1. ● Contributors
Sandra M. Annesi, RN, MSN Jill Cash, MSN, APRN, BC
Assistant Professor Family Nurse Practitioner
Nursing Program Southern Illinois OB-GYN Associates, SC
Daytona Beach Community College Carbondale, Illinois
DeLand, Florida Chapter 59: Assessment and Management of Patients With Hearing
Chapter 25: Respiratory Care Modalities and Balance Disorders
Judith C. Bautch, PhD, RN, CS Linda Carman Copel, PhD, RN, CS, CGP, DAPA
Professor Associate Professor
Department of Nursing Villanova University College of Nursing
Winona State University Villanova, Pennsylvania
Winona, Minnesota Chapter 4: Health Education and Health Promotion
Chapter 54: Assessment and Management of Patients With Chapter 6: Homeostasis, Stress, and Adaptation
Rheumatic Disorders Chapter 7: Individual and Family Considerations Related to Illness
Jo Ann Brooks-Brunn, DNS, RN, FAAN, FCCP Juliet Corbin, RNC, DNS, FNP
Assistant Professor Lecturer
Thoracic Surgery School of Nursing
Pulmonary and Critical Care Medicine San Jose State University
Indiana University School of Medicine San Jose, California
Indianapolis, Indiana Chapter 10: Chronic Illness
Chapter 23: Management of Patients With Chest
and Lower Respiratory Tract Disorders Susanna G. Cunningham, RN, PhD, FAAN, FAHA
Chapter 24: Management of Patients With Chronic Obstructive Professor
Pulmonary Disorders Department of Biobehavioral Nursing and Health Systems
University of Washington School of Nursing
Jacqueline Fowler Byers, PhD, RN, CNAA Seattle, Washington
Associate Professor Chapter 32: Assessment and Management of Patients
School of Nursing With Hypertension
University of Central Florida
Orlando, Florida Lana Currance, RN, BSN, CCRN
Chapter 21: Assessment of Respiratory Function Chief Nursing Officer
National Medical Response System
Kim Cantwell-Gab, BSN, RN, CVN, RVT, RDMS Colorado 2 DMAT/Central U.S. NMRT-Weapons of
Vascular Surgery Nurse Specialist Mass Destruction
Department of Surgery, Division of Vascular Surgery Parker, Colorado
University of Washington School of Medicine Chapter 72: Terrorism, Mass Casualty, and Disaster Nursing
Seattle, Washington
Chapter 31: Assessment and Management of Patients With Vascular Margaret A. Degler, RN, MSN, CRNP, CUNP
Disorders and Problems of Peripheral Circulation Director, Continence Program
West Office of the Center for Urologic Care of Berks County, P.C.
Patricia E. Casey, RN, MSN West Reading, Pennsylvania
Director, Regional Cardiovascular Program Chapter 12: Health Care of the Older Adult
Kaiser Permanente Mid-Atlantic Region Chapter 43: Assessment of Renal and Urinary Tract Function
Rockville, Maryland Chapter 44: Management of Patients With Upper or Lower Urinary
Chapter 27: Management of Patients With Dysrhythmias Tract Dysfunction
and Conduction Problems Chapter 45: Management of Patients With Urinary Disorders
Chapter 28: Management of Patients With Coronary
Vascular Disorders Nancy E. Donegan, RN, BS, MPH
Chapter 29: Management of Patients With Structural, Infectious, Director, Infection Control
and Inflammatory Cardiac Disorders Washington Hospital Center
Chapter 30: Management of Patients With Complications Washington, D.C.
From Heart Disease Chapter 70: Management of Patients With Infectious Diseases
v
2. vi Contributors
Phyllis Dubendorf, RN, MSN, CS-ACNP Janice L. Hinkle, PhD, RN, CNRN
Lecturer, Acute Care Nurse Practitioner Program Assistant Professor
School of Nursing Villanova University College of Nursing
University of Pennsylvania Villanova, Pennsylvania
Philadelphia, Pennsylvania Chapter 5: Health Assessment
Chapter 61: Management of Patients With Neurologic Dysfunction Chapter 62: Management of Patients With Cerebrovascular Disorders
Chapter 65: Management of Patient With Oncologic
Eleanor Fitzpatrick, RN, MSN, CRNP, CCRN and Degenerative Neurologic Disorders
Clinical Nurse Specialist
Surgical ICU/Intermediate Surgical ICU Ryan R. Iwamoto, ARNP, MN, AOCN
Thomas Jefferson University Hospital Oncology Clinical Coordinator
Philadelphia, Pennsylvania Genentech BioOncology, Inc.
Chapter 39: Assessment and Management of Patients With South San Francisco, California
Hepatic Disorders Nurse Practitioner
Chapter 40: Assessment and Management of Patients With Biliary Department of Radiation Oncology
Disorders Virginia Mason Medical Center
Clinical Instructor
Mary Beth Flynn, RN, MS University of Washington and Seattle University
CNS/Clinical Educator Seattle, Washington
University of Colorado Hospital Chapter 49: Assessment and Management of Problems Related to Male
Clinical Faculty Reproductive Processes
University of Colorado Health Science Center
Denver, Colorado Joyce Young Johnson, RN, PhD, CCRN
Chapter 15: Shock and Multisystem Failure Assistant Chair
Department of Nursing
Kathleen K. Furniss, MSN, APN-C Georgia Perimeter College
Nurse Practitioner, Women’s Health Clarkston, Georgia
Women’s Health Initiative Chapter 1: Health Care Delivery and Nursing Practice
University of Medicine and Dentistry of New Jersey and Associates in Chapter 2: Community-Based Nursing Practice
Women’s Health Care Chapter 3: Critical Thinking, Ethical Decision Making,
Newark, New Jersey and the Nursing Process
Chapter 46: Assessment and Management of Female Chapter 8: Perspectives in Transcultural Nursing
Physiologic Processes
Rhonda Kyanko, RN, MS
Chapter 47: Management of Patients With Female
Nursing Education Coordinator
Reproductive Disorders
National Rehabilitation Hospital
Washington, DC
Paula Graling, RN, MSN, CNS
Chapter 11: Principles and Practices of Rehabilitation
Clinical Nurse Specialist
Perioperative Services Pamela J. LaBorde, MSN, RN
Inova Fairfax Hospital Clinical Nurse Specialist, Patient Care Services
Falls Church, Virginia University of Arkansas Medical Sciences Center
Chapter 18: Preoperative Nursing Management Little Rock, Arkansas
Chapter 19: Intraoperative Nursing Management Formerly, Clinical Nurse Specialist, Burn Unit
Chapter 20: Postoperative Nursing Management Orlando Regional Medical Center
Orlando, Florida
Randolph E. Gross, RN, MS, CS, AOCN Chapter 57: Management of Patients With Burn Injury
Clinical Nurse Specialist
Evelyn H. Louder Breast Center Dale Halsey Lea, RN, MPH, CGC, APGN, FAAN
Memorial Sloan-Kettering Cancer Center Assistant Director
New York, New York Southern Maine Regional Genetics Services
Chapter 48: Assessment and Management of Patients Foundations for Blood Research
With Breast Disorders Scarborough, Maine
Chapter 9: Genetics Perspectives in Nursing Practice
Doreen Grzelak, RN, MSN, AOCN
Operations Manager Dorothy B. Liddel, RN, MSN, ONC
Medical Imaging Center Associate Professor (Retired)
Department of Radiology Department of Nursing
Reston Hospital Center Columbia Union College
Reston, Virginia Tacoma Park, Maryland
Chapter 35: Management of Patients With Oral and Esophageal Chapter 66: Assessment of Musculoskeletal Function
Disorders Chapter 67: Musculoskeletal Care Modalities
Chapter 37: Management of Patients With Gastric and Duodenal Chapter 68: Management of Patients With Musculoskeletal Disorders
Disorders Chapter 69: Management of Patients With Musculoskeletal Trauma
3. Contributors vii
Martha V. Manning, RN, MSN Kathleen Nokes, PhD, RN, FAAN
Nurse Clinician Professor
Inova Emergency Care Center at Fairfax Hunter-Bellevue School of Nursing
Fairfax, Virginia New York, New York
Chapter 34: Assessment of Digestive and Gastrointestinal Function Chapter 52: Management of Patients With HIV Infection and AIDS
Chapter 38: Management of Patients With Intestinal
and Rectal Disorders Janet A. Parkosewich, RN, MSN, CCRN
Cardiac Clinical Nurse Specialist
Barbara J. Maschak-Carey, RN, MSN, CDE Department of Patient Services
Clinical Nurse Specialist Yale-New Haven Hospital
Department of Endocrinology, Diabetes and Metabolism New Haven, Connecticut
University of Pennsylvania Health System Chapter 26: Assessment of Cardiovascular Function
Philadelphia, Pennsylvania
Chapter 41: Assessment and Management of Patients Anne Gallagher Peach, RN, MSN
With Diabetes Mellitus Chief Operating Officer
M.D. Anderson Cancer Center Orlando
Agnes Masny, RN, MPH, MSN, CRNP Orlando, Florida
Research Associate /Nurse Practitioner Chapter 22: Management of Patients With Upper Respiratory
Population Science Division, Family Risk Assessment Program Tract Disorders
Fox Chase Cancer Center
Philadelphia, Pennsylvania JoAnne Reifsnyder, PhD, RN, AOCN
Chapter 9: Genetics Perspectives in Nursing Postdoctoral fellow, Psychosocial Oncology
School of Nursing
Lou Ann McGinty, MSN, RN University of Pennsylvania
Nurse Science Clinical Specialist Philadelphia, Pennsylvania
Capitol Health System Chapter 17: End-of-Life Care
Trenton, New Jersey
Chapter 64: Management of Patients With Infectious, Inflammatory, Susan A. Rokita, RN, MS, CRNP
and Autoimmune Neurologic Disorders Nurse Coordinator, Cancer Center
Oncology Clinical Nurse Specialist
Nancy A. Morrissey, RN,C, PhD Milton S. Hershey Medical Center of Pennsylvania State University
Patient Care Director Hershey, Pennsylvania
Mental Health and Behavioral Center Chapter 16: Oncology: Nursing Management in Cancer Care
Inova Alexandria Hospital
Alexandria, Virginia Al Rundio, PhD, RN, ANP
Chapter 36: Gastrointestinal Intubation and Special Associate Professor
Nutritional Modalities Medical College of Pennsylvania/Hahnemann University
College of Nursing and Health Professions
Martha A. Mulvey, RN, MS, CNS Philadelphia, Pennsylvania
Advanced Practice Nurse Chapter 50: Assessment of Immune Function
Neurosciences Chapter 51: Management of Patients With Immunodeficiency
University of Medicine and Dentistry of New Jersey, Chapter 53: Assessment and Management of Patients
University Hospital With Allergic Disorders
Newark, New Jersey
Chapter 14: Fluids and Electrolytes: Balance and Distribution Catherine Sackett, RN, BS, CANP
Ophthalmic Research Nurse Practitioner
Victoria Navarro, RN, MAS, MSN Wilmer Eye Institute
Director of Clinical Services Retinal Vascular Center
Wilmer Eye Institute The Johns Hopkins Medical Institutions
The Johns Hopkins Medical Institutions Baltimore, Maryland
Baltimore, Maryland Chapter 58: Assessment and Management of Patients With Eye
Chapter 58: Assessment and Management of Patients With Eye and Vision Disorders
and Vision Disorders
Linda Schakenbach, RN, CNS, MSN, CCRN, COCN, CWCN, CS
Donna Nayduch, RN-CS, MSN, CCRN Clinical Nurse Specialist, Critical Care
Trauma Regional Director Inova Alexandria Hospital
Banner Health Alexandria, Virginia
Greeley, Colorado Chapter 27: Management of Patients With Dysrhythmias
Chapter 71: Emergency Nursing and Conduction Problems
Chapter 72: Terrorism, Mass Casualty, and Disaster Nursing Chapter 28: Management of Patients With Coronary
Vascular Disorders
Chapter 29: Management of Patients With Structural, Infectious,
and Inflammatory Cardiac Disorders
4. viii Contributors
Margaret A. Spera, NP, APRN Dorraine Day Watts, PhD, RN
Nurse Practitioner Interim Director of Research and Education
Family Medical Associates Inova Health System
Ridgefield, Connecticut Falls Church, Virginia
Assistant Clinical Professor Chapter 63: Management of Patients With Neurologic Trauma
Yale University School of Nursing
New Haven, Connecticut Joan Webb, RN, MSN
Chapter 60: Assessment of Neurologic Function Instructor
College of Nursing
Cindy Stern, RN, MSN Widener University
Cancer Network Coordinator Chester, Pennsylvania
University of Pennsylvania Cancer Center Chapter 40: Assessment and Management of Patients
University of Pennsylvania Health System With Biliary Disorders
Philadelphia, Pennsylvania Chapter 42: Assessment and Management of Patients
Chapter 16: Oncology: Nursing Management in With Endocrine Disorders
Cancer Care
Joyce S. Willens, RN, PhD
Christine Tea, RN, MSN, CNA Assistant Professor
Patient Care Director College of Nursing
Main OR Perioperative Services Villanova University
Inova Fairfax Hospital Villanova, Pennsylvania
Falls Church, Virginia Chapter 13: Pain Management
Chapter 18: Preoperative Nursing Management
Chapter 19: Intraoperative Nursing Management Iris Woodard, RN-CS, BSN, ANP
Chapter 20: Postoperative Nursing Management Nurse Practitioner
Department of Dermatology
Mary Laudon Thomas, RN, MS, AOCN Kaiser Permanente
Hematology Clinical Nurse Specialist Springfield, Virginia
Veterans’ Administration, Palo Alto Health Care System Chapter 55: Assessment of Integumentary Function
Palo Alto, California Chapter 56: Management of Patients With Dermatologic Problems
Chapter 33: Assessment and Management of Patients
With Hematologic Disorders
5. ● Consultants
Contributorsand Reviewers
Debbie Amason, BSN, MS, RN Lynn Browning, RN, MSN BC Mary Elliot, BScN, MEd, RN
Assistant Professor Assistant Professor of Nursing Professor
Floyd College Derry Patterson Wingo School of Nursing Humber College of Applied Arts & Technology
Rome, Georgia Charleston Southern University Etobicoke, Ontario, Canada
Charleston, South Carolina
William Ames, MSN, RN, FNP Cheryl Fenton, BHSc, RN
Associate Professor Elizabeth Bruce, RN, MSN Professor
Elizabethtown Community College St. Clair Community College Mohawk College
Elizabethtown, Kentucky Chatham, Ontario Burlington, Ontario, Canada
Susan Arbogast, MS, RN Shirley Cantrell, PhD, RN Kathie Folsom, RN, BSN, MS
Faculty Associate Professor Department Chair
Maricopa Community College District Piedmont College Skagit Valley College
Nursing Program, Phoenix College Demorest, Georgia Oak Harbor, Washington
Campus
Phoenix, Arizona Donna Cartwright, MS, APRN Donna Funk, MN/E ONC, RN
Dean, Professional and Applied Technology Professor of Nursing
Gail Armstrong, ND, RN Education Brigham Young University
Assistant Professor College of Eastern Utah Rexburg, Idaho
University of Colorado School of Nursing Price, Utah
Denver, Colorado Vicki Garlock, BSN, MSN, RN
Pattie Garrett Clark, MSN, RN Professor, Nursing Department
Denise M. Ayers, MSN, RN Associate Professor of Nursing Pensacola Junior College
Assistant Professor, Nursing Abraham Baldwin College Pensacola, Florida
Kent State University at Tuscarawas Tifton, Georgia
New Philadelphia, Ohio Mary Catherine Gebhart, MSN, CRRN, RN
Terry Cicero, MN, CCRN, RN Instructor
Valerie Benedix, BSN, RN Instructor, School of Nursing Georgia State University
Nursing Instructor Seattle University Atlanta, Georgia
Clovis Community College Seattle, Washington
Clovis, New Mexico Donna Gullette, DNS, RN
Tracey D. Cooper, RN, MSN Associate Professor, Critical Care Chair
Ilene Borze, MS, CEN, RN Director, Nursing Learning Resources Lab Mississippi University for Women
Director, Nursing Continuing Education Instructor, South Plains College Columbus, Mississippi
Faculty Levelland, Texas
Gateway Community College Carol Heinrich, PhD, RN
Phoenix, Arizona Dolly I. Daniel, BSN, CDE, RNC Associate Professor
Diabetes Nurse Specialist Department of Nursing
Donna Bowren, RN, MSN, CNOR, CRNFA Inova Alexandria Hospital East Stroudsburg University
Interim Chairperson, Division of Nursing Alexandria, Virginia East Stroudsburg, Pennsylvania
and Allied Health
University of Arkansas Community College Toni Doherty, MSN, RN Sandra Hendelman, MS, RN
at Batesville Associate Professor Adjunct Professor of Nursing
Batesville, Arkansas Department Head, Nursing Palm Beach Community College
Dutchess Community College Lake Worth, Florida
Pat Bradley, RN, MEd MS Poughkeepsie, New York South College
Nursing Faculty
Grossmont College Sandra Edwards, BScN, RN Judith Ann Hughes, EdD, RN
El Cajon, California Instructor Associate Degree Nursing Coordinator
Grant MacEwan College Southwestern Community College
Edmonton, Alberta, Canada Sylva, North Carolina
ix
6. x Consultants and Reviewers
Sadie Pauline Hutson, MSN, RN, CRNP Halton Healthcare Services Kathleen L. Russ, MSN, RN
Cancer Research Training Award Oakville, Ontario Dean of Student Support/Health Careers
PreDoctoral Fellow Clinical Faculty Gateway Technical College
National Cancer Institute, McMaster University School of Nursing Kenosha, Wisconsin
Clinical Genetics Branch Hamilton, Ontario
Rockville, MD Esther Salinas, MSN, MSEd, RN
Lauren O’Hare, MSN, EdD, RN Associate Professor of Nursing
Jennifer Johnson. MSN, RN C Assistant Professor of Nursing Del Mar College
Assistant Professor of Nursing Wagner College Corpus Christi, Texas
Kent State University, Tuscarawas Campus Staten Island, New York
New Philadelphia, Ohio Marsha Sharp, MSN, RN
Caroline Ostand, BC, MSN, RN Associate Professor
Susan J. Lamanna, MA, MSN, RN ANP Clinical Instructor Elizabethtown Community College
Associate Professor University of Charleston Elizabethtown, Kentucky
Onondaga Community College Charleston, West Virginia
Syracuse, New York Kelli Simmons, MS, CS, M-SCNS, RN
Thena E. Parrott, PhD, RNCS Cardiothoracic Clinical Nurse Specialist
Joan Ann Leach, MS, ME, RNC Director, Associate Degree Nursing Program University of Missouri Hospitals and Clinics
Professor of Nursing Blinn College Columbia, Missouri
Capital Community College Bryan, Texas
Hartford, Connecticut Terri Small, MSN, RN C
Billie Phillips, PhD, RN, CDFS Assistant Professor of Nursing
Gayle Lee, PhD, RN, CCRN Assistant Professor Waynesburg College
Faculty Tennessee Wesleyan College Waynesburg, Pennsylvania
Brigham Young University Fort Sanders Nursing Department
Rexburg, Idaho Athens, Tennessee Darla R. Ura, MA, ANP-CS, RN
Clinical Associate Professor
Brenda Lohri-Posey, EdD, RN Pam Primus, BSN, RN Emory University
Assistant Dean of Learning, Nursing Nurse Educator Atlanta, Georgia
& Program Coordination Casper College
Belmont Technical College Casper, Wyoming Weibin Yang, MD
St. Clairesville, Ohio Assistant Professor of Physical Medicine and
Betty E. Richards, RN, MSN Rehabilitation Medicine (PM&R)
Rhonda McLain, MN, RN Professor of Nursing University of Illinois
Assistant Professor of Nursing Middle Georgia College Chicago, Illinois
Clayton College & State University Cochran, Georgia
Morrow, Georgia
Patsy Ruppert Rider, MSN, CS, RN
Pat Nashef, MHSc BA (CPMHN)c, RN Clinical Instructor in Nursing
Professional Practice Clinician, University of Texas at Austin School of Nursing
Mental Health Services Austin, Texas
7. ● Preface
A s the 21st century begins, nurses face a future characterized
by changes comparable to those of no preceding century:
NEW CHAPTERS: GENETICS, END-OF-LIFE
CARE, AND BIOTERRORISM
• Science and technology have made the world smaller by Nursing knowledge is constantly expanding. Chapter 9, Genetics
making it more accessible. Perspectives in Nursing Practice, was written in response to genetics
• Mass communication is more widespread, and information information identified during the last few years. Every nurse needs
is now just an instant away and very easy to obtain. to be aware of the influence of genetics on health and illness, and
• Economies are more global than regional. every nurse needs to have the knowledge and skill to answer pa-
• Industrial and social changes have made world travel and tients’ questions concerning their heredity and health. In addition
cultural exchange common. to Chapter 9, genetics content has been incorporated into each
Today’s nurses enter a realm of opportunities and challenges for clinical unit of the textbook.
providing high-quality, evidence-based care in traditional as well as Chapter 17, End-of-Life Care, also new to the tenth edition, ad-
new and innovative health care settings. The rapid changes in dresses some of the questions posed by technologies that can pro-
health care mandate that nurses be prepared to provide or plan care long life, often in the face of insurmountable obstacles. The chapter
across the continuum of settings—from hospital or clinic, to home, discusses the nurse’s role as it pertains to quality of life, prolonga-
to community agencies or hospice settings—and during all phases tion of dying, pain relief, allocation of resources, ethical issues,
of illness. Recent research has indicated that nurses make significant communication, healing, spirituality, and patient and family care.
contributions to the health care outcomes of patients who are hos- It emphasizes the pivotal role of the nurse in providing end-of-life
pitalized. Therefore, today’s nurses must be prepared to identify care.
patients’ short- and long-term needs quickly and to collaborate ef- A third new chapter—Chapter 72, Terrorism, Mass Casualty,
fectively with patients and families, other members of the health care and Disaster Nursing—completes the text by reviewing the nurse’s
team, and community agencies to create a seamless system of care. role in relation to patients affected by terrorism and other disasters.
The continued emphasis on health promotion efforts to keep well Among the issues addressed are emergency preparedness and plan-
people healthy and to promote a higher level of well-being among ning, triage in cases of mass casualty, radiation, chemical and bio-
those with acute and chronic illnesses requires today’s nurses to as- logic weapons, ethical conflict, stress management, and survival.
sist patients in adopting healthy lifestyles and strategies. Mapping
of the human genome and other advances in genetics have moved NANDA, NIC, NOC: LINKS, LANGUAGES,
the issue of genetics to the bedside and increased the need for nurses AND CONCEPT MAPS
to become knowledgeable about genetics-related issues.
In preparing for these vast opportunities and responsibilities, Although Brunner & Suddarth’s Textbook of Medical-Surgical
today’s nurses must be well informed and up-to-date, not only in Nursing has long used nursing diagnoses developed by the North
nursing knowledge and skills but also in research findings, scien- American Nursing Diagnosis Association (NANDA), this edition
tific advances, and the ethical dilemmas inherent in many areas of presents the links between the NANDA diagnoses and the Nurs-
clinical practice. More than ever, today’s nurses need to think crit- ing Interventions Classification (NIC) and Nursing-sensitive Out-
ically, creatively, and compassionately. comes Classification (NOC). The opening page of each unit
This tenth edition of Brunner & Suddarth’s Textbook of Medical- presents a concept map illustrating these three classification sys-
Surgical Nursing is designed for the 21st century and nurses’ need to tems and their relationships. Each unit’s concept map is accom-
be knowledgeable, highly skilled, perceptive, caring, and compas- panied by a case study and a chart presenting examples of actual
sionate. A goal of the textbook is to provide balanced attention to NANDA, NIC, and NOC terminologies related to the case study.
the art and science of adult medical-surgical nursing. It addresses This material is included to introduce the reader to the NIC and
nursing care issues from a physiological, pathophysiological, and NOC language and classifications and bring them to life in the
psychosocial context and assists the reader to identify priorities of clinical realm. Faculty and students alike may use some of the
care from that context. issues presented in the case studies as a springboard for develop-
ing their own concept maps.
ABOUT THE TENTH EDITION
RECENT NURSING RESEARCH
The tenth edition of Brunner and Suddarth’s Textbook of Medical
Surgical Nursing was constructed to provide today’s nursing stu-
AND OTHER FEATURES
dents with an understanding of the nurse’s role in health and illness As before, Nursing Research Profiles included in the chapters
within evolving practice environments and across the spectrum of identify the implications and applications of recent nursing re-
health and illness. The textbook’s content has been revised and up- search findings for nursing practice. The chapters also include
dated by experts in the field to reflect current practice and advances charts and text detailing special considerations in caring for the
in health care and technology. elderly patient and for those with disabilities.
xi
8. xii Preface
TEACHING TOOLBOX • CD-ROM to help students test their knowledge and enhance
their understanding of medical-surgical nursing. This CD in-
Each chapter opens with Learning Objectives and a Glossary. cludes 500 self-study questions organized by unit; 3000 bonus
Throughout the text the reader will find Nursing Alerts as well as NCLEX-style cross-disciplinary questions; 3-D animated il-
specialized charts focusing on lustrations that explain common disease processes; and in-
• Physiology/Pathophysiology teractive clinical simulations.
• Risk Factors • Student Study Guide to further enhance the learning ex-
• Assessment perience (available at student bookstores)
• Plans of Nursing Care • Instructor’s Resource CD-ROM to help facilitate class-
• Pharmacology room preparation, with an instructor’s manual, test gener-
• Home Care ator, and searchable image collection, among other features
• Patient Education • Supplemental cartridges for Blackboard and WebCT
• Health Promotion • Connection Website—Get connected at connection.LWW.
• Ethics and Related Issues com/go/smeltzer.
• Guidelines
The tenth edition of Brunner and Suddarth’s Textbook of
• Gerontological Considerations
Medical-Surgical Nursing continues the tradition of presenting
• Genetics in Nursing Practice
up-to-date content that addresses the art and science of nursing
Illustrations, photographs, charts, and tables supplement the practice. The updating of the material and use of a variety of
text and round out the applied-learning experience. Each chapter teaching methods to convey that content are intended to provide
concludes with Critical Thinking Exercises, References and Selected the nursing student and other users of the textbook with infor-
Readings, and a list of specialized Resources and Websites. mation needed to provide quality care to patients and families
across health care settings and in the home.
MANY MORE OF THE LATEST RESOURCES Suzanne C. O’Connell Smeltzer, RN, EDD, FAAN
Additional learning tools accompany the tenth edition and offer Brenda G. Bare, RN, MSN
visual, tactile, and auditory reinforcement of the text. These re-
sources include:
9. How to use
Brunner & Suddarth’s
Textbook of Medical-Surgical Nursing
10th edition
The patient recovering from abdominal surgery with
reluctance to move and a history of smoking
▲
receives the requires nursing outcomes should show Concept Maps—with NANDA,
nursing diagnoses interventions improvement in
NIC, and NOC illustrate reality-
Risk for Impaired Respiratory Anxiety based clinical scenarios for the
requires Control
Gas Exchange Monitoring visual learner.
may be
reduced by improves
and and outcomes in and
requires
Cough Respiratory
Risk for Ineffective improves
may be Enhancement Status: Gas
Airway Clearance outcomes in
reduced by Exchange
and and and
limits
▼ Plans of Nursing Care—
Risk for
Thrombophlebitis requires
Embolus
Precautions
Pain Level illustrate applications of the
reduces
risk for
nursing process to diseases
and disorders.
secondary to and and
improves
Acute Pain
may be Pain helps to ofImmobility
Plan Consequences:Care
Nursing
lessened by Management prevent
Care Physiologic
of the Patient With COPD (Continued)
Nursing Interventions Rationale Expected Outcomes
may be helps to
and and and
Nursing Diagnosis: Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction,
prevent
lessened by
and airway irritants
Goal: Improvement in breathing pattern
Impaired Physical Teaching: Prescribed leads to
requires Mobility Level
Mobility 1. Teach patient diaphragmatic and pursed-
improved 1. Helps patient prolong expiration time • Practices pursed-lip and diaphragmatic
Activity/Exercise lip breathing. and decreases air trapping. With these breathing and uses them when short of
techniques, patient will breathe more breath and with activity
efficiently and effectively. • Shows signs of decreased respiratory effort
2. Encourage alternating activity with rest 2. Pacing activities permits patient to per- and paces activities
periods. Allow patient to make some de- form activities without excessive distress. • Uses inspiratory muscle trainer as pre-
cisions (bath, shaving) about care based scribed
on tolerance level.
3. Encourage use of an inspiratory muscle 3. Strengthens and conditions the respira-
trainer if prescribed. tory muscles.
Nursing Diagnosis: Self-care deficits related to fatigue secondary to increased work of breathing and insufficient
ventilation and oxygenation
Goal: Independence in self-care activities
1. Teach patient to coordinate diaphragmatic 1. This will allow the patient to be more ac- • Uses controlled breathing while bathing,
breathing with activity (eg, walking, tive and to avoid excessive fatigue or dys- bending, and walking
bending). pnea during activity. • Paces activities of daily living to alternate
2. Encourage patient to begin to bathe self, 2. As condition resolves, patient will be able with rest periods to reduce fatigue and
dress self, walk, and drink fluids. Discuss to do more but needs to be encouraged to dyspnea
energy conservation measures. avoid increasing dependence. • Describes energy conservation strategies
3. Teach postural drainage if appropriate. 3. Encourages patient to become involved • Performs same self-care activities as before
in own care. Prepares patient to manage • Performs postural drainage correctly
at home.
Nursing Diagnosis: Activity intolerance due to fatigue, hypoxemia, and ineffective breathing patterns
Goal: Improvement in activity tolerance
Chart 16-5 1. Support patient in establishing a regular 1. Muscles that are deconditioned consume • Performs activities with less shortness of
regimen of exercise using treadmill and more oxygen and place an additional bur- breath
Home Care Checklist • Chemotherapy Administration exercycle, walking, or other appropriate den on the lungs. Through regular, graded • Verbalizes need to exercise daily and
exercises, such as mall walking. exercise, these muscle groups become demonstrates an exercise plan to be carried
a. Assess the patient’s current level of more conditioned, and the patient can do out at home
At the completion of the home care instruction, the patient or caregiver will be able to: functioning and develop exercise plan Patient more without getting as short of breath.
Caregiver • Walks and gradually increases walking
based on baseline functional status. time and distance to improve physical
Graded exercise breaks the cycle of
• Demonstrate how to administer the chemotherapy agent in the home. b. Suggest consultation with a physical ✓ ✓
debilitation. condition
• Demonstrate safe disposal of needles, syringes, IV supplies, or unused chemotherapy medications. or pulmonary rehabilitation ✓
therapist ✓ • Exercises both upper and lower body
program to determine an exercise pro- muscle groups
• List possible side effects of chemotherapeutic agents. gram specific to the patient’s capability.✓ ✓
Have portable oxygen unit available if
• List complications of medications necessitating a call to the nurse or physician. oxygen is prescribed for exercise. ✓ ✓
• List complications of medications necessitating a visit to the emergency department. ✓ ✓
Nursing Diagnosis: Ineffective coping related to reduced socialization, anxiety, depression, lower activity level,
• List names and telephone numbers of resource personnel involved in care (ie, home care nurse, infusion
services, IV vendor, equipment company). and the inability to work ✓ ✓
Goal: Attainment of an optimal level of coping
• Explain treatment plan (protocol) and importance of upcoming visits to physician. ✓ ✓
1. Help the patient develop realistic goals. 1. Developing realistic goals will promote a • Expresses interest in the future
sense of hope and accomplishment rather • Participates in the discharge plan
than defeat and hopelessness. • Discusses activities or methods that can be
2. Encourage activity to level of symptom 2. Activity reduces tension and decreases performed to ease shortness of breath
▲ Home Care Checklists—include guidelines • Uses relaxation techniques appropriately
tolerance. degree of dyspnea as patient becomes
conditioned. • Expresses interest in a pulmonary rehabili-
tation program
on goals and management of home-based patients. (continued)
10. Physiology/Pathophysiology
Chart 17-6 • ASSESSMENT
A. Rhinitis Nursing Assessment of Symptoms
Associated With Terminal Illness
Edematous
conchae; polyps • How is this symptom affecting the patient’s life?
may develop
• What is the meaning of the symptom to the patient? To the
family?
• How does the symptom affect physical functioning, mobility,
comfort, sleep, nutritional status, elimination, activity level,
and relationships with others?
Occluded • What makes the symptom better?
sinus
openings • What makes it worse?
• Is it worse at any particular time of the day?
Enlarged
nasal • What are the patient’s expectations and goals for managing the
mucosa symptom? The family’s?
Chart 16-4 • PHARMACOLOGY
Discharging • How is the patient coping with the symptom? Investigational Antineoplastic Therapies
mucus
• What is the economic effect of the symptom and its and Clinical Trials
management?
B. Sinusitis Evaluation of the effectiveness and toxic potential of promising new
modalities for preventing, diagnosing, and treating cancer is accom-
Adapted from Jacox, A., Carr, D. B., & Payne, R. (1994). Management through clinical trials. Before new chemotherapy agents are
plished of
Thick mucus cancer pain. Rockville, MD: AHCPR. approved for clinical use, they are subjected to rigorous and lengthy
occludes
sinus cavity
evaluations to identify beneficial effects, adverse effects, and safety.
and prevents • Phase I clinical trials determine optimal dosing, scheduling,
drainage and toxicity.
• Phase II trials determine effectiveness with specific tumor
▲ Assessment Displays— types and further define toxicities. Participants in these early
trials are most often those who have not responded to stan-
provide clinical features dard forms of treatment. Because phase I and II trials may
be viewed as last-chance efforts, patients and families are
of diseases and disorders fully informed about the experimental nature of the trial
therapies. Although it is hoped that investigational therapy
and include guidelines for will effectively treat the disease, the purpose of early phase
trials is to gather information concerning maximal tolerated
doses, adverse effects, and effects of the antineoplastic agents
FIGURE 22-1 Pathophysiologic processes in rhinitis and sinusitis. Although assessing health history and on tumor growth.
pathophysiologic processes are similar in rhinitis and sinusitis, they affect dif- • Phase III clinical trials establish the effectiveness of new
ferent structures. In rhinitis (A), the mucous membranes lining the nasal pas-
sages become inflamed, congested, and edematous. The swollen nasal conchae
exam findings. medications or procedures as compared with conventional
approaches. Nurses may assist in the recruitment, consent,
block the sinus openings, and mucus is discharged from the nostrils. Sinusitis
(B) is also marked by inflammation and congestion, with thickened mucous
and education processes for patients who participate. In
secretions filling the sinus cavities and occluding the openings. many cases, nurses are instrumental in monitoring adher-
ence, assisting patients to adhere to the parameters of the
trial, and documenting data describing patients’ responses.
▲
Pharmacology Charts—review The physical and emotional needs of patients in clinical tri-
als are addressed in much the same way as those of patients
▲ Pathophysiology Displays— recent or common drug therapies who receive standard forms of cancer treatment.
• Phase IV testing further investigates medications in terms of
utilize illustrations and algorithms with discussion of clinical trials new uses, dosing schedule, and toxicities.
to demonstrate processes. where appropriate.
▲
Risk Factor
Chart 25-3 • P A T I E N T E D U C A T I ON Chart 21-8 Charts—outline
Breathing Exercises Risk Factors for Hypoventilation factors that may impair
General Instructions health (eg, carcinogens,
• Breathe slowly and rhythmically to exhale completely and • Limited neurologic impulses transmitted from the brain to the
empty the lungs completely. respiratory muscles, as in spinal cord trauma, cerebrovascular environmental factors),
• Inhale through the nose to filter, humidify, and warm the accidents, tumors, myasthenia gravis, Guillain-Barré
air before it enters the lungs. syndrome, polio, and drug overdose and offer preventive
• If you feel out of breath, breathe more slowly by prolonging
the exhalation time. • Depressed respiratory centers in the medulla, as with anesthesia measures to sidestep
• Keep the air moist with a humidifier. and drug overdose
• Limited thoracic movement (kyphoscoliosis), limited lung them.
Diaphragmatic Breathing
Goal: To use and strengthen the diaphragm during breathing movement (pleural effusion, pneumothorax), or reduced
• Place one hand on the abdomen (just below the ribs) and functional lung tissue (chronic pulmonary diseases, severe
the other hand on the middle of the chest to increase the pulmonary edema)
awareness of the position of the diaphragm and its function
in breathing.
• Breathe in slowly and deeply through the nose, letting the
abdomen protrude as far as possible.
• Breathe out through pursed lips while tightening (contract-
ing) the abdominal muscles.
• Press firmly inward and upward on the abdomen while
breathing out.
• Repeat for 1 minute; follow with a rest period of 2 minutes.
• Gradually increase duration up to 5 minutes, several times a Gerontologic Considerations
day (before meals and at bedtime). Factors Contributing to Urinary Tract Infection
Pursed-Lip Breathing in Older Adults
Goal: To prolong exhalation and increase airway pressure during ex-
▲
piration, thus reducing the amount of trapped air and the amount Gerontologic • High incidence of chronic illness
of airway resistance.
Considerations— • Frequent use of antimicrobial agents
• Inhale through the nose while counting to 3—the amount • Presence of infected pressure ulcers
of time needed to say “Smell a rose.” provide specific • Immobility and incomplete emptying of bladder
• Exhale slowly and evenly against pursed lips while tighten- Use of a bedpan rather than a commode or toilet
ing the abdominal muscles. (Pursing the lips increases intra- information relevant to •
tracheal pressure; exhaling through the mouth offers less
resistance to expired air.) the older population.
• Count to 7 while prolonging expiration through pursed
lips—the length of time to say “Blow out the candle.”
• While sitting in a chair:
Fold arms over the abdomen.
Inhale through the nose while counting to 3.
Bend forward and exhale slowly through pursed lips while
counting to 7.
• While walking:
▲
Inhale while walking two steps. Patient Education Boxes—provide
Exhale through pursed lips while walking four or five steps.
suggestions on such topics as self-care,
or how to cope with health challenges.
11. How toUnit 5 GAS EXCHANGE AND RESPIRATORY FUNCTION
xvi
use continued
NURSING ALERT It is the responsibility of all nurses, and partic-
ularly perianesthesia and perioperative nurses, to be aware of latex
! allergies, necessary precautions, and products that are latex-free
(Meeker & Rothrock, 1999). Hospital staff are also at risk for de-
veloping a latex allergy secondary to repeated exposure to latex
products.
Glossary
adaptation: a change or alteration designed
to assist in adapting to a new situation or
by the adrenal cortex; they are involved in
carbohydrate, protein, and fat metabolism
tion, manifested by pain, redness, heat,
swelling, and sometimes loss of function
environment and have anti-inflammatory properties metabolic rate: the speed at which some
adrenocorticotropic hormone (ACTH): a gluconeogenesis: the formation of glucose, substances are broken down to yield en-
hormone produced by the anterior lobe of especially by the liver from noncarbohy- ergy for bodily processes and other sub-
▲ Nursing Alerts—offer brief tips for the pituitary gland that stimulates the se-
cretion of cortisone and other hormones
drate sources such as amino acids and the
glycerol portion of fats
stances are synthesized
metaplasia: a cell transformation in which a
by the adrenal cortex
clinical practice and red-flag warnings antidiuretic hormone (ADH): a hormone
guided imagery: use of the imagination to
achieve relaxation or direct attention away
highly specialized cell changes to a less
specialized cell
secreted by the posterior lobe of the pitu-
to help students avoid common mistakes. itary gland that constricts blood vessels,
from uncomfortable sensations or situations
homeostasis: a steady state within the body;
negative feedback: feedback that decreases
the output of a system
elevates blood pressure, and reduces the
excretion of urine the stability of the internal environment positive feedback: feedback that increases
catecholamines: any of the group of amines hyperplasia: an increase in the number of the output of a system
(such as epinephrine, norepinephrine, or new cells steady state: a stable condition that does not
dopamine) that serve as neurotransmitters hypoxia: inadequate supply of oxygen to change over time, or when change in one
coping: the cognitive and behavioral strate- the cell direction is balanced by change in an op-
NURSING RESEARCH PROFILE 12-2 gies used to manage the stressors that tax a infectious agents: biologic agents, such as posite direction
person’s resources viruses, bacteria, rickettsiae, mycoplasmas, stress: a disruptive condition that occurs in
Identification of Agitation in Patients dysplasia: a change in the appearance of a fungi, protozoa, and nematodes, that response to adverse influences from the
cell after exposure to chronic irritation cause disease in people internal or external environments
with Alzheimer’s Disease glucocorticoids: the group of steroid hor-
mones, such as cortisol, that are produced
inflammation: a localized, protective reac-
tion of tissue to injury, irritation, or infec-
vasoconstriction: the narrowing of a blood
vessel
Whall, A. L., Black, M. E. A., Yankou, D. J., et al. (1999). Nurse aides’
identification of onset and level of agitation in late stage dementia
patients. American Journal of Alzheimer’s Disease, 14, 202–206. ▲ Glossary—at the beginning of every chapter,
Purpose helps students learn vocabulary.
Nursing assistants provide the majority of care to patients in nursing
homes. They are vital links in the early identification, and therefore
in the treatment, of agitation in patients with Alzheimer’s disease.
▲
Nurses’ aides (NAs) are sometimes characterized as unwilling or un- Nursing Research Profiles—contain research samples
able to manage patients’ agitation. This study examines the process with purpose of research, study sample, and design and
by which nurses’ aides can successfully identify this agitation. findings, and implications for use in evidence-based nursing.
Design
NAs from five different nursing homes owned by the same cor-
porate entity were asked to participate in the study. Criteria to par-
ticipate included being employed for at least 1 year. (Research
demonstrates that NAs who remain at a facility longer than 1 year Chart 25-15
usually have a commitment to those they serve.) The NAs did not GUIDELINES FOR Care of the Patient Being Weaned From Mechanical Ventilation
receive any additional wages and were only promised a letter to in-
dicate that they had participated in the study. Each NA received ap- NURSING INTERVENTIONS RATIONALE
proximately 1 hour of training via audio tapes and conversation with Maximum inspiratory pressure (MIP) atcapacity—10 to 15 mL/kg 1. Careful assessmentweaning. When the criteria have beendeter-
1. Assess patient for weaning criteria: Vital
least –20 cm H O mine readiness for
of multiple weaning indices helps to
met,
2
nurse experts. Each NA was then paired with a nurse expert to as- Tidal volume—7 to 9 mL/kg the patient’s likelihood of successful weaning increases.
Minute ventilation—6 L/min
sess his or her skill at appropriately identifying levels of agitation in Rapid/shallow breathing index—below 100 breaths/minute/L
patients with late-stage Alzheimer’s disease. PaO greater than 60 mm Hg with FiO less than 40%
2 2
2. Monitor activity level, assess dietary intake, and monitor results 2. Reestablishing independent spontaneous ventilation can be physi-
of laboratory tests of nutritional status. cally exhausting. It is crucial that the patient have enough energy
Conclusions reserves to succeed. Providing periods of rest and recommended
This study demonstrated that NAs with a minimum of 1 year of Assess the patient’s and family’s understanding of the weaning
3.
nutritional intake can increase the likelihood of successful weaning.
3. The weaning process can be psychologically tiring; emotional
employment did an excellent job in acquiring new observation process and address any concerns about the process. Explain that support can help promote a sense of security. Explaining that
skills with only 1 hour of training and positive reinforcement via a the patient may feel Reassurebreath initially and or she will be at-
agement as needed.
short of
the patient that he
provide encour- weaning will be attempted again later helps reduce the sense of
failure if the first attempts are unsuccessful.
letter noting their participation in this study. The NAs’ assessment tended closely and that if the weaning attempt is not successful,
of signs of agitation agreed with that of the nurse expert more than Implement theagain later.
4.
it can be tried
weaning method prescribed: A/C, IMV, SIMV, 4. The prescribed weaning method should reflect the patient’s indi-
90% of the time. All the NAs involved reported gaining helpful in- PSV, PAV, CPAP, or T-piece. vidualized criteria for weaning and weaning history. By having
different methods to choose from, the physician can select the
sights in managing agitated behavior as a result of participation in one that best fits the patient.
the study. 5. Monitor vital signs, pulse oximetry, ECG, and respiratory pattern 5. Monitoring the patient closely provides ongoing indications of
constantly for the first 20 to 30 minutes and every 5 minutes after success or failure.
that until weaning is complete.
Implications for Practice Chart 22-7 • Ethics and Related Issues 6. Maintain a patent airway; monitor arterial blood gas levels and 6. These values can be compared to baseline measurements to evalu-
The results of this study support the ability of NAs to accurately pulmonary function tests. Suction the airway as needed. ate weaning. Suctioning helps to reduce the risk of aspiration and
maintain the airway.
observe and report agitated behavior as a result of a brief training In collaboration with the physician, terminate the weaning process
Situation 7. 7. These signs and symptoms indicate an unstable patient at risk for
session using adult learning principles thatdiagnosed with importance if adverse reactions occur. These include a heart ratemm Hg, of
A 68-year-old attorney was stressed the cancer of the larynx
20 beats/min, systolic blood pressure increase of 20
increase
a
hypoxia and ventricular dysrhythmias. Continuing the weaning
process can lead to cardiopulmonary arrest.
of their input into the training andtreatedquality. Recently, he has complainedre- in oxygen saturation to less than 90%, respiratory rate
8 years ago. He was
learning objectives. Earlytherapy, of
sulting in an altered voice
successfully with radiation
ob- decrease
less than 8 or greater than 20 breaths/minute, ventricular dys-
servation and reporting of agitated behavior is important toIn the pastrhythmias, fatigue, panic, cyanosis, erratic or labored breathing,
shortness of breath and difficulty swallowing. prevent few
agitation from increasing to the level of physical change in his voice and phys-
months, he also has noticed a marked aggression. paradoxical chest movement.
ical condition, which he attributed to “winter colds.” 8. If the weaning process continues, measure tidal volume and minute 8. These values help to determine if weaning is successful and
After a complete physical exam and an extensive diagnostic ventilation every 20 to 30 minutes; compare with the patient’s should be continued.
desired values, which have been determined in collaboration
workup and biopsy, it is determined that the cancer has recurred at physician.
with the
a new primary site. His health care provider recommends surgery for psychological dependence if the physiologic parameters
9. Assess 9. Psychological dependence is a common problem after mechanical
(a total laryngectomy) and chemotherapy as the best options.indicate weaning is feasible and the patient still resists.
The ventilation. Possible causes include fear of dying and depression
patient states that he is not willing to “lose my voice and my liveli- from chronic illness. It is important to address this issue before
hood” but instead will “take my chances.” He has also expressed the next weaning attempt.
concern about his quality of life after surgery. His family has ap-
proached you about trying to convince him to have surgery.
Dilemma ▲ Procedure Guidelines Charts—offer nursing
The patient’s right to refuse treatment conflicts with the family’s
wishes and recommendation from his health care provider. activities and rationales for important skills.
Discussion
1. Is the patient making a decision based upon all pertinent infor-
mation concerning his health status, treatment, options,
risk/benefits, and long-term prognosis?
2. What arguments can be made to support the patient’s decision
to forego treatment?
Ethics and Related Issues—showcase
▲
3. What arguments can be made to question the patient’s
decision to forego treatment? brief scenarios and present possible ethical
dilemmas for discussion.
