Tài liệu DISEASES AND DISORDERS A Nursing Therapeutics Manual THIRD EDITION pdf

Copyright © 2007 by F. A. Davis.
Copyright © 2007 by F. A. Davis.
DISEASES AND
DISORDERS
DISEASES
AND
DISORDERS
A Nursing
Therapeutics Manual
THIRD EDITION
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page i PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK009
Copyright © 2007 by F. A. Davis.
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page ii PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK009
This page left intentionally blank.
Copyright © 2007 by F. A. Davis.
DISEASES
AND
DISORDERS
DISEASES
AND
DISORDERS
A Nursing
Therapeutics Manual
THIRD EDITION
Marilyn Sawyer Sommers, RN, PhD, FAAN
Professor
University of Pennsylvania
Philadelphia, Pennsylvania
Susan A. Johnson, RN, PhD
Program Director & Associate Professor
College of Mount St. Joseph

Cincinnati, Ohio
Theresa A. Beery, PhD, RN
Associate Professor
University of Cincinnati
Cincinnati, Ohio
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page iii PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00
Copyright © 2007 by F. A. Davis.
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2007 by F. A. Davis Company
Copyright © 2007, 2002, 1997 by F. A. Davis Company. All rights reserved. This book is pro-
tected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise,
without written permission from the publisher.
Printed in the United States
Last digit indicates print number: 1098765432
Acquisitions Editor: Joanne P. DaCunha, RN, MSN
Developmental Editor: Kristin L. Kern
Design Manager: Carolyn O’Brien
As new scientific information becomes available through basic and clinical research, recom-
mended treatments and drug therapies undergo changes. The author(s) and publisher have done
everything possible to make this book accurate, up to date, and in accord with accepted standards
at the time of publication. The author(s), editors, and publisher are not responsible for errors or
omissions or for consequences from application of the book, and make no warranty, expressed
or implied, in regard to the contents of the book. Any practice described in this book should be
applied by the reader in accordance with professional standards of care used in regard to the
unique circumstances that may apply in each situation. The reader is advised always to check
product information (package inserts) for changes and new information regarding dose and con-

traindications before administering any drug. Caution is especially urged when using new or
infrequently ordered drugs.
Library of Congress Cataloging-in-Publication Data
Sommers, Marilyn Sawyer.
Diseases and disorders : a nursing therapeutics manual / Marilyn Sawyer
Sommers, Susan A. Johnson, Theresa A. Beery.—3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8036-1337-9
ISBN-10: 0-8036-1337-7
1. Nursing—Handbooks, manuals, etc. 2. Nursing diagnosis—Handbooks, manuals,
etc. 3. Therapeutics—Handbooks, manuals, etc. I. Johnson, Susan A. II. Beery,
Theresa A. III. Title.
[DNLM: 1. Nursing Care—methods—Handbooks. 2. Nursing Process—Handbooks.
WY 49 S697da 2007]
RT51.S66 2007
610.73—dc22
2006019341
Authorization to photocopy items for internal or personal use, or the internal or personal use of
specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clear-
ance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is
paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that
have been granted a photocopy license by CCC, a separate system of payment has been arranged.
The fee code for users of the Transactional Reporting Service is: 8036–0811/ 02 0 ϩ $.10.
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page iv PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00
Copyright © 2007 by F. A. Davis.
To my girls- Marilyn, Melissa, Abigail, and Sophia- with love
MSS
To Ian, Tara, Shannon, Courtney, Michael, Abigail, and Morgan…you bring much love, joy and
pride to our family.

And to all the nursing students I have encountered…many thanks for all the lessons
you have taught me. May you always strive to make a difference in others, in the profession,
and in yourself.
SAJ
To my dear husband, delightful children and extraordinary grandchildren.
You bring me so much joy!
TAB
Dedication
v
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page v PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK009
Copyright © 2007 by F. A. Davis.
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page vi PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00
This page left intentionally blank.
Copyright © 2007 by F. A. Davis.
Preface
vii
The first and second editions of this book were conceived to provide distilled, up-to-date infor-
mation to nursing students and staff nurses about many conditions and diagnoses encountered in
nursing practice. With the third edition, we have responded to the ever-changing health care
environment as well as to the recommendations of our readers and editors. We have held true to
our initial purpose in this third edition: to provide a ready source of information for nurses in a
time of short staffing, brief lengths of stay, and increasing patient acuity in the hospital, in nurs-
ing homes, in rehabilitation centers, and in the home. We have also responded to the ever-
increasing need for nurses to understand the scientific basis of their practice by augmenting the
pathophysiology sections that were in the past two editions.
Perhaps the most significant addition to the third edition is a section entitled Genetic Con-
siderations. Since the completion of the Human Genome Project in 2003, the health care disci-
plines are beginning to understand the enormous significance of the human genome sequence,
which provides foundational information that shows us how genes and proteins work together to
promote human health. This section of the book assists practitioners to consider how the genetic

basis of disease is related to environmental factors in health and disease, and how disease sus-
ceptibility, detection of illness, and drug response are related to people’s genetic make-up. We
are indebted to co-author Dr. Terry Beery for the development of the genetic information con-
tained in this edition.
As in the first edition, we have included relevant information about Gender and Life Span
Considerations, and have enhanced this section with information about racial and ethnic differ-
ences in health and disease. As our society has an ever-increasing diversity, we have developed
this section so that practitioners have a basis from which to develop culturally competent care.
Each entry begins with the Diagnosis Related Group (DRG) category. DRGs were initiated
by the Health Care Financing Administration to serve as an organizing framework to group-
related conditions and to stabilize reimbursements. Because they provide a convenient standard
to evaluate hospital care, DRGs are used by institutions and disciplines to measure utilization
and to allocate resources. We have included DRGs to indicate the expected norms in average
length of stay for each entry. Each entry follows the nursing process, with assessment informa-
tion incorporated in the History and Physical Assessment sections, the Psychosocial Assess-
ment, and Diagnostic Highlights. Based on requests from our readers and reviewers, we have
supplemented information on diagnostic testing from earlier editions to provide normal and
abnormal values for the most important diagnostic tests. We have also added a section to explain
the rationale for the test. These detailed, specific sections provide the foundation needed to per-
form a comprehensive assessment of the patient’s condition so that a Primary Nursing Diag-
nosis can be formulated appropriate to the patient’s specific needs. The Planning and Imple-
mentation section is divided into Collaborative and Independent interventions. The intent of
the Collaborative section is to detail the goals of a multidisciplinary plan of care to manage the
condition or disease. As in the second edition, there is an expanded section on Pharmacologic
Highlights that explores commonly used drugs, their doses, mechanisms of action, and ratio-
nales for use. The Independent section focuses on independent nursing interventions that
demonstrate the core of the art and science of nursing. Each entry then finishes with Documen-
tation Guidelines and Discharge and Home Healthcare Guidelines to help nurses evaluate the
outcomes of care and to prepare hospitalized patients for discharge.
As with the first and second editions, the idea for the book originated with Joanne Patzek

DaCunha, Publisher at F.A. Davis. The authors salute her creativity, perseverance, enthusiasm,
and vision. More importantly, her gracious friendship and support enabled us to accomplish this
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page vii PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00
Copyright © 2007 by F. A. Davis.
viii
Preface
revision with a minimum of difficulty. We also owe a debt of gratitude to Jeff Sommers for his
assistance with manuscript development, editing, proofreading, and supportive cheerleading.
Finally we acknowledge with gratitude the hard work that a host of contributors made to the first
edition.
The entire reason to revise this book is to provide practicing nurses a concise and yet scien-
tifically sound text to guide the professional practice of nursing. The provision of nursing care in
the 21st century presents us with overwhelming challenges, and yet nursing is the discipline of
choice for millions of practitioners. We hope this book honors the science of nursing and makes
it easier to practice the art of nursing.
MSS
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page viii PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK0
Copyright © 2007 by F. A. Davis.
Consultants
ix
Dianne V. Benton,
RN, MS
Instructor, Senior Level Medical-
Surgical Nursing
Louise Obici School of Nursing
Suffolk, Virginia
Barbara Dunn,
RN, MSN
Professor, Nursing
New Hampshire Technical Institute

Concord, New Hampshire
Mary Taylor Martof,
RN, EdD
Associate Professor
Louisiana State Health Sciences
Center
New Orleans, Louisiana
Christine C. Mihal,
RN, MSN
Lecturer of Nursing
Associate Director of Baccalaureate
Nursing
Fairleigh Dickinson University
Teaneck, New Jersey
Anne Pithan, RN, MSN
Nursing Faculty
St. Luke’s College of Nursing
Sioux City, Iowa
Sylvia J. Sheffler,
RN, DNSc
Associate Professor
Delaware State University
Dover, Delaware
Susan Wilkinson,
RN, MSN, PhD(c)
Professional Specialist
Department of Nursing
Angelo State University
San Angelo, Texas
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page ix PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00

Copyright © 2007 by F. A. Davis.
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page x PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK009
This page left intentionally blank.
Copyright © 2007 by F. A. Davis.
Contents
xi
Abdominal Aortic Aneurysm 1
Abdominal Trauma 5
Abortion, Spontaneous 11
Abruptio Placentae 15
Acid-Base Imbalances: Metabolic Acidosis
and Alkalosis; Respiratory Acidosis and
Alkalosis 19
Acquired Immunodeficiency
Syndrome 25
Acromegaly 31
Acute Adrenal Crisis 34
Acute Alcohol Intoxication 37
Acute Respiratory Distress Syndrome 41
Adrenal Insufficiency
(Addison’s Disease) 44
Air Embolism 48
Alcohol Withdrawal 51
Allergic Purpura 56
Alzheimer’s Disease 58
Amputation 62
Amyloidosis 66
Amyotrophic Lateral Sclerosis 69
Anaphylaxis 73
Angina Pectoris 76

Anorectal Abscess and Fistula 81
Anorexia Nervosa 84
Aortic Valve Insufficiency 88
Aortic Valve Stenosis 91
Aplastic Anemia 94
Appendicitis 98
Arterial Occlusive Disease 102
Asthma 106
Atelectasis 110
Atrial Dysrhythmias 113
Basal Cell Carcinoma 119
Benign Prostatic Hyperplasia
(Hypertrophy) 122
Bladder Cancer 126
Blood Transfusion Reaction 130
Bone Cancer 135
Botulism 139
Brain Cancer 142
Breast Cancer 148
Bronchiolitis (Respiratory Syncytial
Viral Infection) 155
Bronchitis 158
Bulimia Nervosa 161
Burns 165
Calculi, Renal 171
Candidiasis (Moniliasis) 174
Cardiac Contusion (Myocardial
Contusion) 177
Cardiac Tamponade 181
Cardiogenic Shock 185

Cardiomyopathy
189
Carpal Tunnel Syndrome 193
Cataract 196
Cerebral Aneurysm 199
Cerebral Concussion 203
Cerebrovascular Accident 207
Cervical Cancer 212
Cervical Incompetence 216
Chlamydial Infections 219
Cholecystitis and Cholelithiasis 223
Chorioamnionitis 227
Chronic Fatigue Immune Dysfunction
Syndrome 230
Cirrhosis 233
Cleft Lip; Cleft Palate 237
Colorectal Cancer 240
Cor Pulmonale 245
Coronary Artery Disease
(Arteriosclerosis) 248
Crohn’s Disease 252
Cushing’s Syndrome 256
Cystic Fibrosis 260
Cystitis 264
Cystocele; Rectocele 268
Cytomegalovirus Infection 271
Degenerative Joint Disease (DJD) 275
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page xi PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00
Copyright © 2007 by F. A. Davis.
xii

Contents
Diabetes Insipidus 279
Diabetes Mellitus 282
Diffuse Axonal Injury 288
Dislocation; Subluxation 291
Disseminated Intravascular
Coagulation 295
Diverticular Disease 299
Dysfunctional Uterine Bleeding 303
Ectopic Pregnancy 307
Emphysema 310
Encephalitis 314
Endometriosis 318
Epididymitis 322
Epidural Hematoma 325
Epilepsy 329
Esophageal Cancer 333
Esophageal Diverticula 337
Fat Embolism 341
Fetopelvic Disproportion 344
Fibrocystic Breast Condition 348
Gallbladder and Biliary Duct
(Biliary System) Cancer 353
Gastric Cancer 356
Gastritis 360
Gastroenteritis 364
Gastroesophageal Reflux Disease
(GERD) 368
Glaucoma 371
Glomerulonephritis, Acute 374

Goiter 378
Gonorrhea 381
Guillain-Barré Syndrome 384
Gunshot Wound 388
Heart Failure 395
Hemophilia 400
Hemorrhoids 403
Hemothorax 406
Hepatitis 410
Herniated Disk 415
Herpes Simplex Virus 418
Herpes Zoster (Shingles) 421
Hodgkin’s Disease 424
Hydronephrosis 429
Hypercalcemia 433
Hyperchloremia 437
Hyperglycemia 439
Hyperkalemia 443
Hyperlipoproteinemia 447
Hypermagnesemia 451
Hypernatremia 454
Hyperparathyroidism 458
Hyperphosphatemia 462
Hypertension 465
Hyperthyroidism 469
Hypocalcemia 473
Hypochloremia 477
Hypoglycemia 480
Hypokalemia 483
Hypomagnesemia 487

Hyponatremia 490
Hypoparathyroidism 494
Hypophosphatemia 498
Hypothyroidism 501
Hypovolemic/Hemorrhagic Shock 505
Idiopathic Thrombocytopenia Purpura 511
Infective Endocarditis 514
Influenza 518
Inguinal Hernia 521
Intestinal Obstruction 524
Intracerebral Hematoma 527
Intrauterine Fetal Demise 531
Intussusception 534
Iron Deficiency Anemia 538
Irritable Bowel Syndrome 541
Junctional Dysrhythmias 545
Kidney Cancer 549
Laryngeal Cancer 553
Laryngotracheobronchitis (Croup) 556
Legionnaires’ Disease 560
Leukemia, Acute 563
Leukemia, Chronic 567
Liver Failure 572
Lung Cancer 576
Lupus Erythematosus 581
Lyme Disease 585
Lymphoma, Non-Hodgkin’s 589
Mallory-Weiss Syndrome 595
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page xii PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00
Copyright © 2007 by F. A. Davis.

Contents
xiii
Mastitis 598
Melanoma Skin Cancer 601
Meningitis 605
Migraine Headache 609
Mitral Insufficiency
(Regurgitation) 612
Mitral Stenosis 616
Mononucleosis, Infectious 620
Multiple Myeloma 623
Multiple Organ Dysfunction
Syndrome 627
Multiple Sclerosis 633
Muscular Dystrophy 636
Musculoskeletal Trauma 641
Myasthenia Gravis 646
Myocardial Infarction 650
Myocarditis 655
Nephrotic Syndrome 659
Neurogenic Bladder 662
Osteomyelitis 669
Osteoporosis 672
Otitis Media 676
Ovarian Cancer 680
Paget’s Disease 685
Pancreatic Cancer 688
Pancreatitis 693
Parkinson’s Disease 697
Pelvic Fractures 701

Pelvic Inflammatory Disease 705
Peptic Ulcer Disease 709
Pericarditis 713
Peritonitis 717
Pernicious Anemia 720
Pheochromocytoma 724
Pituitary Tumor 728
Placenta Previa 732
Pneumocystis carinii Pneumonia 736
Pneumonia 740
Pneumothorax 743
Polycystic Kidney Disease 746
Polycythemia 750
Postpartum Hemorrhage 754
Preeclampsia 758
Premature Rupture of Membranes 763
Pressure Ulcer 767
Preterm Labor 771
Prostate Cancer 776
Prostatitis 781
Psychoactive Substance Abuse 784
Pulmonary Embolism 789
Pulmonary Fibrosis
793
Pulmonary Hypertension 796
Pyelonephritis 800
Renal Failure, Acute 805
Renal Failure, Chronic 810
Retinal Detachment 815
Rheumatic Fever, Acute 818

Rheumatoid Arthritis 822
Rocky Mountain Spotted
Fever 826
Salmonella Infection
(Salmonellosis) 831
Sarcoidosis 834
Septic Shock 837
Sickle Cell Disease 842
Sjögren’s Syndrome 845
Skin Cancer 848
Spinal Cord Injury 853
Subarachnoid Hemorrhage 857
Subdural Hematoma 861
Sudden Infant Death Syndrome 865
Syndrome of Inappropriate Antidiuretic
Hormone (SIADH) 868
Syphilis 871
Tendinitis 877
Testicular Cancer 879
Tetanus 883
Thoracic Aortic Aneurysm 887
Thrombophlebitis 891
Thyroid Cancer 895
Tonsillitis 899
Toxoplasmosis 902
Tuberculosis 906
Ulcerative Colitis 911
Urinary Tract Infection 914
Urinary Tract Trauma 918
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page xiii PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00

Copyright © 2007 by F. A. Davis.
xiv
Contents
Uterine Cancer 923
Vaginal
Cancer 929
Vaginitis 932
Varicose Veins 935
Ventricular Dysrhythmias 938
Volvulus 944
Selected Bibliography 949
Index 951
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page xiv PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK0
Copyright © 2007 by F. A. Davis.
Nursing Diagnoses Accepted for Use and Research (2005–2006)
Activity Intolerance [specify level]
Activity Intolerance, risk for
Adjustment, impaired
Airway Clearance, ineffective
Allergy Response, latex
Allergy Response, risk for latex
Anxiety [specify level]
Anxiety, death
Aspiration, risk for
Attachment, risk for impaired parent/
infant/child
Autonomic Dysreflexia
Autonomic Dysreflexia, risk for
Body Image, disturbed
Body Temperature, risk for imbalanced

Bowel Incontinence
Breastfeeding, effective
Breastfeeding, ineffective
Breastfeeding, interrupted
Breathing Pattern, ineffective
Cardiac Output, decreased
Caregiver Role Strain
Caregiver Role Strain, risk for
Communication, impaired verbal
Communication, readiness for enhanced
Conflict, decisional (specify)
Conflict, parental role
Confusion, acute
Confusion, chronic
Constipation
Constipation, perceived
Constipation, risk for
Coping, compromised family
Coping, defensive
Coping, disabled family
Coping, ineffective
Coping, ineffective community
Coping, readiness for enhanced
Coping, readiness for enhanced
community
Coping, readiness for enhanced family
Death Syndrome, risk for sudden infant
Denial, ineffective
Dentition, impaired
Development, risk for delayed

Diarrhea
Disuse Syndrome, risk for
Diversional Activity, deficient
ϩEnergy Field, disturbed
Environmental Interpretation Syndrome,
impaired
Failure to Thrive, adult
Falls, risk for
Family Processes: alcoholism, dysfunc-
tional
Family Processes, interrupted
Family Processes, readiness for enhanced
Fatigue
Fear [specify focus]
Fluid Balance, readiness for enhanced
[Fluid Volume, deficient hyper/hypotonic]
Fluid Volume, deficient [isotonic]
Fluid Volume, excess
Fluid Volume, risk for deficient
Fluid Volume, risk for imbalanced
Gas Exchange, impaired
Grieving, anticipatory
Grieving, dysfunctional
*Grieving, risk for dysfunctional
Growth, risk for disproportionate 271–275
Growth and Development, delayed
266–271
*New to the 3rd NANDA/NIC/NOC (NNN)
Conference
xv

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page xv PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00
Copyright © 2007 by F. A. Davis.
xvi
Nursing Diagnoses Accepted for Use and Research (2005–2006)
Health Maintenance, ineffective
Health-Seeking Behaviors (specify)
Home Maintenance, impaired
Hopelessness
Hyperthermia
Hypothermia
Identity: disturbed, personal
Infant Behavior, disorganized
Infant Behavior, readiness for enhanced
organized
Infant Behavior, risk for disorganized
Infant Feeding Pattern, ineffective
Infection, risk for
Injury, risk for
Injury, risk for perioperative positioning
Intracranial Adaptive Capacity, decreased
Knowledge, deficient [Learning Need]
(specify)
Knowledge (specify), readiness for
enhanced
*Lifestyle, sedentary
Loneliness, risk for
Memory, impaired
Mobility, impaired bed
Mobility, impaired physical
Mobility, impaired wheelchair

Nausea
Neglect, unilateral
Noncompliance [Ineffective Adherence]
[specify]
Nutrition: less than body requirements,
imbalanced
Nutrition: more than body requirements,
imbalanced
Nutrition: more than body requirements,
risk for imbalanced
Nutrition, readiness for enhanced
Oral Mucous Membrane, impaired
Pain, acute
Pain, chronic
Parenting, impaired
Parenting, readiness for enhanced
Parenting, risk for impaired
Peripheral Neurovascular Dysfunction, risk
for
Poisoning, risk for
Post-Trauma Syndrome [specify stage]
Post-Trauma Syndrome, risk for
Powerlessness [specify level]
Powerlessness, risk for
Protection, ineffective
Rape-Trauma Syndrome
Rape-Trauma Syndrome: compound
reaction
Rape-Trauma Syndrome: silent reaction
*Religiosity, impaired

*Religiosity, readiness for enhanced
*Religiosity, risk for impaired
Relocation Stress Syndrome
Relocation Stress Syndrome, risk for
Role Performance, ineffective
Self-Care Deficit: bathing/hygiene
Self-Care Deficit: dressing/grooming
Self-Care Deficit: feeding
Self-Care Deficit: toileting
Self-Concept, readiness for enhanced
Self-Esteem, chronic low
Self-Esteem, situational low
Self-Esteem, risk for situational low
Self-Mutilation
Self-Mutilation, risk for
Sensory Perception, disturbed (specify:
visual, auditory, kinesthetic, gustatory,
tactile, olfactory)
Sexual Dysfunction
Sexuality Pattern, ineffective
Skin Integrity, impaired
Skin Integrity, risk for impaired
Sleep, readiness for enhanced
Sleep Deprivation
Sleep Pattern, disturbed
Social Interaction, impaired
Social Isolation
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page xvi PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK0
Copyright © 2007 by F. A. Davis.
Nursing Diagnoses Accepted for Use and Research (2005–2006)

xvii
ϩRevised ND
Sorrow, chronic
Spiritual Distress
ϩSpiritual Distress, risk for
Spiritual Well-Being, readiness for enhanced
Suffocation, risk for
Suicide, risk for
Surgical Recovery, delayed
Swallowing, impaired
Therapeutic Regimen Management,
effective
Therapeutic Regimen Management,
ineffective
Therapeutic Regimen Management,
ineffective community
Therapeutic Regimen Management,
ineffective family
Therapeutic Regimen Management,
readiness for enhanced
Thermoregulation, ineffective
Thought Processes, disturbed
Tissue Integrity, impaired
Tissue Perfusion, ineffective (specify
type: renal, cerebral, cardiopulmonary,
gastrointestinal, peripheral)
Transfer Ability, impaired
Trauma, risk for
Urinary Elimination, impaired
Urinary Elimination, readiness for

enhanced
Urinary Incontinence, functional
Urinary Incontinence, reflex
Urinary Incontinence, risk for urge
Urinary Incontinence, stress
Urinary Incontinence, total
Urinary Incontinence, urge
Urinary Retention [acute/chronic]
Ventilation, impaired spontaneous
Ventilatory Weaning Response,
dysfunctional
Violence, [actual/] risk for other-directed
Violence, [actual/] risk for self-directed
Walking, impaired
Wandering [specify sporadic or
continuous]
Used with permission from NANDA
International: Definitions and
Classification, 2005–2006. NANDA,
Philadelphia, 2005.
Information that appears in brackets has
been added by the authors to clarify and
enhance the use of NDs.
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page xvii PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK0
Copyright © 2007 by F. A. Davis.
FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page xviii PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK
This page left intentionally blank.
Copyright © 2007 by F. A. Davis.
Abdominal Aortic Aneurysm
1

DRG Category: 130
Mean LOS: 5.8 days
Description:
MEDICAL: Peripheral Vascular
Disorder with CC
DRG Category: 110
Mean LOS: 9.1 days
Description:
SURGICAL: Major Cardiovascular
Procedures with CC
Abdominal Aortic
Aneurysm
An abdominal aortic aneurysm (AAA) is a localized outpouching or dilation of the arterial
wall in the latter portion of the descending segment of the aorta. Aneurysms of the abdominal
aorta occur more frequently than those of the thoracic aorta. AAAs are the most common type
of arterial aneurysms, occurring in 3% to 10% of people older than 50 years of age in the United
States. AAA may be fusiform (spindle-shaped) or saccular (pouchlike) in shape. A fusiform
aneurysm in which the dilated area encircles the entire aorta is most common. A saccular
aneurysm has a dilated area on only one side of the vessel.
The outpouching of the wall of the aorta occurs when the musculoelastic middle layer or
media of the artery becomes weak (often caused by plaque and cholesterol deposits) and degen-
erative changes occur. The inner and outer layers of the arterial wall are stretched, and as the pul-
satile force of the blood rushes through the aorta, the vessel wall becomes increasingly weak,
and the aneurysm enlarges. Abdominal aneurysms can be fatal. More than half of people with
untreated aneurysms die of aneurysm rupture within 2 years.
CAUSES
Most authorities believe that the most common cause of AAA is atherosclerosis, which is one of
several degenerative processes that can lead to the condition. The atherosclerotic process causes
the buildup of plaque, which alters the integrity of the aortic wall. Ninety percent of AAAs are
believed to degenerative in origin; 5% are inflammatory. Other causes include high blood pres-

sure, heredity, connective tissue disorders, trauma, and infections (syphilis, tuberculosis, and
endocarditis). Smoking is also a contributing cause.
GENETIC CONSIDERATIONS
It is highly likely that there are genetic factors that make one susceptible to AAA. Recent work
has provided evidence for genetic heterogeneity and the presence of susceptibility loci for AAA
on chromosomes 19 and 4. Family clustering of AAAs has been noted in 15% to 25% of patients
undergoing surgery for AAA. In addition,AAAs are seen in rare genetic diseases such as Ehlers-
Danlos syndrome or Marfan syndrome
GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS
Abdominal aneurysms are far more common in hypertensive men than women; from three to
eight times as many men as women develop AAA. They are 3.5 times more common in whites
than in blacks/African Americans. The incidence of AAA increases with age. The occurrence is
rare before the age of 50 and common between the ages of 60 and 80, when the atherosclerotic
process tends to become more pronounced. Ethnicity and race have no known effects on the risk
for AAAs.
FABK009-SEC-A[001-118].qxd 11/7/06 10:49 AM Page 1 PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:
Copyright © 2007 by F. A. Davis.
ASSESSMENT
HISTORY. Seventy-five percent of AAAs are asymptomatic and are found incidentally. When
the aorta enlarges and compresses the surrounding structures, patient complaints may include
flank and back pain, epigastric discomfort, or altered bowel elimination. The pain may be deep
and steady with no change if the patient shifts position. If the patient reports severe back and
abdominal pain, rupture of the AAA may be imminent.
PHYSICAL EXAMINATION. Inspect the patient’s abdomen for a pulsating abdominal mass
in the periumbilical area, slightly to the left of midline. Auscultate over the pulsating area for an
audible bruit. Gently palpate the area to determine the size of the mass and whether tenderness
is present.
Watch for signs that may indicate impending aneurysm rupture. Note subtle changes such as
a change in the characteristics and quality of peripheral pulses, changes in neurological status,
and changes in vital signs such as a drop in blood pressure, increased pulse, and increased res-

pirations. An abdominal aneurysm can impair flow to the lower extremities and cause what are
known as the five Ps of ischemia: pain, pallor, pulselessness, paresthesias, and paralysis.
Because emergency surgery is indicated for both a rupture and a threatened rupture, careful
assessment is important. When the aneurysm ruptures into the retroperitoneal space, hemorrhage
is confined by surrounding structures, preventing immediate death by loss of blood. Examine the
patient for signs of shock, including decreased capillary refill, increased pulse and respirations, a
drop in urine output, weak peripheral pulses, and cool and clammy skin. When the rupture occurs
anteriorly into the peritoneal cavity, rapid hemorrhage generally occurs. The patient’s vital signs
and vital functions diminish rapidly. Death is usually imminent because of the rapidity of events.
PSYCHOSOCIAL. In most cases, the patient with an AAA faces hospitalization, a serious sur-
gical procedure, a stay in an intensive care unit, and a substantial recovery period. Therefore,
assess the patient’s coping mechanisms and existing support system. Assess the patient’s anxiety
level regarding surgery and the recovery process.
2
Abdominal Aortic Aneurysm
General Comments: Because this condition causes no symptoms, it is often diagnosed
through routine physical exams or abdominal x-rays.
Abnormality with
Test Normal Result Condition Explanation
Diagnostic Highlights
Standard test:
Computed tomog-
raphy (CT) scan
Abdominal x-ray
Negative study
Negative study
Locates outpouching within the aortic wall
May show location of aneurysm with an
“eggshell” appearance; AAA is evident by
calcification in the anterior wall of the

aorta, displaced significantly anterior from
the vertebrae
Assesses size
and location of
aneurysm
Assesses size
and location of
aneurysm
Other Tests: Ultrasound of the abdomen; magnetic resonance (MR); aortography
PRIMARY NURSING DIAGNOSIS
Risk for fluid volume deficit related to hemorrhage
OUTCOMES. Fluid balance; Circulation status; Cardiac pump effectiveness; Hydration
INTERVENTIONS. Bleeding reduction; Fluid resuscitation; Blood product administration;
Intravenous therapy; Circulatory care; Shock management
FABK009-SEC-A[001-118].qxd 11/7/06 10:49 AM Page 2 PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:
Copyright © 2007 by F. A. Davis.
PLANNING AND IMPLEMENTATION
Collaborative
PREOPERATIVE. The treatment of choice for AAA 6 cm or greater in size is surgical repair.
When aneurysms are smaller, some controversy exists regarding treatment. Some authorities
suggest the smaller aneurysm should just be evaluated frequently by ultrasound examination or
CT scan, with surgical intervention only if the aneurysm expands. There is increasing evidence
suggesting that beta blockade, particularly propranolol, may decrease the rate of AAA expan-
sion, and blood pressure control as well as smoking cessation is important. Others suggest elec-
tive surgical repair regardless of aneurysm size. If the aneurysm is leaking or about to rupture,
immediate surgical intervention is required to improve survival rates.
SURGICAL. The type and extent of surgery depend on the location of the aneurysm. Typically,
an abdominal incision is made, the aneurysm is opened, clots and debris are removed, and a syn-
thetic graft is inserted within the natural arterial wall and then sutured. During this procedure,
the aorta is cross-clamped proximally and distally to the aneurysm to allow the graft to take hold.

The patient is treated with heparin during the procedure to decrease the clotting of pooled blood
in the lower extremities.
POSTOPERATIVE. Patients will typically spend 2 to 3 days in the intensive care setting until their
condition stabilizes. Monitor their cardiac and circulatory status closely, and pay particular attention
to the presence or absence of peripheral pulses and the temperature and color of the feet. Immedi-
ately report to the physician any absent or diminished pulse or cool, pale, mottled, or painful extrem-
ity. These signs could indicate an obstructed graft. Ventricular dysrhythmias are common in the post-
operative period because of hypoxemia (deficient oxygen in the blood), hypothermia (temperature
drop), and electrolyte imbalances. An endotracheal tube may be inserted to support ventilation. An
arterial line, central venous pressure line, and peripheral intravenous lines are all typically ordered
to maintain and monitor fluid balance. Adequate blood volume is supported to ensure patency of the
graft and to prevent clotting of the graft as a result of low blood flow. Foley catheters are also used
to assist with urinary drainage, as well as with accurate intake and output measurements. Monitor
for signs of infection; watch for temperature and white blood cell count elevations. Observe the
abdominal wound closely, noting poor wound approximation, redness, swelling, drainage, or odor.
Also report pain, tenderness, and redness in the calf of the patient’s leg. These symptoms may indi-
cate thrombophlebitis from clot formation. If the patient develops severe postoperative back pain,
notify the surgeon immediately; pain may indicate that a graft is tearing.
EXPERIMENTAL THERAPY. Several medical centers are using an experimental graft that is
inserted through a groin artery into the area of the aneurysm. Intravascular stents covered with
prosthetic graft material such as Dacron are expandable and carry blood past the weakened por-
tion of the aneurysm. The procedure can be performed without extensive surgery, and although
in limited use, patients have had positive short-term (approximately 4 years) results.
Abdominal Aortic Aneurysm
3
Medication or
Drug Class Dosage Description Rationale
Pharmacologic Highlights
Morphine
Fentanyl

Antihypertensives
and/or diuretics
Propranolol
1–10 mg IV
50–100 mcg IV
Varies by drug
80–400 mg/day in
divided doses
Opioid analgesic
Opioid analgesic
Beta blocker
Relieves surgical pain
Relieves surgical pain
Rising BP may stress graft suture
lines
Used in people with small aneurysms
without risk for rupture; decreases
rate of AAA expansion
FABK009-SEC-A[001-118].qxd 11/7/06 10:49 AM Page 3 PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:
Copyright © 2007 by F. A. Davis.
Independent
PREOPERATIVE. Teach the patient about the disease process, breathing and leg exercises, the
surgical procedure, and postoperative routines. Support the patient by encouraging him or her to
share fears, questions, and concerns. When appropriate, include support persons in the discus-
sions. Note that the surgical procedure may be performed on an emergency basis, which limits
the time available for preoperative instruction. If the patient is admitted in shock, support airway,
breathing, and circulation, and expedite the surgical procedure.
POSTOPERATIVE. Keep the incision clean and dry. Inspect the dressing every hour to check
for bleeding. Use sterile techniques for all dressing changes. To ensure adequate respiratory
function and to prevent complications, assist the patient with coughing and deep breathing after

extubation. Splint the incision with pillows, provide adequate pain relief prior to coughing ses-
sions, and position the patient with the head of the bed elevated to facilitate coughing. Turn the
patient side to side every 2 hours to promote good ventilation and to limit skin breakdown.
Remember that emergency surgery is a time of extreme anxiety for both the patient and the
significant others. Answer all questions, provide emotional support, and explain all procedures
carefully. If the patient or family is not able to cope effectively, you may need to refer them for
counseling.
DOCUMENTATION GUIDELINES
• Location, intensity, and frequency of pain, and the factors that relieve pain
• Appearance of abdominal wound (color, temperature, intactness, drainage)
• Evidence of stability of vital signs, hydration status, bowel sounds, electrolytes
• Presence of complications: Hypotension, hypertension, cardiac dysrhythmias, low urine out-
put, thrombophlebitis, infection, graft occlusion, changes in consciousness, aneurysm rupture,
excessive anxiety, poor wound healing
DISCHARGE AND HOME HEALTHCARE GUIDELINES
WOUND CARE. Explain the need to keep the surgical wound clean and dry. Teach the patient to
observe the wound and report to the physician any increased swelling, redness, drainage, odor, or
separation of the wound edges. Also instruct the patient to notify the physician if a fever develops.
ACTIVITY RESTRICTIONS. Instruct the patient to lift nothing heavier than 5 pounds for
about 6 to 12 weeks and to avoid driving until her or his physician permits. Braking while driv-
ing may increase intra-abdominal pressure and disrupt the suture line. Most surgeons temporar-
ily discourage activities that require pulling, pushing, or stretching—activities such as vacuum-
ing, changing sheets, playing tennis and golf, mowing grass, and chopping wood.
SMOKING CESSATION. Encourage the patient to stop smoking and to attend smoking ces-
sation classes. Smoking cessation materials are available through the Agency for Healthcare
Research and Quality ( or the National Institute on Drug Abuse (http://
www.nida.nih.gov/).
COMPLICATIONS FOLLOWING SURGERY. Discuss with the patient the possibility of
clot formation or graft blockage. Symptoms of a clot may include pain or tenderness in the calf,
and these symptoms may be accompanied by redness and warmth in the calf. Signs of graft

blockage include a diminished or absent pulse and a cool, pale extremity. Tell patients to report
such signs to the physician immediately.
COMPLICATIONS FOR PATIENTS NOT REQUIRING SURGERY. Compliance with the
regime of monitoring the size of the aneurysm by computed tomography over time is essential.
The patient needs to understand the prescribed medication to control hypertension. Advise the
patient to report abdominal fullness or back pain, which may indicate a pending rupture.
4
Abdominal Aortic Aneurysm
FABK009-SEC-A[001-118].qxd 11/7/06 10:49 AM Page 4 PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:
Copyright © 2007 by F. A. Davis.
DRG Category: 188
Mean LOS: 4.9 days
Description:
MEDICAL: Other Digestive System
Diagnoses, Age Ͼ 17 with CC
DRG Category: 154
Mean LOS: 13.3 days
Description:
SURGICAL: Stomach, Esophageal,
and Duodenal Procedures, Age Ͼ
17 with CC
Abdominal trauma accounts for approximately 15% of all trauma-related deaths. Intra-abdom-
inal trauma is usually not a single organ system injury; as more organs are injured, the risks of
organ dysfunction and death climb. The abdominal cavity contains solid, gas-filled, fluid-filled,
and encapsulated organs. These organs are at greater risk for injury than are other organs of the
body because they have few bony structures to protect them. Although the last five ribs serve as
some protection, if they are fractured, the sharp-edged bony fragments can cause further organ
damage from lacerations or organ penetration (Table 1).
Abdominal Trauma
5

Abdominal Trauma
• TABLE 1 Injuries to the Abdomen
ORGAN
OR TISSUE COMMON INJURIES SYMPTOMS
Diaphragm
Esophagus
Stomach
•
Decreased breath sounds
•
Abdominal peristalsis heard
in thorax
•
Acute chest pain and shortness of
breath may indicate diaphragmatic
tear
•
May be hard to diagnose because of
multisystem trauma, or the liver may
“plug” the defect and mask it
•
Pain at site of perforation
•
Fever
•
Difficulty swallowing
•
Cervical tenderness
•
Peritoneal irritation

•
Epigastric pain
•
Epigastric tenderness
•
Signs of peritonitis
•
Bloody gastric drainage
Partially protected by bony structures,
diaphragm is most commonly injured
by penetrating trauma (particularly
gunshot wounds to the lower chest)
Automobile deceleration may lead to
rapid rise in intra-abdominal pressure
and a burst injury
Diaphragmatic tear usually indicates multi-
organ involvement
Penetrating injury is more common than
blunt injury
May be caused by knives, bullets, foreign
body obstruction
May be caused by iatrogenic perforation
May be associated with cervical spine
injury
Penetrating injury is more common than
blunt injury; in one-third of patients,
both the anterior and the posterior
walls are penetrated
May occur as a complication from cardio-
pulmonary resuscitation or from

gastric dilation
(table continues on page 6)
FABK009-SEC-A[001-118].qxd 11/7/06 10:49 AM Page 5 PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:
Copyright © 2007 by F. A. Davis.
6
Abdominal Trauma
Liver
Spleen
Pancreas
Small
intestines
Large
intestines
•
Persistent hypotension despite ade-
quate fluid resuscitation
•
Guarding over right lower quadrant six
ribs or right upper quadrant
•
Dullness to percussion
•
Abdominal distension and peritoneal
irritation
•
Persistent thoracic bleeding
•
Hypotension, tachycardia, shortness of
breath
•

Peritoneal irritation
•
Abdominal wall tenderness
•
Left upper quadrant pain
•
Fixed dullness to percussion in left
flank; dullness to percussion in right
flank that disappears with change of
position
•
Pain over pancreas
•
Paralytic ileus
•
Symptoms may occur late (after 24
hours); epigastric pain radiating to
back; nausea, vomiting
•
Tenderness to deep palpation
•
Testicular pain
•
Referred pain to shoulders, chest,
back
•
Mild abdominal pain
•
Peritoneal irritation
•

Fever, jaundice, intestinal obstruction
•
Pain, muscle rigidity
•
Guarding, rebound tenderness
•
Blood on rectal exam
•
Tenderness, fever
Most commonly injured organ (both
blunt and penetrating injuries); blunt
injuries (70% of total) usually occur
from motor vehicle crashes and steer-
ing wheel trauma
Highest mortality from blunt injury (more
common in suburban areas); gunshot
wounds (more common in urban
areas)
Hemorrhage is most common cause of
death from liver injury; overall mortality
10%–15%
Most commonly injured organ with blunt
abdominal trauma
Injured in penetrating trauma of the left
upper quadrant
Most often penetrating injury (gunshot
wounds at close range)
Blunt injury from deceleration; injury from
steering wheel
Often associated (40%) with other organ

damage (liver, spleen, vessels)
Duodenum, ileum, and jejunum; hollow
viscous structure most often injured
by penetrating trauma
Gunshot wounds account for 70% of
cases
Incidence of injury is third only to liver
and spleen injury
When small bowel ruptures from blunt
injury, rupture occurs most often at
proximal jejunum and terminal ileum.
One of the more lethal injuries because
of fecal contamination; occurs in 5%
of abdominal injuries
More than 90% of incidences are pene-
trating injuries
Blunt injuries are often from safety
restraints in motor vehicle crashes
• TABLE 1 Injuries to the Abdomen (continued)
ORGAN
OR TISSUE COMMON INJURIES SYMPTOMS
FABK009-SEC-A[001-118].qxd 11/7/06 10:49 AM Page 6 PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:
Copyright © 2007 by F. A. Davis.