Timby's MedSurg 14e

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TIMBY’S INTRODUCTORY

Medical-Surgical Nursing Loretta A. Donnelly-Moreno, DNP, RN, MSN Nurse Faculty Brigitte Moseley, MSN, RN Adjunct Nurse Faculty BSN Nursing Department Blackfeet Community College Browning, Montana Staff Nurse Angels of Care Pediatric Home Health San Antonio, Texas

FOURTEENTH EDITION

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This textbook is dedicated to all current and future nursing students in their quest to comprehend diseases and disorders that continue to plague the human body, and to learn how to care for them with understanding and compassion. —LADM & BM

Contributor

Rikke Sorensen, RN, BSN, MBA

Brief Contents

UNIT 1 Nursing Roles and Responsibilities 1 1 Concepts and Trends in Healthcare 1 2 Settings and Models for Nursing Care 12 3 The Nursing Process 20 4 Interviewing and Physical Assessment 27 5 Legal and Ethical Issues 36 6 Leadership Roles and Management Functions 52 7 Nurse–Client Relationships 61 8 Cultural Care Considerations 77 9 Integrative Medicine and Alternative Therapies 87 10 End-of-Life Care 102 UNIT 3 Foundations of Medical-Surgical Nursing 115 11 Pain Management 115 12 Infection 134 UNIT 4 Caring for Clients With Multisystem Disorders 215 16 Caring for Clients With Fluid, Electrolyte, and Acid–Base Imbalances 215 17 Caring for Clients in Shock 234 18 Caring for Clients With Cancer 248 UNIT 5 Caring for Clients With Respiratory Disorders 273 19 Introduction to the Respiratory System 273 20 Caring for Clients With Upper Respiratory Disorders 288 21 Caring for Clients With Lower Respiratory Disorders 310 UNIT 2 Client Care Concerns 61 13 Intravenous Therapy 153 14 Perioperative Care 172 15 Disaster Situations 201

UNIT 6 Caring for Clients With Cardiovascular Disorders 353

22 Introduction to the Cardiovascular System 353 23 Caring for Clients With Infectious and Inflammatory Disorders of the Heart and Blood Vessels 369 24 Caring for Clients With Valvular Disorders of the Heart 391 25 Caring for Clients With Disorders of Coronary and Peripheral Blood Vessels 405 26 Caring for Clients With Cardiac Dysrhythmias 432 27 Caring for Clients With Hypertension 447 28 Caring for Clients With Heart Failure 460 29 Caring for Clients Undergoing Cardiovascular Surgery 476 UNIT 7 Caring for Clients With Hematopoietic and Lymphatic Disorders 495 30 Introduction to the Hematopoietic and Lymphatic Systems 495 31 Caring for Clients With Disorders of the Hematopoietic System 506 32 Caring for Clients With Disorders of the Lymphatic System 528 UNIT 8 Caring for Clients With Immune Disorders 539 33 Introduction to the Immune System 539 34 Caring for Clients With Immune-Mediated Disorders 548 35 Caring for Clients With HIV/AIDS 567 UNIT 9 Caring for Clients With Neurologic Disorders 589 36 Introduction to the Nervous System 589 37 Caring for Clients With Central and Peripheral Nervous System Disorders 604 38 Caring for Clients With Cerebrovascular Disorders 641

39 Caring for Clients With Head and Spinal Cord Trauma 659 40 Caring for Clients With Neurologic Deficits 680 UNIT 10 Caring for Clients With Sensory Disorders 691 41 Introduction to the Sensory System 691 42 Caring for Clients With Eye Disorders 704 43 Caring for Clients With Ear Disorders 728 UNIT 11 Caring for Clients With Gastrointestinal Disorders 743 44 Introduction to the Gastrointestinal System and Accessory Structures 743 45 Caring for Clients With Disorders of the Upper Gastrointestinal Tract 759 46 Caring for Clients With Disorders of the Lower Gastrointestinal Tract 787 47 Caring for Clients With Disorders of the Liver, Gallbladder, or Pancreas 814 48 Caring for Clients With Ostomies 847 UNIT 12 Caring for Clients With Endocrine Disorders 863 49 Introduction to the Endocrine System 863 50 Caring for Clients With Disorders of the Endocrine System 874 51 Caring for Clients With Diabetes Mellitus 905 UNIT 13 Caring for Clients With Breast and Reproductive Disorders 933 52 Introduction to the Female and Male Reproductive Systems 933 53 Caring for Clients With Disorders of the Female Reproductive System 949 54 Caring for Clients With Breast Disorders 974 55 Caring for Clients With Disorders of the Male Reproductive System 994 56 Caring for Clients With Sexually Transmitted Infections 1019

58 Caring for Clients With Disorders of the Kidneys and Ureters 1048 59 Caring for Clients With Disorders of the Bladder and Urethra 1077 UNIT 15 Caring for Clients With Musculoskeletal Disorders 1101 60 Introduction to the Musculoskeletal System 1101 61 Caring for Clients Requiring Orthopedic Treatment 1111 62 Caring for Clients With Traumatic Musculoskeletal Injuries 1134 63 Caring for Clients With Orthopedic and Connective Tissue Disorders 1145 UNIT 16 Caring for Clients With Integumentary Disorders 1171 64 Introduction to the Integumentary System 1171 65 Caring for Clients With Skin, Hair, and Nail Disorders 1184 66 Caring for Clients With Burns 1205 UNIT 17 Caring for Clients With Psychobiologic Disorders 1223 67 Interaction of Body and Mind 1223 68 Caring for Clients With Anxiety Disorders 1234 69 Caring for Clients With Mood Disorders 1246 70 Caring for Clients With Eating Disorders 1267 71 Caring for Clients With Substance Use Disorders 1284 72 Caring for Clients With Dementia and Thought Disorders 1301

APPENDIX A Commonly Used Abbreviations and Acronyms 1317 Glossary 1323 Index 1359

UNIT 14 Caring for Clients With Urinary and Renal Disorders 1033 57 Introduction to the Urinary System 1033

133

CHAPTER 11 Pain Management

CLINICAL JUDGMENT EXERCISES 1. What questions should the nurse ask when a client states that they have pain? 2. Discuss how acute pain after surgery is different from pain experienced by a client with chronic back pain. 3. Discuss nursing interventions that are appropriate if a client does not experience adequate pain relief from a prescribed analgesic. 4. What actions should a nurse take if a client who they assume to be in pain cannot verbalize discomfort? 5. If a client has an order for morphine sulfate 5 mg IM q3 to 4h prn and ibuprofen (Motrin) 800 mg po tid prn and has not experienced pain relief 2 hours after re ceiving the morphine, what could the nurse do? 1. A nurse observes that the client who is experiencing ab dominal pain is curled in a fetal position and rocking back and forth. What nursing action is best at the present time? a. Ask the client to rate the pain on a scale from 0 to 10. b. Determine if the client can stop moving about. c. Give the client a prescribed pain-relieving drug. d. Observe if the client is breathing heavily. 2. A postoperative client requests pain medication. Fol lowing the administration of morphine sulfate, what information is most important for the nurse to collect? a. Color and temperature of the skin b. Presence and activity of bowel sounds c. Rate and depth of respirations d. Rhythm and force of the heart rate 3. A primary provider orders ketamine 1 mg/kg IM now. The client weighs 220 lb. The vial of ketamine has been diluted to contain 50 mg/mL. Fill in the blank with the volume the nurse should administer. Record your answer in a whole number. _________mL 4. A client has developed physical dependence on an opi oid drug for pain relief. Which of the following inter ventions is appropriate first? a. Immediately discontinue all drug therapy. b. Replace the opioid with a nonopioid drug. c. Gradually decrease the dosage and frequency of the opioid. d. Increase the dosage but decrease the frequency of the opioid. 5. The nurse cares for a client with metastatic cancer who is receiving hospice care and who has an advance directive that requests no aggressive treatment. If there is a primary provider’s order for pain medication every 3 to 4 hours as necessary, which action by the hospice nurse is most appropriate in order to provide the client with maximum comfort at this time? a. Administer the medication every 3 hours. b. Ask the primary provider to prescribe a high dose. c. Give the medication immediately upon request. d. Give the medication when the pain is severe. Words To Know barium enema barium swallow cholangiography cholecystography colonoscopy enteroclysis esophagogastroduodenoscopy flexible sigmoidoscopy gallbladder series lower gastrointestinal series panendoscopy percutaneous liver biopsy peristalsis proctosigmoidoscopy radionuclide imaging ultrasonography upper gastrointestinal series virtual colonoscopy KEY POINTS ■ Pain Management ● Types of pain ◆ Nociceptive pain—noxious stimuli transmitted from point of cellular injury to the brain ◆ Somatic pain—caused by mechanical, chemical, thermal, or electrical injuries or disorders ◆ Visceral pain—arises from internal organs ◆ Neuropathic pain—pain that is processed abnormally by the nervous system ◆ Acute pain—discomfort for a short duration— seconds to less than 6 months ◆ Chronic pain—pain that lasts longer than 6 months ● Pain transmission ◆ Transduction—conversion of chemical information in the cellular environment to electrical impulses that move toward the spinal cord ◆ Transmission—phase where peripheral nerve fibers • Craving • Dysfunctional behaviors • Inability to control impulses regarding consumption of a substance • Compulsive use despite harmful consequences (Sowicz et al., 2023) Substance use disorders are a worldwide problem. The treatment and prescribing of opioid medications have been reduced due to the addictive properties of the drugs. Per the CDC’s National Center for Health Statistics (2025), in January 2024 there were approximately 79,000 deaths in the United States related to opioids (Ahmad et al., 2025). Unfortunately, the fear of developing a substance use disorder causes many clients to refuse or self-limit prescribed drug therapy. Nurses often assume that a client’s desire to experience a drug’s pleas ant effects motivates their desire for frequent doses of narcot ics. What may be happening is that the prescribed dose or frequency of administration is not controlling the pain. Clients with severe, unrelieved pain may be falsely labeled as having a substance use disorder because they are focused on receiving analgesics, when in reality they are only seeking relief from unrelenting discomfort. Consequently, nurses may administer subtherapeutic doses or may convince the primary provider to prescribe a placebo , an inactive substance intended to produce a beneficial effect without any physiologic alteration. Although substance use disorders rarely develop, toler A NEXT-GENERATION NCLEX-STYLE REVIEW QUESTIONS

Features and Learning Tools UNIT 11 Caring for Clients With Gastrointestinal Disorders CHAPTER 11 Pain Management Vertebra The 14th edition includes updated features that long-time users of Timby’s Introductory Medi cal-Surgical Nursing love: A user-friendly design along with images of diseases, procedures, signs, symptoms, and nor mal-versus-abnormal comparisons helps visual learners understand the whole picture.

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NEXT-GENERATION NCLEX-STYLE Review Questions and Clinical Scenario Review Questions found at the end of each chapter help the students understand how the Na tional Council Licensure Examination for Practical Nurses (NCLEX-PN) examination relates to the chapter content they just read. Words To Know listed at the beginning of each chapter along with the chapter Learning Objectives help focus student reading and identify important information to learn in each chapter. Spinal nerve root Spinal cord

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vii Just as tolerance is not a characteristic of substance use disorder, neither is physical dependence. Physical depen dence means that a person experiences physical discomfort, known as withdrawal symptoms , when a drug that a person Key Points are at the end of each chapter. Important infor mation is included in outline form to assist the reader with studying key information from each chapter. Stop, Think, and Respond exercises encourage rapid recall and practical assimilation of contents. These questions are found in every chapter and require students to apply content as they read. Learning Objectives On completion of this chapter, you will be able to: 1. Identify major organs and structures of the gastrointestinal system. 2. Discuss important information to ascertain about gastrointesti nal health. 3. Identify facts in the client’s history that provide pertinent data about the present illness. 4. Discuss physical assessments that are pertinent to gastrointes tinal tract function. 5. Describe common diagnostic tests performed on clients with gastrointestinal disorders. 6. Describe nursing measures after liver biopsy. 7. Explain nursing management of clients undergoing diagnostic testing for a gastrointestinal disorder. T he gastrointestinal (GI) system (Fig. 44-1) may be considered as having three sections: the upper GI tract, the small intestine or mid dle portion of the GI tract, and the lower GI tract. The upper GI tract begins at the mouth and ends at the pyloric sphincter. The small intestine has three subdivisions: the duodenum, the jejunum, and the ileum. The lower GI tract begins at the cecum and ends at the anus. Accessory structures include the peritoneum, liver, gallbladder, and pancreas. The primary functions of the GI tract are digestion (Table 44-1) and distribution of food. CHAPTER 11 Pain Management CLINICAL JUDGMENT EXERCISES 1. What questions should the nurse ask when a client states that they have pain? 2. Discuss how acute pain after surgery is different from pain experienced by a client with chronic back pain. 3. Discuss nursing interventions that are appropriate if a client does not experience adequate pain relief from a prescribed analgesic. 4. What actions should a nurse take if a client who they assume to be in pain cannot verbalize discomfort? 5. If a client has an order for morphine sulfate 5 mg IM q3 to 4h prn and ibuprofen (Motrin) 800 mg po tid prn B Epidural anesthesia indication of substance use disorder. The most appropriate nursing action is to consult with the primary provider re garding the need for an increased dose of the drug and not to reduce its dosage or frequency of administration. As a rule of thumb, an ineffective dose should be increased by 25% to 50% (McCaffery & Ferrell, 1999). Because opioids depress the respiratory center in the brain, some nurses fear giving larger and larger doses of nar cotic analgesics. In reality, respiratory depression is rare in those receiving opioids for prolonged periods of time. How ever, even if large doses of opioid analgesics coincidentally hasten death, the primary intention for their administration is controlling pain. The Hospice and Palliative Nurses Associa tion (2025) and other professional organizations, therefore, acknowledge that it is an ethically acceptable intervention. Stop,Think, and Respond 11-2 A medical order states meperidine hydrochloride 50 to 100 mg IM q3h prn for pain. If a client does not ex perience adequate pain relief after receiving 50 mg, what dose should the nurse administer? and has not experienced pain relief 2 hours after re ceiving the morphine, what could the nurse do? NEXT-GENERATION NCLEX-STYLE REVIEW QUESTIONS 1. A nurse observes that the client who is experiencing ab-

Figure 11-12 Intraspinal anesthesia. (A) Epidural catheter insertion. (B) Epidural catheter placement. ( A , reprinted with permission from Ricci, S. S. [2017]. Essentials of maternity, newborn, and women’s health nursing [4th ed.]. Lippincott Williams & Wilkins.)

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(Packham et al., 2020) See Evidence-Based Practice 11-1 for research on as sessing pain in older adults. being taken to avoid drug–drug interactions. • Take prescribed drugs exactly as directed and report untoward effects. • Avoid taking over-the-counter drugs unless the primary provider has been consulted; follow label directions for administration. • Avoid alcohol and sedative drugs if the analgesic causes sedation. • Keep analgesic drugs out of the reach of children; request childproof caps. • Never share medications with others or take someone else’s medications for pain. TABLE 11-1 Characteristics of Acute and Chronic Pain ACUTE PAIN CHRONIC PAIN Recent onset Remote onset Symptomatic of primary injury or disease Uncharacteristic of primary injury or disease Specific and localized Nonspecific and generalized Severity associated with the acuity of the injury or disease process Severity out of proportion to the stage of the injury or disease Lasts less than 6 months Lasts longer than 6 months Responds favorably to drug therapy Responds poorly to drug therapy Requires gradually decreased drug therapy Requires increasing drug therapy Diminishes with healing Persists beyond healing stage Suffering decreases Suffering intensifies Concept Mastery Alert Acute pain is discomfort that has a short duration (from a few seconds to less than 6 months). It is associated with tissue trauma, including surgery, or some other recent identi able etiology. Although severe initially, acute pain eases with healing and eventually disappears. Clinical Scenario A client arrives at the emergency department of a hospital at 4 p.m. They report that they have a “throbbing” pain in their left side that started this morning and hasn’t stopped. They state that they have never felt this intense pain before today. “Please make it stop!” How does the nurse assess this client and plan for their care? What data are needed for this assessment? See Nursing Care Plan 11-1.

PAIN T The transm tion, transm Transdu Transduc the cellula toward the lar disrupt Evidence “The glo projectio be over t As the p likely car Barriers c pain asse confusion sometim barriers c acute an ability for the healt Nursing Im Nurses m sessmen an asses this popu ment, co team. Reference Aragaki, D., Pangarkar, Q and innovat B978-0-323

viii hance the effect of opioid and nonopioid analgesics or as a substitute when drug side effects jeopardize the cli ent’s safety. When planning the client’s discharge from the healthcare agency, the nurse includes interventions for pain relief to facilitate a comfortable transition to the next level of care. Box 11-2 summarizes nursing responsibilities for managing pain. An important component of pain management is client and family teaching (Client and Family Teaching 11-1). Features and LearningTools Concept Mastery Alerts highlight and clarify fundamental nursing concepts to improve understanding of difficult top ics that are identified by Misconception Alerts in Lippincott’s Adaptive Learning Powered by PrepU, an adaptive quizzing platform. Data from hundreds of actual students using this program in medical-surgical courses across the United States identified common misconceptions for the authors to clarify in this feature. Clinical Scenarios, related to Nursing Care Plans and Nurs ing Process sections, introduce the reader to a client’s prob lem and include a clinical judgment question to help students begin to think through each situation. Nutrition Notes The Client Receiving DrugTherapy for Pain ■ Administering pain medications 30 to 45 minutes before meals may relieve pain, enabling the client to consume an adequate nutritional intake. ■ Small, frequent meals may help maximize intake in cli ents with drug-related or pain-related anorexia. Solicit food preferences. ■ A high-fiber diet (i.e., a diet rich in whole-grain breads and cereals, fresh fruits, and vegetables) along with increased fluids may help ease constipation, a possible side effect of opioids.

Nursing Care Plans provide an overview of nursing care (with rationales) for clients experiencing common conditions. Each Nursing Care Plan relates to the client introduced in the Clinical Scenario. (See Quick Reference to Nursing Care Plans on p. xix.) 132 UNIT 3 Foundations of Medical-Surgical Nursing

NURSING CARE PLAN 11-1

The Client With Acute Pain

Assessment • Determine the following:

Associated with sympathetic nervous system responses such as hypertension, tachy cardia, restlessness, anxiety • Pain-related behaviors such as grimacing, crying, moaning, and assuming a guarded position • Measure vital signs. • Perform a physical assessment, taking care to gently support and assist client to turn as you examine various structures. Use light palpation in areas that are tender. Show concern when assessment techniques increase client’s pain. • Postpone nonpriority assessments until client’s pain has been reduced.

Absence of autonomic nervous system responses; manifests depression and irritability

• Source of client’s pain; when it began; its intensity, location, characteristics, and related factors such as what makes the pain better or worse • How client’s pain interferes with life, such as diminishing the ability to meet their own needs for hygiene, eating, sleep, activity, social interactions, emotional stability, concentration, and so forth • At what level client can tolerate pain

Nursing Diagnosis. Acute pain related to cellular injury or disease as manifested by stating, “I’m in severe pain”; rating pain at 10 using a numeric scale; pointing to the lower left abdominal quadrant; describing the pain as “continuous, throbbing, and starting this morning” without any known cause. Expected Outcome. Client will rate the pain intensity at their tolerable level of “5” within 30 minutes of implementing a pain management technique. Interventions Rationales

Quick interventions prevent or minimize pain.

Assess client’s pain and its characteristics at least every 2 hours while awake and 30 minutes after implementing a pain management technique. Modify or eliminate factors that contribute to pain such as a full bladder, uncomfortable position, pain-aggravating activity, excessively warm or cool environment, noise, and social isolation. Determine client’s choice for pain relief techniques from among those available. Administer prescribed analgesics or alternative pain management techniques promptly. Advocate on client’s behalf for higher doses of prescribed analgesics or addition of adjuvant drug therapy if pain is not satisfactorily relieved. Administer a prescribed analgesic before a procedure or activity that is likely to result in or intensify pain.

Multiple stressors decrease pain tolerance.

Encourage and respect client’s participation in decision making .

Suffering contributes to the pain experience and can be reduced by eliminating delays in nursing response . The Joint Commission standards mandate that nurses and other healthcare providers facilitate pain relief for clients .

Prophylactic interventions facilitate keeping pain at a manageable level.

Plan for periods of rest between activities.

Fatigue and exhaustion interfere with pain tolerance .

Reassure client that there are many ways to modify the pain experience.

Suggesting that there are additional untried options helps alleviate frustration or despair that there is no hope for pain relief .

Interventions

Rationales

Assist client to visualize a pleasant experience.

Imaging interrupts pain perception.

Diverting attention to something other than pain reduces pain perception.

Help client focus on deep breathing, relaxing muscles, watching television, putting together a puzzle, or talking to someone on the phone. Apply warm or cool compresses to a painful sensory site.

Flooding the brain with alternative stimuli closes the spinal gates that transmit pain.

Copyright © 2025 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. Gently massage a painful area or the same area on the opposite side of the body (contralateral massage). Massage promotes the release of endorphins and enkephalins that moderate the sensation .

Promote laughter by suggesting that client relate a humorous story or watch a video or comedy of their choice.

Laughter releases endorphins and enkephalins that promote a feeling of well-being .

Evaluation of Expected Outcomes • Client reports that pain is gone or is at a tolerable level of “5” within 30 minutes. • Client perceives the pain experience realistically and copes effectively. • Client participates in self-care activities without undue pain.

that the procedure will not be any longer than 2 hours. The client will be able to go home after recovering from the anesthesia.

suddenly without explanation (Gray & Thomas, 2017). The circulating nurse closely monitors the client for signs of hyperthermia. If the client’s temperature begins to rise rapidly, anesthesia is discontinued and the OR team im plements measures to correct physiologic problems, such as fever or arrhythmias.

What information does the nurse need to collect? What are important considerations for the nurse to monitor while the client is sedated? See the following Nursing Process section.

Features and LearningTools

Nursing Process sections also relate to a specific client introduced in the Clinical Sce nario. These sections emphasize a nursing process approach to care and provide ratio nales in italics for all interventions.

NURSING PROCESS FOR THE CLIENT UNDERGOING PROCEDURAL SEDATION

The client undergoing procedural sedation requires special con siderations for intraoperative nursing management. Assessment Before sedation, the nurse gathers important client data, records baseline vital signs and oximeter readings, and provides educa tion to clients and their families. Education includes instructions specific to the procedure, preparations for the procedure, likely sensations (pain, discomfort, cramping, gagging, nausea), and common side effects of medications. During sedation, the nurse continuously evaluates the cli ent. Monitoring during all phases includes assessment of heart rate, respiratory rate, BP, oxygen saturation, and level of

consciousness. The nurse monitors cardiac rhythm in clients who are at risk for arrhythmias or cardiovascular compromise. If vital signs deviate significantly during sedation, the nurse collects additional information to help determine if those devia tions are secondary to an adverse reaction to the sedation or to the procedure itself. When the client shows signs of distress (i.e., deviation in vital signs, respiratory compromise), the nurse immediately reports these signs to the primary provider and provides interventions such as suctioning, gentle tactile stimula tion, or administration of oxygen. They continue to monitor the client’s response until the level of consciousness and vital signs are at baseline. The nurse documents these observations at inter vals specified by the institution.

Analysis, Planning, and Interventions Altered Breathing Pattern: Related to effect of sedative medications Expected Outcome: Client will maintain an effective breathing pattern without signs of cyanosis, hypoxia, and with arterial blood gases in normal range.

• Position client in an upright or semi-Fowler’s position. These positions facilitate lung expansion and oxygenation. • Observe for signs and symptoms of distress related to inap propriate head position (stridor, increased respiratory effort); reposition head as indicated. Early intervention prevents further complications.

• Encourage client to take deep breaths and cough at least ev ery hour. Deep breathing and coughing improve oxygenation and assist in clearing the effects of anesthesia.

Perioperative Injury Risk: Related to sensory/perceptual disturbances due to anesthesia Expected Outcome: Client will remain safe and free of injury while recovering from the effects of anesthesia.

• Provide safety by preventing client from falling out of bed, stretcher, or recliner; assisting with ambulation; and care fully monitoring all activities. Clients recovering from seda tion may have impaired judgment and re exes; the nurse must protect them from injury. • Monitor client for return to presedation level of conscious ness. Until client is fully responsive, they continue to be at risk for a perioperative injury. The client has a patent airway and effective breathing patterns. They are alert and oriented and able to follow instructions re lated to deep breathing and coughing and maintaining safety. Evaluation of Expected Outcomes

• Discharge client to the care of a person who has received instructions regarding client safety. Sedative effects may last for several more hours; the client requires continued care after discharge.

The client has not experienced any perioperative injury. The cli ent’s caregiver verbalizes the need to keep the client safe while recovering from the effects of anesthesia.

urgical Nursing

Evidence-Based Practice boxes include a Clinical Question, Evidence, and Nursing Implications to help students understand how research re lates to current nursing practice.

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Evidence-Based Practice 14-1 The Nurse’s Role in Informed Consent Clinical Question What is the nurse’s role in informed consent of a client? Evidence A hospital in Italy conducted a research study (Strini et al., 2021) to determine the role that the nurses felt they per formed related to informed consent for treatment. With this observational study, there were initially 300 nurses involved, with 206 nurses completing the study over 13 wards in the facility. The average work experience was 15 years, with 27 nurses being males and 179 nurses be ing female. The results of the study showed that the nurses felt that there were issues with lack of privacy when provid ing information to clients and their caregivers, lack of time to ensure that information is provided appropriately, and conferring with other nurses and caregivers regarding the diagnostic and therapeutic procedures for the client. The nurse may be the person responsible for providing medical information to the patient and the family mem bers and may be asked questions by these people that are not nursing related. In conclusion, nurses do take a fundamental role in the patient process of informed con sent. They advocate for the patient and their family mem bers, care directly for the patients, and are able to help empower the patient to make the best decision for each situation while remaining within their scope of practice. Nursing Implications Interdisciplinary communication takes place in nursing with different staff and practitioners. Nurses have a role respon sibility in informed consent of a client. Nurses should be current in their state law on ethics and standards of practice in informed consent. In the nursing role, it is also important to know the primary provider’s role responsibilities to make sure that the client is informed correctly before any type of care or treatment occurs. Increasing nurse communication in an interdisciplinary approach may decrease gaps, barriers, and ultimately the client’s experience. Reference Strini, V., Schiavolin, R., & Prendin, A. (2021). The role of the nurse in informed consent to treatments: An observational-descriptive study in the Padua hospital. Clinics and Practice , 11 (3), 472–483. https://doi.org/10.3390/clinpract11030063

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Features and LearningTools ration of and recovery from anesthesia, team members closely monitor the client for effective breathing and oxygenation, ef fective circulatory status including BP and pulse within nor mal ranges, effective regulation of temperature, and adequate fluid balance. When anesthetics are carefully withdrawn at the end of a surgical procedure, the client will wake enough to fol low commands and breathe independently. The endotracheal

Concept Mastery Alert Regional anesthesia involves injecting an anesthetic agent around the nerves so that the area supplied by these nerves is anesthetized. Local anesthesia is one of several types of regional anesthesia that can be given by injection or topically.

Drug Therapy tables provide an overview of the major categories of drugs used for common conditions ensuring safe, effective practice. CHAPTER 14 Perioperative Care 191

DRUG THERAPY TABLE 14-2 Types of Regional Anesthesia

Type of Anesthesia Local anesthesia

Administration and Intended Use

Drug Examples

Administered topically or by local infiltration. Palliative pain management may be delivered by pump into subcutaneous tissue. Provides local loss of sensation. Used with epinephrine to keep in local tissue and reduce bleeding Used primarily for dental, eye, and minor surgeries Local anesthetic injected into the subarachnoid space of the lumbar area Used for surgery involving the abdomen, perineum, and lower extremities Local anesthetic injected into or near a specific nerve trunk Uses vary widely—Epidural for obstetrics or brachial plexus block for arm/hand surgeries, trigeminal facial pain

Lidocaine (Xylocaine), procaine (Novo caine), tetracaine

C Skin Integrity/Wound Healing. A surgical incision is a wound or injury to skin integrity. Initially, the client may have a wound or incisional drain, which is a tube that exits from the peri-incisional area into either a dressing or portable wound suction device. Figure 14-5 depicts three types of wound devices: Penrose, Jackson-Pratt, and Hemovac drains. When assessing the wound, the nurse inspects for ap proximation of the wound edges, intactness of staples or su tures, redness, warmth, swelling, tenderness, discoloration, or drainage. They also note any reactions to the tape or dress ings. The first phase of wound healing is the inflammatory stage , which is when a blood clot forms, swelling occurs, and phagocytes ingest the debris from damaged tissue and the blood clot. This phase lasts 1 to 4 days. The second phase is the proliferative phase , in which collagen is produced and granulation tissue forms. It occurs over 5 to 20 days. The last phase is referred to as the maturation or remodeling phase and lasts from 21 days to several months and even 1 to 2 years. During this phase, the tensile strength of the wound increases through synthesis of collagen by fibroblasts and lysis by collagenase enzymes. Stop,Think, and Respond 14-3 Postoperatively, the client complains of nausea. What is an important nursing action? If the client is malnourished, hypermetabolic, or not ex pected to resume an oral intake within a few days, a needle catheter jejunostomy tube may be inserted during surgery so that enteral feedings can be given. Resuming Oral Fluids After Surgery • Most clients can begin to take fluids within 4 to 24 hours after surgery (except when surgery involves the GI tract). Check primary provider’s orders to ensure that fluids can be given. • If not allowed oral fluids, provide the client with mouth rinses and a cool, wet cloth or ice chips against the lips to relieve dryness. • Before giving fluids, assess that the client has recovered sufficiently from anesthesia to swallow. Ask the client to try swallowing without drinking anything. If the client can do so, offer a small sip of water or a few ice chips. • Give only a few sips of water or ice chips at a time. In troduce fluids slowly and give them in small amounts to prevent vomiting. The client can take fluids through a straw so they do not have to sit up. Once the client can sit up, however, straws are discouraged because clients tend to swallow air as well, which can lead to abdominal distention and gastric discomfort. • If the client vomits, reassure them that it should cease shortly. Offer mouthwash to remove the taste of anesthetics and vomitus. Administer antiemetics as indicated. Bupivacaine (Marcaine), lidocaine (Xylocaine) NURSING GUIDELINES 14-1 Bupivacaine (Marcaine), lidocaine (Xylo caine), tetracaine

Spinal anesthesia

Drain sponge

Conduction nerve block

191

CHAPTER 14 Perioperative Care

Safety pin keeps drain from slipping into wound

Nursing Guidelines present essential information nurses need to perform specific nursing skills or to manage care for a client with a particular disorder. CHAPTER 14 Perioperative Care 195 B

NURSING GUIDELINES 14-1

Stop,Think, and Respond 14-3 Postoperatively, the client complains of nausea. What is an important nursing action? If the client is malnourished, hypermetabolic, or not ex pected to resume an oral intake within a few days, a needle catheter jejunostomy tube may be inserted during surgery so that enteral feedings can be given. Skin Integrity/Wound Healing. A surgical incision is a wound or injury to skin integrity. Initially, the client may have a wound or incisional drain, which is a tube that exits from the peri-incisional area into either a dressing or portable wound suction device. Figure 14-5 depicts three types of wound devices: Penrose, Jackson-Pratt, and Hemovac drains. When assessing the wound, the nurse inspects for ap proximation of the wound edges, intactness of staples or su tures, redness, warmth, swelling, tenderness, discoloration, or drainage. They also note any reactions to the tape or dress ings. The first phase of wound healing is the inflammatory stage , which is when a blood clot forms, swelling occurs, and phagocytes ingest the debris from damaged tissue and the blood clot. This phase lasts 1 to 4 days. The second phase is the proliferative phase , in which collagen is produced and granulation tissue forms. It occurs over 5 to 20 days. The last phase is referred to as the maturation or remodeling phase and lasts from 21 days to several months and even 1 to 2 years. During this phase, the tensile strength of the wound increases through synthesis of collagen by fibroblasts and lysis by collagenase enzymes. 116 UNIT 3 Foundations of Medical-Surgical Nursing Gerontologic Considerations ■ Approximately 60% to 75% of people over the age of 65 years report having persistent pain. The percentage is believed to be considerably higher for people who are in assisted living or nursing homes (Larsson et al., 2017). About 20% take pain medications several times per week for joint- or muscle-related pain, lingering pain from previous injuries, cancer pain, and other types of chronic pain. Pain is reported to be described as being in multiple sites by 60% to 70% of this population, and multiple types of pain are described by more than 60% of these people (Miaskowski et al., 2020). ■ Lack of an adequate pain assessment can contribute to undertreatment of pain in institutionalized older adults, especially those from cultural backgrounds that differ from those of care providers. ■ Older adults may hesitate to relate pain, considering it a part of aging or from fear of being labeled as “difficult.” Pain assessment must include attention to nonverbal and body positioning cues that conflict with verbal messages. ■ Older adults frequently experience constipation from decreased fluid, decreased mobility secondary to pain with movement, or as an adverse reaction to pain medication. Providing fluid, fiber, or a stool softener along with pain medication can prevent discomfort from a prolonged lack of bowel movement or impaction. ■ An older adult who receives pain medication around the clock (ATC) must have careful urine and bowel elimination as sessment and documentation. Medication levels can increase to dangerous levels from prolonged absorption, metabolism, or elimination times. A change in level of consciousness may be an initial indicator of increasing medication levels. ■ Some people assume that pain sensitivity and perception decrease with aging. Such an assumption can cause inac Resuming Oral Fluids After Surgery • Most clients can begin to take fluids within 4 to 24 hours after surgery (except when surgery involves the GI tract). Check primary provider’s orders to ensure that fluids can be given. • If not allowed oral fluids, provide the client with mouth rinses and a cool, wet cloth or ice chips against the lips to relieve dryness. • Before giving fluids, assess that the client has recovered sufficiently from anesthesia to swallow. Ask the client to try swallowing without drinking anything. If the client can do so, offer a small sip of water or a few ice chips. • Give only a few sips of water or ice chips at a time. In troduce fluids slowly and give them in small amounts to prevent vomiting. The client can take fluids through a straw so they do not have to sit up. Once the client can sit up, however, straws are discouraged because clients tend to swallow air as well, which can lead to abdominal distention and gastric discomfort. • If the client vomits, reassure them that it should cease shortly. Offer mouthwash to remove the taste of anesthetics and vomitus. Administer antiemetics as indicated.

Drain sponge

Client and Family Teaching boxes present instructions and informa tion the nurse can give to the client and family to help improve client outcomes. Safety pin keeps drain from slipping into wound A causes tenseness and difficulty voiding. Signs and symptoms of bladder distention include restlessness, lower abdominal pain, discomfort or distention, and fluid intake without urinary output. If the client does not have a catheter, the nurse assesses the client’s ability to void and measures urine output. If the client cannot void within 8 hours following surgery, the nurse uses methods to encourage voiding, such as running water or having the client stand or use a bedside commode or toilet if permitted. If this does not work, the nurse notifies the primary provider, unless catheterization orders are in place. Psychosocial Status. Many clients experience anxiety and fear after surgery as well as an inability to cope with changes in body image, lifestyle, and other factors. The nurse assesses what the client is experiencing and how the client is dealing with those issues. Many clients need referrals for counseling, support groups, and social services. The nurse acts as an effective listener, identifies areas of concern, and works with other healthcare professionals to assist the client and family to work through the problems. Box 14-6 lists the potential complications that clients may experience postoperatively. Client and FamilyTeaching and Discharge Before discharge, the client needs to receive instructions on how to carry out treatments at home. The nurse conveys the discharge instructions verbally and in writing. The nurse evaluates clients to determine their ability to carry out their care and to determine their specific needs, such as the need for the following: • Supervised home care (e.g., visiting nurse, other health care agencies and providers) • Supplies (e.g., dressings, tape, ostomy supplies, crutches) antidepressants also increases the potential for falls from sedation and changes in cognitive functioning. ■ Because constipation is a common side effect of opioid use, a bowel regimen to prevent constipation should be started when any older adult is treated with opioids. Older adults taking medications for multiple chronic or acute con ditions have an increased susceptibility to drug reactions and interactions. Older adults taking nonsteroidal antiinflam matory drugs (NSAIDs) are at increased risk for renal toxic ity and gastric ulceration. ■ Analgesics given intramuscularly (IM) to older adults are less effective because of their diminished muscle mass. ■ Older adults may avoid taking medication, especially opi oids, out of fear of developing a substance use disorder or drug side effects. Nurses can educate older clients about opioids, facts about substance use disorder, and effective treatment options for any breakthrough pain or side effects such as constipation. ■ In older adults who experience diminished sensation, risk for burns can be minimized by careful monitoring of applica tions using heat. Monitoring is similarly required for cold pack applications to prevent hypothermia. TYPES OF PAIN Pain can be classified into categories according to (1) its source or (2) its onset, intensity, and duration. When classified accord ing to its source, pain can be categorized as either nociceptive or neuropathic. When classified according to its onset, inten sity, and duration, pain can be categorized as either acute or chronic. Pharmacologic Consid erations highlight special considerations nurses need to remember when admin istering or caring for clients receiving specific drugs. ■ Normal weight loss during the early postoperative period is about half a pound daily. Weight gain during this period signifies fluid accumulation. ■ Protein, calories, vitamins A and C, and zinc are important for wound healing and immune system functioning; actual requirements depend on the client’s nutritional status, ex tent of surgery, and development of complications. ■ Unlike the stomach, which does not regain motility for 24 to 48 hours after surgery, the small intestine resumes peristalsis and the ability to absorb nutrients within several hours after surgery. Acute urine retention Urinary tract infection Neurologic Delirium Stroke Dehiscence Evisceration Delayed healing Hemorrhage Hematoma B Figure 14-5 Types of surgical drains: (A) Penrose, (B) Jackson Pratt, and (C) Hemovac. ■ Antibiotics to prevent or fight infection may be ordered be fore as well as after surgery. The drugs must be given at speci fied intervals to maintain consistent therapeutic blood levels. Respiratory Atelectasis Pneumonia Pulmonary embolism Aspiration Cardiovascular Shock Thrombophlebitis Urinary Gastrointestinal Constipation Paralytic ileus Bowel obstruction Functional Weakness Fatigue Functional decline Wound Infection

Client and FamilyTeaching 14-2 Postoperative Instructions

The nurse develops a teaching plan to meet the client’s needs. Points may include the following: • Follow primary provider’s instructions about cleaning the incision, applying the dressing, bathing, diet, and physical activity. • Notify primary provider of any of the following: chills or fever; drainage from the incision (some drainage may be expected in certain instances); foul odor or pus from the incision; redness, streaking, pain, or tenderness around the incision; other symptoms not present at discharge (e.g., vomiting, diarrhea, cough, or chest or leg pain). • Take medications as prescribed, including pain medica tions. Do not omit or change the dose unless the primary provider advises to do so. • Do not take nonprescription medications unless ap proved by the primary provider. • Follow dietary advice and drink fluids liberally, unless di rected otherwise. • Do not drive or operate machinery until cleared by the primary provider. • Keep all postoperative appointments. • Tell the primary provider about any problems during recovery. The Postoperative Client ■ Progress the diet as soon as possible after surgery to promote an adequate oral intake. ■ Encourage clients who are anorexic or nauseated to consume small, frequent feedings. They may tolerate high-protein, low-fat liquids better than traditional meals. ■ If possible, schedule pain medications enough in advance to allow the client a pain-free mealtime. C Figure 14-5 Types of surgical drains: (A) Penrose, (B) Jackson Pratt, and (C) Hemovac. Nutrition Notes

Gerontologic Considerations are now located at the beginning of each chap ter so that the student can incorporate these considerations into their think ing as they read the chapter. Students can reflect on current research and theory as they read and think about how pathophysiology, signs and symp toms, or nursing care differs for the older population. Nutrition Notes The Postoperative Client ■ Progress the diet as soon as possible after surgery to promote an adequate oral intake. ■ Encourage clients who are anorexic or nauseated to consume small, frequent feedings. They may tolerate high-protein, low-fat liquids better than traditional meals. ■ If possible, schedule pain medications enough in advance to allow the client a pain-free mealtime. BOX 14-6 Potential Postoperative Complications Because sedative medications affect memory for events surrounding their administration, the nurse must review discharge instructions with an adult who will be respon sible for the client after discharge. They instruct the client not to drink alcoholic beverages for a specified period after the procedure and to resume prescription and nonprescrip tion medications when appropriate. The nurse must instruct the client about when it is appropriate to begin taking pain medications because they may have an additive effect with the sedative medications that were administered. Client and Family Teaching 14-2 outlines key information to teach postoperatively. ■ Normal weight loss during the early postoperative period is about half a pound daily. Weight gain during this period signifies fluid accumulation. ■ Protein, calories, vitamins A and C, and zinc are important for wound healing and immune system functioning; actual requirements depend on the client’s nutritional status, ex tent of surgery, and development of complications. ■ Unlike the stomach, which does not regain motility for 24 to 48 hours after surgery, the small intestine resumes peristalsis and the ability to absorb nutrients within several hours after surgery. Pharmacologic Considerations • Special dietary needs • Adjustments to the living environment (e.g., special bed, portable commode, wheelchair access)

For clients who have undergone ambulatory surgery, surgical units use outcome criteria to determine if the client’s condition is stable and if they can safely leave the hospital or outpatient setting. These criteria include that the client • has stable cardiovascular function and a patent airway; • is easily aroused; • has intact protective reflexes; • can talk; • can sit up unaided; • is adequately hydrated. ■ Antibiotics to prevent or fight infection may be ordered be fore as well as after surgery. The drugs must be given at speci fied intervals to maintain consistent therapeutic blood levels.

Nociceptive Pain

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