthma have an exaggerated immunoglobulin E (IgE) response to certain allergens (e.g., dust, pollen, grasses, mites, roaches, moulds, animal dander, latex). These allergens attach to IgE receptors on mast cells (see Figure 31.2). The IgE–mast cell complexes remain for a long time; therefore, a second exposure to the allergen triggers mast cell degranulation even years after the initial exposure to the allergen. Patients with allergic rhinitis or atopic dermatitis should be asked specifically about any incidence of respiratory symptoms (GINA, 2020). Allergic reactions are discussed further in Chapter 16.  Tobacco and Marijuana Smoke.  Smoke is an air pollutant; exposure to smoke of any kind—tobacco, marijuana, forest fires, or campfire—can be harmful for a person with asthma (Asthma Canada, 2019). Tobacco smoking is associated with the onset of asthma symptoms, a faster decline in lung function, increased disease severity, more frequent visits to a health care provider, and a decreased response to treatment. The smoke exhaled by a smoker, known as secondhand smoke, is also a risk factor for an asthma attack. Tobacco misuse is a term used to describe the

CHAPTER 31  Nursing Management: Obstructive Pulmonary Diseases TABLE 31.­1    TRIGGERS OF ASTHMA ATTACKS Allergens • Animal dander (e.g., from cats, dogs, horses, mice, guinea pigs) • Household dust mites • Cockroaches • Pollens • Moulds • Air pollutants • Diesel particulates • Exhaust fumes • Perfumes • Ozone • Sulphur dioxides • Cigarette smoke • Aerosol sprays Viral upper respiratory infection Sinusitis Exercise Cold, dry air Stress

Hormones or menses Gastroesophageal reflux disease (GERD) Medications • Acetylsalicylic acid (ASA; Aspirin) • Nonsteroidal anti-­inflammatory medications • β  -­Adrenergic blockers Occupational exposure • Agriculture • Metal salts • Wood and vegetable dusts • Industrial chemicals and plastics (isocyanates) • Pharmaceutical medications Food additives • Sulphites (bisulphites and metabisulphites) found in beer, wine, dried fruit, shrimp • Monosodium glutamate • Tartrazine

recreational use of cigarettes, pipes, chewing tobacco, snuff, and electronic cigarettes; use of traditional tobacco by Indigenous people, however, is not considered tobacco misuse. Among Indigenous people, traditional tobacco is used in medicinal and ceremonial contexts and is intended to establish a direct link with the spiritual world; it is not used for inhalation purposes. The rate of smoking is two to five times higher among Indigenous people than among non-­Indigenous Canadians (Canadian Partnership Against Cancer, 2019). Marijuana smoke contains many of the same chemicals that tobacco smoke has and can cause many existing lung conditions to worsen (American Thoracic Society, 2017). Marijuana may be inhaled through a multitude of ways, including joints, electronic cigarettes, water bongs, and vaporizers. None of these delivery devices are considered safe (American Thoracic Society, 2017).  Exercise.  Acute airway narrowing that is induced or exacerbated during physical exertion is referred to as exercise-­ induced asthma or exercise-­induced bronchospasm (EIB). While EIB affects a substantial proportion of patients with an asthma diagnosis, EIB can also be experienced by people who do not have the clinical features or diagnosis of asthma (Cote et  al., 2018). Typically, EIB occurs after, not during, vigorous exercise and is characterized by bronchospasm (airway smooth muscle contraction) that causes shortness of breath, cough, wheeze, a sensation of chest tightness, or a combination of these. EIB is pronounced during activities in cold, dry air. Airway hyper-­ responsiveness may result from changes in the airway mucosa caused by the hyperventilation that occurs during exercise with either the cooling or rewarming of air and capillary leakage in the airway wall. Several strategies can be incorporated to prevent EIB: an adequate warm-­up period before the activity begins, breathing through a scarf or mask during exercise in a cold or dry climate to promote humidification, and using inhaled short-­acting β2-­ adrenergic agonists either to relieve the symptoms or, 15 minutes before exercising, to prevent symptoms. Too frequent use of β2-­adrenergic agonists indicates poor asthma control, may mask asthma severity, and may cause a reduction in medication effectiveness. In such cases, patients may need escalation of

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therapy. (Control criteria and controller therapy are discussed later in this chapter.)  Respiratory Infections.  Respiratory infections (particularly viral) are among the most common triggers of worsening asthma. Infections cause increased inflammation in the tracheobronchial system, resulting in increased airway hyper-­ responsiveness, which can last from 2 to 8 weeks after infection both in individuals with asthma and in those without asthma. Patients with asthma should take steps to reduce the possibility of infections by using proper hand hygiene and receiving an annual influenza vaccination. Influenza vaccines are recommended for patients with asthma aged 6 months and older, especially because of the prevalence of high-­risk influenza-­ related complications in patients with asthma (PHAC, 2019a). Indigenous communities that have poor housing conditions, overcrowding, and high rates of indoor tobacco use, dampness, and mould are at significant risk for increased respiratory symptoms. Indigenous people (identifying as North American Indian, First Nation, Metis, or Inuit) have 1.5 greater odds of being hospitalized for asthma compared to non-­Indigenous people when housing is reported to be in need of major repairs (Carriere et al., 2017). Statistics Canada Census of the Population 2016 reported that one in five Indigenous people in Canada live in a home in need of repairs, and 18.3% live in overcrowded housing (Statistics Canada, 2017).  Nose and Sinus Conditions.  Some patients with asthma have chronic sinus and nasal conditions. Nasal conditions include allergic rhinitis, either seasonal or perennial, and nasal polyps. Sinus conditions are usually related to inflammation of the mucous membranes, most commonly from noninfectious causes such as allergies. However, bacterial sinusitis may also occur. It is important to treat these comorbid conditions because they often contribute to poor asthma control. (Sinusitis is discussed further in Chapter 29.)  Medications and Food Additives.  Some patients with asthma, especially those with nasal polyps, may have sensitivity to specific medications. Some people with asthma have what is termed the asthma triad: nasal polyps, asthma, and sensitivity to acetylsalicylic acid (ASA; Aspirin) and nonsteroidal anti-­inflammatory drugs (NSAIDs). Salicylic acid can be found in many over-­the-­counter medications and some foods, beverages, and artificial flavours. In some asthmatic patients, wheezing develops within 2 hours after they take ASA (Aspirin) or NSAIDs (e.g., ibuprofen [Motrin]). In addition, most affected patients have profound rhinorrhea, congestion, and tearing. Facial flushing, gastrointestinal symptoms, and angioedema can also occur. Although sensitivity to salicylates persists for many years, the nature and severity of the reaction can change over time. These patients should avoid taking ASA (Aspirin) and NSAIDs. However, patients with ASA (Aspirin) sensitivity can, under the care of an allergist, be desensitized by daily administration of the medication (Cortellini et al., 2017). Such patients may be more likely to benefit from antileukotriene medications (further discussed later under Medication Therapy). β-­Adrenergic blockers in oral form (e.g., metoprolol) or topical eye drops (e.g., timolol [Timoptic]) may trigger asthma episodes because they induce bronchospasm. Angiotensin-­ converting enzyme inhibitors (e.g., lisinopril) may induce cough in susceptible individuals, thus worsening asthma symptoms. Other irritants that may precipitate asthma symptoms in

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SECTION 5  Conditions of Oxygenation: Ventilation

susceptible patients are tartrazine (yellow dye no. 5, found in many foods) and sulphites (e.g., sodium metabisulphite), which are widely used in the food and pharmaceutical industries as preservatives and sanitizing agents. Sulphites are commonly found in fruits, beer, and wine and are used extensively in salad bars to protect vegetables from oxidation. These medications and food additives are thought to interfere with metabolic pathways, resulting in enhanced production of leukotrienes, some of which are potent bronchoconstrictors. The onset of a typical reaction occurs 15 minutes to 3 hours after ingestion and is marked by profuse rhinorrhea, often accompanied by nausea, vomiting, intestinal cramps, and diarrhea. An acute episode of asthma typically begins after the nasal symptoms appear. Food allergies triggering asthma reactions in adults are rare. Avoidance diets are not recommended until testing has proven an allergy is present. Gastroesophageal Reflux Disease.  The exact mechanism by which gastroesophageal reflux disease (GERD) triggers asthma is unknown. It is postulated that reflux of stomach acid into the esophagus can be aspirated into the lungs, which causes reflex vagal stimulation and bronchoconstriction. Although GERD is involved primarily in nocturnal asthma, it can trigger daytime asthma as well. By monitoring esophageal pH and peak expiratory flow rate (PEFR) simultaneously, the examiner can determine whether GERD is the cause of the asthma symptoms. H2-­histamine blockers or proton pump inhibitors are given to ameliorate symptoms. (GERD is discussed further in Chapter 44.)  Genetics.  Asthma has an inherited component, but the genetics are complex. Numerous genes may be involved in the development of asthma. They are likely responsible for varying responses among patients to different types of asthma medications. Atopy, the genetic predisposition to develop an allergic (IgE-­mediated) response to common allergens, is a major risk factor for asthma.  Air Pollutants.  Various air pollutants such as wood smoke, vehicle exhaust, diesel particulate, elevated ozone levels, sulphur dioxide, and nitrogen dioxide can trigger asthma attacks. Ongoing studies are being done to better understand how chronic exposure to urban air pollution and to “hotspots” of air pollution within Canadian cities affects people who work and live in these areas. The Air Quality Health Index (AQHI) was developed by the Government of Canada (2019) as a tool to help alert the public of health risks posed by air pollution (Figure 31.4).  Emotional Stress.  Asthma is not a psychosomatic disease. However, physiological stress that elicits emotional responses such as crying, laughing, anger, and fear can lead to hyperventilation and hypocapnia, which can cause airway narrowing (GINA, 2020). An asthma exacerbation can produce panic and anxiety, which are not unexpected emotions during this experience. Panic is a normal response to not being able to breathe. The extent to which psychological factors contribute to the induction and continuation of any given acute exacerbation is unknown, but it probably varies from patient to patient and in the same patient from episode to episode. 

Clinical Manifestations Asthma has an unpredictable, episodic, and variable course. Recurrent episodes of wheezing, breathlessness, sensation of chest tightness, coughing, or a combination of these, particularly at night and in the early morning (typically between 0200 and 0500 hours), are common features. The onset of an attack

1

2

3

Low Risk (1-3)

4

5

Moderate Risk (4-6)

6

7

8 High Risk (7-10)

9

10

+ Very High Risk

FIG. 31.4  The Air Quality Health Index (AQHI) is measured on a scale rang-

ing from 1 to 10+. The AQHI values are also grouped into health risk categories: 1 to 3 indicates low risk; 4 to 6, moderate risk; 7 to 10, high risk; and 10+, very high risk. These categories help patients easily and quickly identify their level of risk. Source: Courtesy Environment and Climate Change Canada (ECCC).

or episode of asthma may be abrupt (minutes) or more gradual (1 hour to days). Between attacks, the patient may have no symptoms, with normal or near-­normal pulmonary function, depending on the severity of disease. However, in some people, prolonged and uncontrolled asthma may result in compromised pulmonary function and chronic debilitation, resulting in irreversible or fixed airway disease. The characteristic clinical manifestations of asthma are wheezing, cough, dyspnea, and sensation of chest tightness after exposure to a precipitating factor or trigger. Expiration is often prolonged. The inspiratory–expiratory ratio, instead of being the normal 1:2, may be prolonged to 1:3 or 1:4. As a result of bronchospasm, edema, and mucus in the bronchioles, the airways become narrower, taking longer for the air to move out of the bronchioles. This produces the characteristic wheezing, air trapping, and hyperinflation. Wheezing is an unreliable sign for gauging the severity of an attack. Many patients with minor attacks wheeze loudly, whereas others with severe attacks do not wheeze. A patient with a severe asthma attack may have no audible wheezing because of the marked reduction in airflow. For wheezing to occur, the patient must be able to move enough air to produce the sound. Wheezing usually occurs first on exhalation. As an asthma attack progresses, the patient may wheeze during inspiration and expiration. Severely diminished breath sounds or their absence, often referred to as a “silent chest,” is an ominous sign of severe obstruction and impending respiratory failure. During an acute attack, the person with asthma usually sits upright or slightly bent forward and uses the accessory muscles of respiration in an attempt to make breathing easier. The more difficult the breathing becomes, the more anxious the patient feels. SAFETY ALERT

• If a patient has been wheezing but the wheeze abruptly disappears (i.e., silent chest) and the patient is obviously in distress, the situation has become life-­threatening and may necessitate mechanical ventilation.

In some patients with asthma, cough is the only symptom, which is termed cough variant asthma. The bronchospasm may not be severe enough to cause airflow obstruction, but it can increase bronchial tone and cause irritation and stimulation of the cough receptors. The cough may be nonproductive. Mobilizing secretions may be difficult as a result of their thick, tenacious, gelatinous quality. In patients experiencing an acute attack of moderate or severe asthma, examination usually reveals signs of hypoxemia, which may include restlessness, increased anxiety, inappropriate behaviour, increased pulse and blood pressure, and pulsus paradoxus (a drop in systolic pressure during the inspiratory cycle

CHAPTER 31  Nursing Management: Obstructive Pulmonary Diseases of more than 10 mm Hg). The respiratory rate is significantly increased (usually >30 breaths/minute), and the use of accessory muscles is evident. The patient also has difficulty speaking in complete sentences; typically, they are able to complete only two to five words without requiring another breath. Percussion of the lungs indicates hyper-­resonance, and auscultation indicates the presence of inspiratory or expiratory wheezing. 

Asthma Control and Severity A dynamic continuum of treatment is used to manage asthma. With this approach, medication therapy can be adapted to the severity of the underlying illness and the current level of asthma control. The concepts of asthma “control” and “severity” are related to each other but not correlated (GINA, 2020). For example, even severe asthma may be well controlled, whereas mild disease may remain uncontrolled. Optimal asthma control is defined by the absence of both asthma symptoms and the need for rescue bronchodilator, as well as by normal pulmonary function; however, this is difficult to achieve in all patients with asthma. According to the Guidelines for Asthma in Adults, treatment needs should be based on achieving acceptable asthma control at the lowest step in the stepwise approach to treatment, which is determined through clinical and physiological criteria (BC Guidelines.ca, Guidelines and Protocols Advisory Committee, 2015; Lougheed et al., 2012) (Table 31.2). Asthma control is obtained through treatment of modifiable risk factor comorbidities (e.g., smoking cessation and increased physical activity), use of written asthma action plans, self-­management education and skills training, and pharmacotherapy tailored to the individual (GINA, 2020). Asthma control must be assessed regularly and treatment adjusted accordingly. The severity of asthma is determined from the frequency and duration of symptoms, the presence of persistent airflow limitation, and the medication required to maintain control (Lougheed et al., 2012). When asthma is well controlled, severity is gauged by level of treatment required to maintain the state of acceptable control (GINA, 2020). Signs of severe or poorly controlled asthma include a history of a previous near-­fatal asthma episode (loss of consciousness, need for intubation), recent hospitalization or recent emergency department visit for asthma, nighttime symptoms, limitations in daily activities, and the need for inhaled β2 agonists several times each day or night. Asthma severity levels can change for better or worse over the course of a patient’s life. This is particularly true for children with asthma, as severity often decreases as the child gets older. When asthma control is good, patients have minimal to no symptoms, are able to sleep through the night, and participate in sports, exercise, and strenuous activity. Once asthma has been kept under control for at least 3 months with a corresponding plateau in lung function, an attempt should be made to reduce medication dosages while maintaining acceptable asthma control (GINA, 2020). Status Asthmaticus.  A life-­threatening medical emergency, status asthmaticus is the most extreme form of an acute asthma attack. It is characterized by hypoxia, hypercapnia, and acute respiratory failure. Of the people with asthma admitted to the hospital, approximately 3 to 5% require ventilatory assistance in the critical care unit, as they are unresponsive to bronchodilation and corticosteroid treatment. Common causes of severe acute attacks include viral illnesses, increases in environmental pollutants or other allergen exposure, food allergy, outdoor air pollution, seasonal changes, poor adherence to inhaled

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TABLE 31.­2    ASTHMA CONTROL CRITERIA Characteristic

Frequency or Value

Daytime symptoms Nighttime symptoms Physical activity Exacerbations Absence from work or school because of asthma Need for a fast-­acting β2 agonist FEV1 or PEF PEF diurnal variation* Sputum eosinophils†