Lewis’s medical–surgical nursing Assessment and Management of Clinical Problems FOURTH EDITION Australia and New Zealand Edition

FOURTH EDITION Lewis’s Australia and New Zealand Edition Di Brown Helen Edwards Lesley Seaton Thomas Buckley Sharon L. Lewis Shannon Ruff Dirksen Margaret McLean Heitkemper Linda Bucher Lewis’s FOURTH EDITION medical–surgical nursing Australia and New Zealand Edition EDITED BY Di Brown RN, PhD, MACN, AFCHSM Project Director, Sister Hospital Program, Royal Darwin Hospital, Darwin, NT, Australia and RSUP Sanglah, Denpasar, Bali, Indonesia Professorial Fellow, Charles Darwin University, Brinkin, NT, Australia Helen Edwards RN, PhD, FACN, FAAN, OAM Professor and Assistant Dean (International and Engagement), Institute of Biomedical Innovation, Queensland University of Technology, Brisbane, Qld, Australia Lesley Seaton PhD, MN, BN, Grad Dip Adult Education, Dip Midwifery, ICcert, RN Senior Lecturer and Program Director (International), School of Nursing and Midwifery, Griffith University, Brisbane, Qld, Australia Adjunct Associate Professor, School of Health Sciences, Canterbury University, Christchurch, New Zealand Thomas Buckley RN, BSc, MN, PhD Senior Lecturer/Co-ordinator Master of Nursing (Clinical Nursing & Nurse Practitioner), Sydney Nursing School, The University of Sydney, Sydney, NSW, Australia Adjunct Associate Professor, School of Health and Human Sciences, Southern Cross University, Lismore, NSW, Australia Sharon L Lewis Shannon Ruff Dirksen Margaret McLean Heitkemper Linda Bucher Sydney Edinburgh London New York Philadelphia St Louis Toronto Contents SECTION 1 Concepts in nursing practice 1 The importance of nursing 2 2 Patient safety and clinical reasoning: Thinking like a nurse 21 3 Health disparities and cultural care 32 4 Pain management 48 5 Palliative care 81 6 Substance use and dependency 97 7 Rural and remote area nursing 125 SECTION 2 Pathophysiological mechanisms of disease 8 Nursing management: Inflammation and wound healing 144 9 Genetics and genomics 164 10 Altered immune responses and transplantation 176 11 Nursing management: Infection and human immunodeficiency virus infection 200 12 Cancer 223 13 Nursing management: Fluid, electrolyte and acid–base imbalances 262 SECTION 3 Perioperative care 14 Nursing management: Preoperative care 294 15 Nursing management: Intraoperative care 312 16 Nursing management: Postoperative care 330 SECTION 4 Problems related to altered sensory input 17 Nursing assessment: Visual and auditory systems 356 18 Nursing management: Visual and auditory problems 375 19 Nursing assessment: Integumentary system 411 20 Nursing management: Integumentary problems 425 21 Nursing management: Burns 449 SECTION 5 Problems of oxygenation: Ventilation 22 Nursing assessment: Respiratory system 476 23 Nursing management: Upper respiratory problems 500 24 Nursing management: Lower respiratory problems 524 25 Nursing management: Obstructive pulmonary diseases 564 SECTION 6 Problems of oxygenation: Transport 26 Nursing assessment: Haematological system 616 27 Nursing management: Haematological problems 637 SECTION 7 Problems of oxygenation: Perfusion 28 Nursing assessment: Cardiovascular system 692 29 Nursing management: Hypertension 716 30 Nursing management: Coronary artery disease and acute coronary syndrome 737 31 Nursing management: Heart failure 775 32 Nursing management: ECG monitoring and arrhythmias 796 33 Nursing management: Inflammatory and structural heart disorders 820 34 Nursing management: Vascular disorders 843 SECTION 8 Problems of ingestion, digestion, absorption and elimination 35 Nursing assessment: Gastrointestinal system 876 36 Nursing management: Nutritional problems 900 37 Nursing management: Obesity 921 38 Nursing management: Upper gastrointestinal problems 941 39 Nursing management: Lower gastrointestinal problems 978 40 Nursing management: Liver, pancreas and biliary tract problems 1024 SECTION 9 Problems of urinary function 41 Nursing assessment: Urinary system 1066 42 Nursing management: Renal and urological problems 1086 43 Nursing management: Acute kidney injury and chronic kidney disease 1124 SECTION 10 Problems related to regulatory and reproductive mechanisms 44 Nursing assessment: Endocrine system 1160 45 Nursing management: Diabetes mellitus 1181 46 Nursing management: Endocrine problems 1221 47 Nursing assessment: Reproductive system 1250 48 Nursing management: Breast disorders 1272 49 Nursing management: Sexually transmitted infections 1298 50 Nursing management: Female reproductive problems 1315 51 Nursing management: Male reproductive problems 1348 SECTION 11 Problems related to movement and coordination 52 Nursing assessment: Nervous system 1376 53 Nursing management: Acute intracranial problems 1404 54 Nursing management: The patient with a stroke 1436 55 Nursing management: Chronic neurological problems 1459 56 Nursing management: Delirium, depression and dementia 1492 57 Nursing management: Peripheral nerve and spinal cord problems 1517 58 Nursing assessment: Musculoskeletal system 1546 59 Nursing management: Musculoskeletal trauma and orthopaedic surgery 1566 60 Nursing management: Musculoskeletal problems 1605 61 Nursing management: Arthritis and connective tissue diseases 1630 SECTION 12 Nursing care in specialised settings 62 Nursing management: Critical care environment 1670 63 Nursing management: Shock, systemic inflammatory response syndrome and multiple organ dysfunction syndrome 1706 64 Nursing management: Respiratory failure and acute respiratory distress syndrome 1730 65 Nursing management: Emergency care situations 1751 66 Chronic illness and complex care 1780 APPENDICES A Cardiopulmonary resuscitation and basic life support 1795 B Nursing diagnoses 1801 C Answer key to review questions 1803 D Image and text credits 1805 Index 1817 Preface The fourth Australian and New Zealand (ANZ) edition of Lewis’s Medical–Surgical Nursing: Assessment and Management of Clinical Problems builds on the combined strengths of the third ANZ edition and the ninth US edition. It has been written to address the needs of ANZ students and educators. Professors Di Brown and Helen Edwards, and Drs Lesley Seaton and Tom Buckley, led a team of nurse clinicians and academic contributors from across ANZ to develop this cutting-edge text. The fourth edition has been thoroughly revised and incorporates the most recent nursing knowledge in an engaging and reader-friendly format. More than a textbook, this is a comprehensive resource containing essential information that students need in order to prepare for lectures, classroom activities, examinations, clinical assignments and the professional care of patients. In addition to its accessible writing style and quality illustrations, the text provides special features—such as evidence-based practice boxes, review questions and clinical reasoning exercises—to facilitate student learning. Recurring topics include patient teaching guides, gerontological advice, management of chronic diseases, multidisciplinary care, cultural and ethnic considerations, nutrition, community- and home-based care, and nursing research. The use of the nursing process as an organising frame- work for nursing practice has been retained and new content has been added to reflect rapid changes in practice. Contributors have been selected for their expertise in specific areas, and clinical specialists have thoroughly reviewed each chapter to ensure accuracy, currency and regional relevance. From the outset, the text firmly establishes the ANZ sociocultural context and includes, for example, a chapter on current national patient safety priorities in ANZ (Ch 2), current information on rural and remote area nursing (Ch 7), as well as a framework for the management of chronic and complex conditions (Ch 66). In addition, this edition includes chapters on contemporary health issues such as obesity (Ch 37) and emergency and disaster nursing (Ch 65). Organisation The content is organised into 12 sections. Section 1 (Chs 1–7) introduces key healthcare concepts within Australia and New Zealand. Sections 2–12 (Chs 8–66) present nursing assessment and nursing management of medical and surgical patient problems both within acute care settings and within the community. The focus of each section is across the whole trajectory of healthcare, including health promotion, risk assessment, management of acute and chronic conditions, and the various nursing roles and responsibilities, as well as the roles of the whole multidisciplinary healthcare team. The various body systems are grouped to reflect their interrelated functions. Each section is organised around two central themes: assessment and management. Chapters dealing with assessment of a body system include a discussion of the following: 1. a brief review of anatomy and physiology, focusing on information that will promote an understanding of nursing care 2. health history and non-invasive 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, signs and symptoms, diagnostic study results, multidisciplinary care and nursing management of various diseases and disorders. The sections on nursing management are organised into assessment, identification of priority care problems, planning, implementation and evaluation. To emphasise the importance of patient care in various clinical settings, nursing implementation of all major health problems is organised by the following levels of care: 1. health promotion 2. acute intervention 3. ambulatory and community/home care. Classic features • Critical thinking, clinical judgement and clinical reasoning (introduced in Ch 2) provide a framework to enable students to think about patient situations effectively. The use of multiple case studies at the end of each section enables students to practise prioritising care between a number of different patients. The multiple case studies and the individual ones in the assessment and management chapters are structured so that students need to use their clinical reasoning and judgement skills to plan and outline care priorities. Key delegation decisions are included to enable the student to begin to more clearly understand the responsibilities of the registered nurse. • National patient safety goals for both New Zealand and Australia are introduced in the new Chapter 2 of the text, which are then addressed in more detail in relevant chapters throughout the text. Important patient safety information such as drug interactions are highlighted within specific chapters. • Key epidemiological information is provided to enable students to understand the incidence and prevalence of the various conditions in the Australian and New Zealand context. • Priority care problems outlined in each of the management chapters illustrate the multidisciplinary nature of contemporary healthcare. • Multidisciplinary care is further highlighted in special multidisciplinary care sections in all management chapters and more than 80 multidisciplinary care boxes and tables throughout the text. • The whole trajectory of care is included. Chapters include prevention and health promotion, through the xxi xxii PREFACE acute care phase into rehabilitation and chronic disease management where appropriate. These chapters have been thoroughly updated to reflect current nursing practice and include defining characteristics, expected patient outcomes, specific nursing interventions with rationales and multidisciplinary care. The book is structured to enable students of nursing to gain a comprehensive understanding of the nursing role and the differences (and similarities) in nursing and other healthcare roles and functions. The information and structure of the chapters increases students’ understanding about the multidisciplinary nature of current healthcare practice and the roles that nurses play. • Patient and carer education is an ongoing theme throughout the text. Coverage includes more than 80 patient teaching guides throughout the text. • Gerontological differences are included in each chapter where the differences in assessment and the effects of ageing are detailed. Chapter 56 provides a thorough explanation about delirium, dementia and depression in older adults who are admitted to an acute care setting. • Nutrition is highlighted throughout the book and includes a separate chapter (Ch 36). Nutritional therapy boxes and tables summarise nutritional interventions for patients with various health problems. • Complementary and alternative therapies boxes in various chapters summarise what nurses need to know about non-traditional therapies, such as herbal remedies and acupuncture. • Nursing research boxes included throughout the text demonstrate how clinical research and evidence can be used to enhance clinical knowledge and nursing practice. • Culturally competent care is covered in Chapter 3, and cultural information is integrated into other chapters highlighting the risk factors and other important issues related to the epidemiological incidence of various conditions and the associated nursing care as it relates to different groups in the community. • Rural and remote area nursing is covered in Chapter 7 and is referenced throughout the text to highlight the importance of this field of nursing in Australia and New Zealand. • Current issues in healthcare, such as management of the older person within acute care settings (addressed in Ch 56) and management of chronic and complex illness (in Ch 66), provide students with a broad overview of many of the key issues facing nursing and the community in the current healthcare system. • Clinical practice boxes promote critical thinking about ethical dilemmas relating to timely and sensitive issues that nursing students may deal with in clinical practice. • Emergency management tables outline the emergency treatment of health problems that are most likely to require emergency intervention. • Common assessment abnormalities tables in assessment chapters alert the nurse to frequently encountered abnormalities and their possible aetiologies. • Nursing assessment tables summarise the key subjective and objective data related to common diseases. Subjective data are organised by functional health patterns. • Health history boxes and tables in assessment chapters present key questions to ask patients related to a specific disease or disorder. • Student-friendly pedagogy includes the following: Learning objectives and key terms at the beginning of each chapter help students to identify the key content for each body system or disorder. Key priority care problems are identified in individual chapters to illustrate the specific needs of individual patients and their carers. Detailed nursing care plans are available from the web-based resources of the text. Evidence-based practice boxes present the evidence of results from research to improve patient outcomes and the implications for nursing practice. Several health disparities boxes highlight the genetic basis, genetic testing and clinical implications for genetic disorders that affect adults. Review questions at the end of each chapter help students learn the important points in the chapter. Answers are provided in Appendix C so that the review questions serve as a self-study tool. Further questions can be found in the web resources. Resources at the end of each chapter contain information about nursing and healthcare organisations that provide patient teaching and disease and disorder information. Resources include internet sites to help students find current information online, as well as to provide access to the best practice, evidence-based guidelines developed by many of the specialty clinical colleges and organisations within Australia and New Zealand. Ancillary website LEARNING SUPPLEMENTS FOR THE STUDENT AND INSTRUCTOR The fourth edition Evolve website is available at http://evolve. • review questions and answers with answer rationale • key points from the chapters to provide a brief snapshot of content • quick quizzes • concept map creator and concept map for case studies • etables and efigures • image collection, including all figures and tables from the book • videos and animations • answer guidelines for case study clinical reasoning questions • additional case studies and answer guidelines • fluids and electrolytes tutorial • eNursing Care Plans • PowerPoint slides Patient safety and clinical reasoning: Thinking like a nurse Written by Di Brown LEARNING OUTCOMES 1. Consider the relationship between national patient safety goals, nursing practice and the use of effective clinical reasoning skills. 2. Explain why critical thinking and clinical reasoning are important nursing skills. 3. Analyse the key characteristics of the critical thinker. 4. Describe the relationship between critical thinking, clinical reasoning and clinical judgement. 5. Explore the tools that can assist the application of clinical reasoning and clinical judgement in the clinical setting. 6. Explain how ‘track and trigger’ tools can be used to assist the process of clinical decision making. 7. Apply clinical reasoning skills to case study analysis. KEY TERMS clinical judgement, p 22 clinical reasoning, p 22 critical thinking, p 22 early warning systems, p 25 medical emergency team, p 24 national patient safety goals, p 21 The clinical care environment is increasingly complex and turbulent. It requires nurses who are adaptable and intelligent, and who have sound knowledge, skills and understanding relevant to the work that they carry out. We know that nurses save lives.1–4 However, Gordon5 explains that nurses also prevent suffering and provide cost-effective care. To do this effectively, nurses need to have the knowledge, skills and confidence to be able to provide safe, high-quality care. There has been increasing recognition in both New Zealand and Australia of the need to improve the quality and safety of healthcare services. While the systems in both countries are among the world’s best, the care environment in hospitals can still be risky. In Australia, it is estimated that about 10% of patients will suffer adverse events while hospitalised.6 In New Zealand, while the number of serious and sentinel events has fallen since 2011, medication errors were the third leading cause of death or injury in hospitals in 2012.7 In the United States, the Institute of Medicine8,9 estimates that medical errors are among the top five leading causes of death in hospitalised patients. To begin to address this issue in a systematic manner the Health Quality and Safety Commission New Zealand (HQSC)7 was commissioned in November 2010 to lead quality and safety improvements in the health sector. The aim of the Commission is to work with clinicians and health managers to support and encourage quality and safety improvements, to identify areas where improvements can take place, and to drive change. The Australian Commission on Safety and Quality in Health Care (ACSQHC)10,11 was established in 2010 by the Australian federal, state and territory governments to lead and coordinate national improvements in the safety and quality of healthcare provision. The Commission engages in collaborative work in the area of patient safety and healthcare quality, which includes the development of the Australian Charter of Healthcare Rights and the National Safety and Quality Health Service Standards, and National Patient Safety Goals. The Commission has also developed a National Safety and Quality Framework to improve the safety and quality of the Australian health system. Patient safety WHY IS PATIENT SAFETY IMPORTANT? Both the HQSC7 and the ACSQHC11,12 have identified similar areas of focus for their national patient safety priorities to ensure that people receive their healthcare without experienc- ing preventable harm. National patient safety goals in Australia and New Zealand include consumer and patient involvement in care,1,2,10–13 medication safety,7,11 reducing healthcare-associated infec- tions,7,10,11,14 management of falls,7,11 pressure ulcers,7,11 surgical safety,7,13,14 and recognising and responding to clinical deterioration.11,15 While it is clear that preventing harm in any of these priority areas is a multidisciplinary and collaborative endeavour, there is much here that is part of the work of nurses. Within this text, attention is given to the identified national patient safety goals: medication safety (in all nursing management chapters), wound care and the assessment and management of decubitus ulcers (Ch 8), infection prevention and control (Ch 11), and reducing perioperative harms (Chs 14, 15 and 16). Chapter 58 outlines the need for a sound falls assessment and provides a useful assessment chart (Fig 58-7), and Section 12 provides guidance on the assessment and management of potential clinical deterioration. As well, each assessment chapter outlines nursing and multidisciplinary responsibilities for patient assessment and the parameters of relevant clinical observations. However, in order to apply this essential knowledge about patient safety, the nurse needs the skills of critical thinking, clinical reasoning and clinical judgement. This chapter discusses the application of clinical reasoning and clinical judgement to clinical practice and 21