Nurse’s 5-Minute Clinical Consult: Treatments

509 Pages·2006·8.853 MB·English

by  Springhouse

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N U R S E’S
5-MINUTE
CLI N ICAL
CONSU LT
Treat ments
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STAFF The clinical treatments described and recom-
mended in this publication are based on re-
Executive Publisher
search and consultation with nursing, medical,
Judith A. Schilling McCann, RN, MSN and legal authorities. To the best of our knowl-
edge, these procedures reflect currently accept-
Editorial Director
ed practice. Nevertheless, they can’t be consid-
H. Nancy Holmes ered absolute and universal recommendations.
For individual applications, all recommenda-
Clinical Director
tions must be considered in light of the pa-
Joan M. Robinson, RN, MSN tient’s clinical condition and, before adminis-
Senior Art Director tration of new or infrequently used drugs, in
light of the latest package-insert information.
Arlene Putterman
The authors and publisher disclaim any re-
Art Director sponsibility for any adverse effects resulting
from the suggested procedures, from any unde-
Elaine Kasmer
tected errors, or from the reader’s misunder-
Editorial Project Manager standing of the text.
Jennifer Kowalak © 2007 by Lippincott Williams & Wilkins. All
rights reserved. This book is protected by copy-
Clinical Project Manager
right. No part of it may be reproduced, stored in
Carol A. Saunderson, RN, BA, BS a retrieval system, or transmitted, in any form
Editors or by any means—electronic, mechanical, pho-
tocopy, recording, or otherwise—without prior
Naina D. Chohan, Julie Munden
written permission of the publisher, except for
Clinical Editors brief quotations embodied in critical articles
and reviews and testing and evaluation materi-
Joanne M. Bartelmo, RN, MSN; Collette als provided by publisher to instructors whose
Bishop Hendler, RN, BS, CCRN; Jennifer schools have adopted its accompanying text-
Meyering, RN, MS, CCRN; Kate McGovern book. Printed in the United States of America.
Stout, RN, MSN, CCRN; Beverly Ann For information, write Lippincott Williams &
Tscheschlog, RN, BS Wilkins, 323 Norristown Road, Suite 200,
Ambler, PA 19002-2756.
Copy Editors
NCCTREAT010906
Kimberly Bilotta (supervisor), Scotti Cohn,
Tom DeZego, Heather Ditch, Amy Furman,
Library of Congress
Pamela Wingrod Cataloging-in-Publication Data
Designers Nurse's 5-minute clinical consult treatments.
Jan Greenberg (project manager), BJCrim, p. ; cm.
Joseph John Clark Includes bibliographical references and index.
1. Nursing—Handbooks, manuals, etc. 2.
Digital Composition Services Clinical medicine—Handbooks, manuals, etc. I.
Diane Paluba (manager), Joyce Rossi Biletz, Lippincott Williams & Wilkins. II. Title: Nurse's
Donald G. Knauss, Donna S. Morris five-minute clinical consult treatments.
[DNLM: 1. Nursing Care—methods—Hand-
Manufacturing books. 2. Clinical Medicine—Handbooks. 3.
Beth J. Welsh Therapeutics—Handbooks. WY 49 N972955
2007]
Editorial Assistants
RT51.N87 2007
Megan L. Aldinger, Karen J. Kirk, 610.73—dc22
Linda K. Ruhf ISBN 1-58255-512-5 (alk. paper) 2006017482
Indexer
Barbara Hodgson
5125 FM.qxd 8/15/08 9:36 AM Page iii
Contents
Contributors and consultants iv
TREATMENTS
A toZ 2
Appendices 477
Alternative and complementary treatments 478
Cosmetic treatments 481
Index 485
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Contributors and consultants
Lillian Craig,RN,MSN,FNP-C Ann S.McQueen,RNC,MSN,CRNP
Instructor Family Nurse Practitioner
Oklahoma Panhandle State University Health Link Medical Center
Goodwell Southampton, Pa.
Colleen Davenport,RN,C,MSN Noel C.Piano,RN,MS
Consultant Instructor Lafayette School of Practical
Renton, Wash. Nursing
Vivian Gamblian,RN,MSN Adjunct Faculty
Thomas Nelson Community College
Professor of Nursing
Williamsburg, Va.
Collin County Community College
District Kendra S.Seiler,RN,MSN
McKinney, Tex. Nursing Instructor
Timothy Hudson,RN,BSN,MS,MEd Rio Hondo College
Whittier, Calif.
Chief Nurse, 274th Forward Surgical Team
U.S. Army Kelley Straub,RN,BSN,CCRN,RCIS
Fort Bragg, N.C. Critical Care Nurse
Julia A.Isen,RN,MS,FNP-C Intelistaff
Bala Cynwyd, Pa.
Nurse Practitioner (primary care)
Assistant Clinical Professor Allison J.Terry,RN,MSN,PhD
University of California Director, Center for Nursing
San Francisco Alabama Board of Nursing
Patricia Lemelle-Wright,RN,MS Montgomery
Staff Nurse/Clinical Instructor-Educator Brenda Williams,MSN
University of Chicago Hospital and Director of Student Health/Assistant
Malcolm X Community College Professor
Albany (Ga.) State University
iv
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NURSE’S
5-MINUTE
CLINICAL
CONSULT
Treatments
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Abdominal aortic aneurysm repair or resection
fluid and blood and possible adminis-
OVERVIEW PROCEDURE
tration of I.V.propranolol (Inderal) to
reduce myocardial contractility.An
◆Abdominal aortic aneurysm (AAA): OPEN SURGICAL REPAIR arterial line and indwelling urinary
abnormal widening of the distal de- ◆AAAs usually require resection and catheter are also placed.
scending part of the aorta; descend- replacement of the aortic section ◆Left-sided heart failure
ing aorta subdivided into thoracic with a vascular (patient’s or donor ◆Arrhythmias
(above diaphragm) and abdominal vein) or polymer (polytetrafluoroeth- ◆Myocardial infarction
(below diaphragm down to iliac ar- ylene, Dacron, Teflon, or Gore-Tex) ◆Renal failure
teries) synthetic graft. ◆Acute tubular necrosis
◆May be saccular (outpouching), ◆Surgery requires general anesthesia. ◆Ileus or bowel rupture
fusiform (spindle shaped), or dissect- ◆Abdominal incision is made to ex- ◆Pancreatitis
ing in form pose the aneurysm site, and clamps ◆Ischemia of the left colon
◆95% of AAAs caused by pattern of in- are applied to the aorta above and ◆Paralysis due to spinal cord ischemia
flammatory changes within the arte- below the aneurysm. ◆Lower-extremity ischemia or em-
rial walls with weakening of the mus- ◆The aneurysm sac is opened and the bolization
cular architecture (which can resem- aneurysm is resected. ◆Infection such as peritonitis, catheter
ble atherosclerotic changes); re- ◆A prosthetic graft is sewn into place insertion site
maining AAAs the result of congeni- and carefully tested for leakage. ◆Aortic dissection or perforation
tal cystic medial necrosis, trauma, ◆Endovascular graft migration
syphilis, or other inflammatory or in- ENDOVASCULAR REPAIR
fectious disease processes ◆Uncomplicated AAAs beginning be-
◆Mortality greatly reduced by repair
low the left renal artery may be re-
and resection techniques, which can
paired endovascular grafting.
be performed by open surgery or ◆This procedure is performed under
minimally invasive (endovascular) fluoroscopy with a local or regional
surgery anesthetic. Repairing an AAA with
endovascular grafting
◆The access site in the femoral or iliac
INDICATIONS
artery is prepared.
◆Large (greater than 4 cm diameter) or ◆A delivery catheter with an attached Endovascular grafting (shown below) is a
symptomatic aneurysms (symptoms compressed graft is inserted over a minimally invasive procedure for the pa-
may be result of aneurysmal infec- guide wire. tient who requires repair of an abdominal
tion, adherence to or bleeding into ◆The delivery catheter is advanced to aortic aneurysm (AAA).
nearby abdominal organs, or slow or the aorta, where it’s positioned The patient is instructed to walk the first
rapid leaking into the abdominal across the aneurysm. day after surgery and is discharged from
cavity) ◆A balloon inside the graft expands the hospital in 1 to 3 days.
the aortic and right femoral seg-
ments and affixes them to the vessel
walls where they’re sewn in place.
(See Repairing an AAA with endovas-
cular grafting.)
◆Before elective surgery, such medica-
tions as I.V. nitroprusside (Nitro-
press) to maintain blood pressure at
100 to 120 mm Hg systolic and an
analgesic to relieve pain may be re-
quired.
COMPLICATIONS
◆Hemorrhage and shock from
aneurysm repair or rupture
WARNING Rupture of an AAA is a
medical emergency requiring
prompt surgical intervention.Other
emergency procedures initiated before
or during surgery are replacement of
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◆Insert an arterial line to allow for
NURSING DIAGNOSES PATIENT TEACHING
continuous blood pressure monitor-
ing.
◆Acute pain ◆Assist with insertion of a pulmonary GENERAL
◆Ineffective tissue perfusion: artery catheter to assess hemody- ◆Provide psychological support for the
Peripheral namic balance if ordered. patient and his family.
◆Risk for infection ◆Observe the patient for signs of rup- ◆Reinforce instructions for controlling
ture, including decreasing blood hypertension; stress the importance
EXPECTED OUTCOMES pressure; increasing pulse and respi- of medication and diet therapy and
The patient will: ratory rates; cool, clammy skin; rest- the need for smoking cessation.
◆express feelings of comfort and relief lessness; and decreased sensorium. ◆Instruct the patient to take all med-
from pain ◆Prepare the patient for preoperative ications as prescribed and to carry a
◆maintain present and strong periph- abdominal computed tomography list of them at all times in case of an
eral pulses without skin color or tem- scan, magnetic resonance imaging, emergency.
perature change or angiography to assist the surgeon ◆Advise the patient about activity
◆show no evidence of infection. in locating landmarks and involve- restrictions, such as no pushing,
ment of other nearby tissues. pulling, or lifting heavy objects, until
◆Administer ordered medications to the physician allows him to do so.
PRETREATMENT CARE prevent aneurysm progression.
Provide an analgesic to relieve pain, RESOURCES
◆Explain the treatment and prepara- if present. Organizations
tion to the patient and his family. On ◆If rupture occurs, insert a large-bore American College of Surgeons:
admission to the critical care unit, I.V. catheter, begin fluid resuscita- www.facs.org
help ease their fears about this type tion, and administer propranolol I.V. Society of Vascular Surgery:
to reduce left ventricular ejection ve- www.vascularweb.org
of care, the threat of impending rup-
locity as ordered. Expect to adminis-
ture, and planned surgery. Take time
ter additional doses every 4 to 6 Selected references
to provide appropriate explanations
hours until oral medications can be Kukreja, N. “Randomized Clinical Trial of
and to answer questions.
used. Vertical or Transverse Laparotomy for
◆Verify that the patient has signed an
◆Prepare the patient for elective sur- Abdominal Aortic Aneurysm Repair,”
appropriate consent form.
gery, as indicated, or emergency sur- British Journal of Surgery93(2):251,
◆Assess the patient’s vital signs, espe-
gery if rupture occurs. February 2006.
cially blood pressure, every 2 to 4 Kunihara, T., et al. “The Less Incisional
hours or more frequently, depending Retroperitoneal Approach for Abdomi-
on the severity of his condition. POSTTREATMENT CARE nal Aortic Aneurysm Repair to Prevent
◆Monitor blood pressure and pulses Postoperative Flank Bulge,” Journal of
inthe extremities, and compare Cardiovascular Surgery (Torino)
findings bilaterally. If the difference ◆Perform pulmonary hygiene meas- 46(6):527-31, December 2005.
in systolic blood pressure exceeds ures, including suctioning, chest Nano, G., et al. “Sac Enlargement Due to
10mm Hg, notify the physician im- physiotherapy, and deep-breathing Seroma After Endovascular Abdominal
mediately. exercises. Aortic Aneurysm Repair with the En-
◆Assess heart rate and rhythm fre- ◆Provide continuous cardiac monitor- dologix PowerLink Device,” Journal of
quently via telemetry; obtain 12-lead ing. Vascular Surgery43(1):169-71, January
electrocardiogram results and car- ◆Assess urine output hourly. 2006.
diac enzyme levels. ◆Maintain nasogastric tube patency to
◆Monitor kidney function by obtain- ensure gastric decompression.
ing blood urea nitrogen, creatinine, ◆Assist with serial Doppler examina-
and electrolyte levels and measuring tion of extremities to ensure that the
intake and output regularly. vascular area is healing properly and
◆Monitor complete blood count for that no emboli are present.
evidence of blood loss as indicated ◆Monitor the patient for signs and
by a decrease in hemoglobin level, symptoms of poor arterial perfusion,
hematocrit, and red blood cell count. such as pain, paresthesia, pallor,
◆Monitor liver function test results for pulselessness, paralysis, and cold-
signs of impaired perfusion. ness.
◆Obtain an arterial sample for arterial
blood gas analysis as ordered.
3
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Abdominal myomectomy
AGE FACTOR Uterine fibroids
OVERVIEW PROCEDURE
may cause complications,in-
cluding spontaneous abortion,
◆Surgery to remove large or sympto- preterm labor,malposition of the ◆A low horizontal (“bikini”) incision is
matic uterine leiomyomas—tumors uterus,and secondary infertility made in the abdomen, and the
composed of smooth muscle that (rare),in a woman of childbearing uterus is lifted through it.
usually occur in the uterine body, al- age. ◆The uterus is palpated to identify fi-
though may appear on the cervix or ◆Patients usually discharged from broids deep inside that may not be
on the round or broad ligament; also hospital within 48 hours of surgery visible.
called fibroids,myomas,and fibro- ◆Recovery varied; women whose work ◆A vasoconstrictive drug is injected
myomasand are classified according doesn’t require heavy lifting can re- into the uterus to shrink the blood
to location turn to work in 4 to 6 weeks vessels, and then a laser is used to in-
◆Location and removal of fibroids: cise the uterus so the fibroids can be
– Submucosal: inner surface of the INDICATIONS removed.
uterus; usually removed hystero- ◆Abnormal and extensive uterine ◆Each fibroid is carefully dissected
scopically (vaginally with a resecto- from the muscular portion of the
bleeding
scope) ◆Abdominal pressure and impinge- uterus (myometrium) until the blood
– Subserosal: outer surface of the supply to the fibroid can be identi-
ment on adjacent viscera resulting in
uterus; may be pedunculated fied. Special care is taken in tying,
mild hydronephrosis, bladder com-
(stemmed; on a stalk), commonly re- cauterizing, and suturing these ves-
pression, or bowel obstruction
moved laparoscopically, through sev- ◆Abdominal pain associated with tor- sels to prevent bleeding.
eral small incisions in the abdomen ◆The uterine walls are sutured togeth-
sion of a pedunculated subserous fi-
– Intramural: deep within the muscu- er with dissolving sutures. This is
broid or a fibroid undergoing degen-
lar wall of the uterus; generally re- done in many layers to ensure
eration
moved by abdominal myomectomy; ◆Anemia secondary to excessive greater strength of the repair.
for the patient not concerned about ◆A special nonadhesive cloth barrier
bleeding
future childbearing, hysteroscopic ◆Infection (if tumor protrudes out of to prevent adhesions is wrapped
myomectomy (alternative surgery) around the uterus. This material dis-
the vaginal opening)
performed vaginally (see Under- integrates in about 2 weeks, when
standing hysteroscopic myomectomy) sufficient healing has occurred to
◆Preserves uterus for future childbear- prevent most adhesions.
ing as opposed to hysterectomy for ◆The uterus is replaced into the ab-
fibroids domen and the incision is closed.
COMPLICATIONS
Understanding hysteroscopic myomectomy ◆Excessive bleeding and hemorrhage
◆Ruptured uterus during pregnancy
Submucosal (and some in- if inadequate surgical closing (in-
tramural) myomas can be creased risk with laparoscopic proce-
removed by inserting a re- dure)
sectoscope,a special type Submucosal Resectoscope ◆Accidental laceration or perforation
of hysteroscope,through fibroid loop of nearby organs
the vagina and cervix and ◆Smaller fibroids, which may likely be
into the uterus.The resecto- left behind if a laparoscopic ap-
scope has a wire loop or a proach is used
roller-type tip that directs ◆Adhesion formation
high-frequency electrical
◆Ureter damage from laceration, inad-
energy to ablate the fibroid.
vertent ligation of the ureter, com-
The fibroid tissue can be
pression, or puncture (rare)
seen through the resecto-
scope’s telescopic-like lens. ◆Blood clot formation
◆Continued menorrhagia despite
treatment
Resectoscope ◆Infertility
◆Infection
4
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NURSING DIAGNOSES PRETREATMENT CARE PATIENT TEACHING
◆Acute pain ◆Explain the treatment and prepara- GENERAL
◆Deficient knowledge (disorder and tion to the patient and her family. ◆Be sure to cover the importance of
treatment) ◆Verify that the patient has signed an reporting abnormal bleeding or
◆Risk for deficient fluid volume appropriate consent form. pelvic pain immediately, and the im-
◆Send a blood sample for type and portance of receiving regular gyneco-
EXPECTED OUTCOMES cross-matching because blood trans- logic examinations.
The patient will: fusions may be necessary. ◆Reassure the patient that abdominal
◆report increased comfort and de- ◆Administer a gonadotropin-releasing myomectomy doesn’t cause prema-
creased pain hormone agonist to suppress pitu- ture menopause because the ovaries
◆verbalize an understanding of the itary gonadotropin release, reducing are left intact.
disorder and its treatment the size of the uterine fibroid if or- ◆Review prescribed medications with
◆maintain normal blood pressure and dered. her, including dosage and possible
heart rate, intake and output, and ◆Reinforce teaching about the proce- adverse effects; in a patient with se-
adequate peripheral pulses. dure and posttreatment care. vere anemia from excessive bleeding,
an iron supplement may be adminis-
tered.
POSTTREATMENT CARE ◆Reassure women of childbearing age
that pregnancy may still be possible
◆Monitor the patient for signs of if desired. Explain, however, that a
bleeding. cesarean delivery may be necessary.
◆Monitor laboratory results, especially ◆Advise the patient about complica-
hemoglobin level and hematocrit. tions of blood transfusions.
◆Administer an analgesic, as ordered,
for pain. RESOURCES
◆Maintain patency of I.V. line. Record Organizations
intake and output, and monitor hy- American College of Obstetrics and
dration. Gynecology: www.acog.org
◆Monitor the patient’s vital signs, and Obstetrics, Gynecology, Infertility, and
report changes in trends. Women’s Health: www.obgyn.net
Selected references
Damiani, A., et al. “Laparoscopic Myo-
mectomy for Very Large Myomas Using
an Isobaric (Gasless) Technique,” Jour-
nal of the Society of Laparoendoscopic
Surgeons9(4):434-38, October-Decem-
ber 2005.
Huang, J.Y., et al. “Failure of Uterine Fi-
broid Embolization,” Fertility and
Sterility 85(1):30-35, January 2006.
West, S., et al. “Abdominal Myomectomy
in Women with Very Large Uterine
Size,” Fertility and Sterility85(1):36-39,
January 2006.
5
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Ablation therapy for arrhythmias
INDICATIONS
OVERVIEW PROCEDURE
◆Atrial fibrillation
◆Atrial flutter
◆Destroys (ablates) heart tissue that’s ◆Supraventricular tachycardia, includ- ◆The procedure is typically performed
creating a heart beat originating out- ing atrioventricular (AV) nodal under conscious sedation with an I.V.
side the sinoatrial node (an ectopic reentry and Wolff-Parkinson-White tranquilizer and opioid. General
foci) or permitting conduction of syndrome, and certain types of ven- anesthesia is used in children and se-
such foci (see Types of cardiac abla- tricular tachycardia lected adults undergoing surgical ab-
tion) lation.
◆Type of ablation performed depend- ◆A nonsurgical procedure generally
ent on the type of arrhythmia and takes place in the electrophysiology
the presence of other heart disease laboratory. The patient’s groin area is
shaved and his neck, upper chest,
arm, and groin are cleaned with anti-
Types of cardiac ablation
septic. Sterile drapes are placed over
the patient.
Cardiac ablation therapy depends on the ectopic foci in the heart muscle,obliterating ◆The physician numbs the insertion
specific ablative method and type of medical small portions of abnormal tissue by heat. site with an anesthetic.
procedure required.Here’s a list of common These areas also scar,permanently blocking ◆Two to five electrode catheters are in-
types of cardiac ablation: abnormal conduction.Newer radiofrequency serted via the femoral or internal
◆ Surgical ablation:This term is generally used ablation equipment comes with the capacity to jugular vein into the left side of the
to specify that the patient will be undergoing direct cooled saline to the area to reduce ex-
heart, the right side of the heart, or
surgical opening of the chest.It can refer to cessive heat production,making the procedure
both. The coronary sinus may also be
open heart with cardiopulmonary bypass or any more comfortable and safer.Most of these
entered to evaluate for left-sided ab-
of the newer techniques for open chest or procedures are carried out with minimally
normal conduction.
minimally invasive chest procedures.The invasive techniques through peripheral access
ablation technique itself may not involve direct sites,but can be done during other cardiac ◆Anticoagulation with I.V. heparin is
surgical incision of the heart. surgery as well. used to reduce the risk of thrombo-
◆ Minimally invasive ablation:Although this ◆ Microwave and ultrasound techniques: embolism.
term can be used as above,it generally means Microwave and high-frequency sound waves ◆The patient is connected to monitors
a procedure where peripheral access (femoral, are being used in several research hospitals to for electrocardiography, heart rate,
brachial,subclavian) to a vein is obtained determine if either of these methods of tissue blood pressure, pulse oximetry and,
followed by placement of several specialized destruction reduce the risks of ablation,such as possibly, hemodynamic monitoring.
catheters that provide intracardiac rhythm damage to adjacent tissues or stenosing of ◆After the catheters are in place, the
monitoring and a source of energy for ablation veins or arteries proximal to the ectopic tissue.
heart’s conduction system is assessed
of the cardiac tissue.This procedure generally These procedures are primarily done via
and present rhythm confirmed.
takes place in the electrophysiology laboratory peripheral access sites and specialized cathe-
◆During traditional ablation, the
instead of the operating suite. ters and monitoring leads.
physician uses a pacemaker to initi-
◆ The Maze or Cox-Maze III procedure:The ◆ Laser ablation:The increased technology of
gold standard for arrhythmia treatment,in- laser use has made delicate procedures,such ate the arrhythmia. Then the physi-
cluding atrial fibrillation,this procedure was as cardiac ablation,possible with small,very cian moves the catheters around the
originally only done during open heart surgery focused laser beams.The essential goals of the heart to determine the area of origin.
with cardiopulmonary bypass.The procedure procedure remain the same.There’s hope that When the physician finds the area,
can now be done in some patients via mini- this technique will be particularly useful for energy is applied to ablate the
mally invasive access to the beating heart atrial fibrillation by reducing the risk of pulmo- source.
through a smaller chest incision where endo- nary vein stenosis.The procedure can be done WARNING The patient may feel
scopes guide the surgical treatment.However, by peripheral access or during cardiac surgery. some discomfort or a burning
not all arrhythmias can be treated with this ◆ Cryoablation:This technique uses a special
sensation in the chest when the tissue
more limited access. extremely cold catheter tip to freeze and
is being destroyed,which may provoke
The surgeon makes several small, destroy tiny amounts of abnormally conducting
anxiety;determine if the patient
specifically located cuts in the heart muscle cardiac tissue.Still being studied extensively,
would like extra pain medication.Also
where abnormal impulses are originating based preliminary results show equal results com-
on intracardiac monitoring leads,leaving the pared to the Maze procedure,and equal com- remind him that the discomfort is
normal conduction pathways open.The cut plication rates.Cryoablation has been done by normal and ask him to lie quietly and
areas form scar tissue that then prevents the peripheral access and during other cardiac avoid taking deep breaths.
abnormal impulses from being conducted surgical procedures. ◆Atrial fibrillation is commonly treat-
through the heart. ed with pulmonary vein ablation
◆ Radiofrequency ablation:Instead of surgical where the tissue circling each en-
incisions,radio waves are directed to the trance to the four pulmonary veins is
6