GNRS 588

Dr. Alomari

AZUSA PACIFIC UNIVERSITY

SCHOOL OF NURSING
GNRS 588: ADVANCED NURSING CARE FOR ADULTS
CARE MAP #: ____1_____
Care Map must be completed and submitted within one week of the date of care.

Student: Lauren Ratiani

Instructor: Richards
Date of Care: February 13, 2015
Date of Submission: February 27, 2015

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ADMITTING DATA
Interview your patient or his/her family to obtain a complete health history. Do not just copy from the patients chart unless the patient
and family are not available.
Total 5.0 points (no point for initial, age, gender, or medical diagnoses).
Patients Initial
Age
Gender

Medical History
(0.5)

Surgical History
(0.5)
Allergies and
Reactions (0.5)
Psychosocial History
(0.5)

JV
42
Female
Cardiovascular
HTN
Respiratory
Pneumonia
Neurologic
Stroke
Urinary
UTI
Digestive
Ulcer
Endocrine
DM
Musculoskeletal
Hema/Oncology Anemia
Infectious
Shingles
Integumentary
Reproductive
Psychiatric
Depression
Other
No surgical history

MI
COPD
Parkinsons
ESRD
Diverticulosis
Hyperthyroidism

Dysrhythmias
TB
Guillain-Barre
Renal Failure
Dysphasia
Hypothyroidism

Hyperlipidemia
HF
Respiratory Failure
Encephalopathy
IICP

Cancer:
Hepatitis

Meningitis

STI

PVD
ICH

Anxiety

PCN
Marital status
Education level
Social resources
Spiritual resources
Occupation
Employment
Smoking

Married
High school
Medical (pending)
Catholic
Homemaker
Unemployed
Denies

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History of Present
Illness
(1.0)
Chronological
account of patients
current illness with
pertinent +s and s
included and correct
medical terminology
used.
OLDCART
Initial Symptom(s) at
the time of admission
(in ED)
(1.0)
Medical Diagnosis
(Diagnoses)

Findings that
support/confirm the
medical diagnosis at
admission and
during your care
(1.0)

3
Alcohol
Denies
Recreational Drugs Denies
JV is a 43-year old female with a history of uncontrolled hypertension who presented to Parkview Community Hospital
the evening of February 6, 2015 via ambulance. JV was at a parent-teacher meeting regarding cyber-bullying of her 14year old daughter when she began to experience right-sided hemiparesis including the right side of her face, right hand,
and right leg, along with a decreased level of consciousness. Paramedics were called and the patient was transported to
the hospital. Upon arrival, a brain CT was done which revealed a left-sided thalamic intracranial hemorrhage (ICH). She
was then transferred to Riverside Community Hospital (RCH) for a higher level of care. JV had been warned by a
physician several weeks prior to this incident regarding the risk of stroke that accompanies uncontrolled HTN and was
counseled regarding her noncompliance with medications. After arrival at RCH, a secondary brain CT confirmed the
brain bleed and the patient was taken into surgery where doctors unsuccessfully attempted to place a ventriculostomy
drain in the right frontal area four times. After counsel with the patients family, the placement of a Camino bolt was
performed to monitor intracranial pressure. JV experienced post-operative respiratory failure and remains intubated and
on mechanical ventilation. The patient was admitted to the Surgical Intensive Care Unit and has since been monitored
closely. She is kept sedated and intubated to avoid further increased ICP. Several attempts have been made to wean her
off of sedation, but each time, ICP and BP increase to critical levels. The patient has a triple lumen central venous catheter
to the right femoral vein and an arterial line placed at the left radial artery.
Sudden onset of right-sided hemiparesis occurred during a parent-teacher meeting. JV experienced weakness of the right
hand and was unable to hold onto her cell phone. Paresis then presented as right-sided facial drooping, right arm
flaccidity, and right leg weakness and then flaccidity along with a decreased LOC. JV stated, I think Im having a
stroke as she fell to the floor from her chair. Teachers attempted to help JV and paramedics were called. The patient was
then transported to the hospital. This was the first time the patient had ever reported any symptoms of paresis.
Hypertensive intracranial hemorrhage (ICH), thalamic S/P ventriculostomy attempt and eventual bolt placement
Physical Exam
Diagnostic Tests
2/6/15 Right-sided hemiparesis including facial
2/6/15 CT brain w/o IV contrast left thalamic hematoma, likely
droop, right arm weakness and paresis, right
hypertensive, measuring 26 mm transversely by 21.5 mm
leg weakness and paresis; ALOC
anterior-posteriorly by 30 mm cephalocaudal with
2/13/15 Sedated and intubated with increasing ICP
intraventricular extension into the third ventricle and left lateral
and SBP when daily sedation vacations are
ventricle; a slight approximately 2 mm midline shift from left to
attempted; SBP readings greater than 140 with
right is present; orotracheal and orogastric tubes are present;
daily antihypertensive meds; Pupils pinpoint
severe left sided sinusitis present.
with sluggish response bilaterally; ICP2/9/15 CXR heart enlarged; small patchy infiltrate at left lung base,
monitoring Camino bolt in place
possible mild interstitial edema: correlate clinically.
2/10/15 ICP spiking to mid 20s

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2/11/15 Bilateral carotid duplex U/S normal carotid and vertebral
artery delineation w/o hemodynamically significant stenosis
2/12/15 CT brain w/o IV contrast intraparenchymal hemorrhage
redemonstrated at level of left basal ganglia and thalamus
measuring up to 3.4 cm in the AP transverse and craniocaudal
dimensions, penetrating into left cerebral peduncle and lateral
ventricles; stable and acute, not significantly changed since
previous exam; surrounding edema with localized mass effect;
extensive sinusitis again also noted
2/13/15 ICP ranging from 8-24 mmHg

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HEAD-TO-TOE ASSESSMENT
Perform a head-to-toe assessment on your patient.
Total 7.0 points.
General Status (0.5)

VS & Hemodynamics (1.0)

Neurologic & Pupils (0.5)

Head, Face, & Neck (0.5)
ENT (0.5)

Cardiovascular (1.0)

Pulmonary (1.0)

Gastrointestinal (0.5)
Genitourinary (0.5)

Patient is sedated and intubated with a GCS of 6, no eye opening, no verbal response, flexion/withdrawal to pain
(E:1 V:1, M:4). Patient in semi-fowlers position with head of bed at 30 degrees.
Time T(F) RR
HR
ABP
MAP BS
CO CVP SVR PAP SpO2
ICP
EtCO2
0800 97.6
17
49 132/77
89
N/A N/A N/A N/A
N/A
100
14-24
34
0945

98.6

17

47

140/84

97

N/A

N/A

N/A

N/A

N/A

100

13

33

1130

98.0

17

48

148/80

96

96

N/A

N/A

N/A

N/A

100

8-12

32

Sedated; pupils pinpoint and sluggish bilaterally; unable to assess mentation d/t sedation.
Head is normocephalic, skull symmetric. Camino bolt in place in right frontal area.
Neck is supple; full ROM. No palpable lymph nodes. Thyroid gland non-palpable.
Ears equal size; no swelling or lesions.
Nose symmetric; nostrils patent; no swelling, discharge, or bleeding.
Lips, gums, and buccal mucosa pink, slightly dry r/t intubation. Oral gastric tube in place: placement confirmed
with auscultation; endotracheal tube in place: 23 cm at the lip, size 7.5
Sinus bradycardia; S1, S2 present; no extra heart sounds or murmurs. EF 50-55% per previous echocardiogram.
Carotid artery smooth, no bruit; no JVD. Apical pulse palpable at 5th ICS, MCL; Capillary Refill: < 3 seconds.
Edema +2 in all extremities; radial pulses present, pedal pulses weak. SCDs on lower extremities bilaterally.
Triple lumen CVL at right femoral vein. Arterial line at left radial artery.
A/P diameter appropriate; neck muscles supple. Chest expansion symmetric; clear, diminished breath sounds.
ET tube in place; respirations of 16 bpm on 30% FiO2 via ventilator. ABGs revealed uncompensated metabolic
acidosis.
Ventilator Mode
TV
RR
FiO2
PEEP
I: E Ratio
AC 16 1/min
550 ml
16
30%
5 cm/H2O
1:2.1
pH
PaO2
PaCO2
HCO3BE
SpO2
7.51 (H)
90
35.2
27.3 (H)
4.3
100
Abdomen symmetric bilaterally; soft, not distended. Bowel sounds hypoactive in all quadrants; oral-gastric tube in
place set to low-wall suction, patient NPO. Last bowel movement: none since admission to SICU.
24 Fr Foley in place draining clear dark amber urine. Output approximately 29 ml/hr.
I&O: Input: 1897, Output: 700, Balance: 1197

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Skin (wounds) (0.5)

Musculoskeletal (0.5)

Color slightly pale, warm to touch; no cyanosis; skin turgor is tight r/t slight edema. Blanching red on coccyx;
Camino bolt in place in right frontal area of skull, incision clean and dry with xeroform dressing in place.
Passive ROM in all joints; right-sided weakness and paresis r/t ICH, generalized weakness and paresis in all
extremities r/t sedation. Non-ambulatory.

Other

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PATHOPHYSIOLOGY
On your own words, describe the: (Total 6.0 points)
Pathophysiology of the admitting diagnosis (4.0 points):
Intracranial hemorrhage (ICH) resulting in hemorrhagic stroke is the third most common cause of cerebrovascular accident (CVA). An
ICH can occur anywhere in the brain, resulting in an intracerebral hematoma in the parenchyma or the ventricles. The most common cause of ICH
is hypertension. Significantly increased systolic and diastolic blood pressures over several years can lead to ICH via the rupture of a small
penetrating artery in the subcortical region. Microaneurysms in the smaller vessels or arteriolar necrosis may precipitate the bleed. The most
common locations for hypertensive hemorrhages are the putamen of the basal ganglia (40%), the thalamus (15%), the cortex and subcortex (22%
collectively), followed by the pons, caudate nucleus, and cerebellar hemispheres. Other causes for ICH include ruptured aneurysms or
arteriovenous malformation, coagulation or clotting disorders, head trauma, illicit drug use, and liver disease.
Secondary injury can occur following the initial hemorrhage as a mass of blood accumulates and grows. The mass compresses and
displaces adjacent brain tissue causing further ischemia, edema, and increased intracranial pressure (IICP). Blood may also seep into the
ventricular system (via the lateral ventricle) creating risk for communicating hydrocephalus. Cerebral edema is usually at its peak approximately
72 hours after the initial CVA. This process is related to the disruption of plasma membranes and compression of capillaries at the site of ischemia
and infarct. Cerebral edema takes approximately two weeks to subside. If cerebral edema becomes massive, it is nearly always fatal. Seizures can
occur in patients with ICH related to the cerebral edema and brain injury.
The prevention of stroke extension related to secondary effects of ICH depends on sufficient perfusion of the penumbra. The penumbra is
the ischemic brain tissue surrounding the initial infarct, and is at immediate risk of infarction itself. Controlling arterial BP with potent vasoactive
medications is vital in keeping the blood pressure high enough via vasoconstriction to ensure adequate perfusion to this area. Eventually, the ICH
will be reabsorbed as macrophages and astrocytes clear the mass of blood. A cavity encased with a glial scar will remain (Baird & Bethel, 2011;
Huether & McCance, 2012).
Correlation between medical/surgical history and admitting diagnosis (2.0 point):
Mrs. JVs history of uncontrolled hypertension was likely the cause of her intracranial hemorrhage (ICH). She has no known medical
history other than a family history of HTN and noncompliance with antihypertensive medications. Common risk factors for ICH include
hypertension, smoking, African American ethnicity, excessive alcohol consumption, bleeding disorders, and liver dysfunction. Because her
hypertension was uncontrolled for a long period of time, Mrs. JV was at high risk for CVA. Several weeks before the incident, a physician had
counseled Mrs. JV regarding her increased risk of stroke due to hypertension and medication noncompliance.
Typical symptoms of thalamic hypertensive hemorrhage include contralateral hemiplegia, hemisensory loss, small, poorly reactive pupils,
and decreased levels of consciousness. At the time of the left-sided intracranial bleed, Mrs. JV noticed that she could not hold onto her cell phone

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with her right hand. After letting the phone fall to the floor several times, the woman she was having a meeting with noticed that the right side of
Mrs. JVs face started to droop. The patient then complained of right arm and right leg paresthesia and paresis, stating, I think Im having a
stroke. She then experienced a decreased level of consciousness. Currently, her pupils are pinpoint and poorly reactive. She is kept intubated and
sedated to control BP and ICP levels in order to prevent secondary damage. The ventilator is providing her with plenty of oxygen to encourage
adequate oxygenation of the penumbra.

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DIAGNOSTIC TESTS
Include all diagnostic tests and ECG strip.
Remember, a diagnostic test is any kind of medical test performed to aid in the diagnosis or detection of disease (i.e. laboratory tests, radiology
tests, biopsies, endoscopies, etc.).
Total 6.0 points
Test

Results

Normal Range

Patient-Specific Etiology

Nursing Implications
- If patient is conscious, explain procedure to
patient. CT scanner is circular, with a
doughnut-like opening. The scanner revolves
around the area to be examined and clicking
noises will be heard from the scanner as the
radiologist or technician observes from a
control room. The test is not painful.
- Obtain history of allergies to seafood, iodine,
and contrast dye if contrast is to be used during
the test.
- Observe for S/S of allergic reaction to dye if
dye is used.
- Explain the purpose and procedure to the client
and/or clients family. Explain that a lubricant
is applied to the skin surface at the site of the
arteries and that a probe will move with light
pressure back and forth over the area.
- The procedure is painless and is considered to
be safe and fast.
- Instruct client to remain still during procedures.
- Be supportive of client and family
- Describe x-ray procedure to client and/or
family, explaining that it takes from 10-15
minutes.
- Encourage family to ask questions

CT Brain

Intraparenchymal
hemorrhage at
left thalamic
region (26 x 21.5
x 30 mm) with
ventricular
extension and
surrounding
edema; extensive
sinusitis

Normal tissue;
no pathologic
findings

Initial CT scan shows evidence of

intracranial brain bleed in the left
thalamic region with extension into the
ventricles and surrounding edema.
Follow-up CT redemonstrates
relatively unchanged results, with
Camino bolt in place in the right
frontal area.

Carotid
Duplex

Normal
delineation of
carotid and
vertebral arteries
without
hemodynamically
significant
stenosis.

Normal pattern
image of carotid
and vertebral
arteries with
normal Doppler
analysis

Size, structure, and position of carotid

and vertebral arteries appears normal,
observed arterial blood flow appears to
be normal and there is no evidence of
carotid stenosis.

CXR

Heart enlarged;
small patchy
infiltrate left lung
base, possible

Normal bony
structure and
normal lung
tissue; normal

Infiltrates seen at left lung base likely

reflect mild interstitial edema related to
uncontrolled blood pressure and the
resulting shift of fluid from

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Dr. Alomari
mild interstitial
edema.

size and shape

of heart

intravascular spaces to third spaces.

Enlarged heart likely related to
uncontrolled HTN.
Serum Na levels increased per MD
orders. Goal: to cause fluid shift into
vascular spaces -> diuresis of fluid ->
decreased BP and ICP. Serum Na goal
currently 140-150 mEq/L.

Serum Na

150 mEq/L

135-145 mEq/L

Serum
osmolality

314 mOsm/kg

280-300
mOsm/kg

Serum osmolality increased related to

infusion of 3% NaCl (see above).
Serum osmolality goal currently <320
mOsm/kg.

BUN

19 mg/dL

7-18 mg/dL (per

pt chart)

Urea is formed as an end product of

protein metabolism and is excreted by
the kidneys. Elevated BUN is
indicative of dehydration, prerenal
failure, or renal failure. Patient-specific
etiology likely related to elevated
serum sodium levels and elevated
serum osmolality.

Intracranial
Pressure

8-24 mm Hg

0-15 mm Hg

Monitored in this patient by a subdural

Camino bolt, ICP reflects the pressure

- Observe for S/S of hypernatremia (restlessness,

thirst, flushed skin, dry/sticky mucous
membranes, tachycardia, rough/dry tongue
- Check for body fluid loss by keeping accurate
I/O record and weighing pt daily.
- Check specific gravity of urine (>1.030 could
indicate hypernatremia)
- Observe for edema and overhydration resulting
from an elevated serum sodium level. S/S are
constant, irritated cough; dyspnea; neck-andhand-vein engorgement; chest rales.
- Assess S/S of dehydration (thirst, dry mucous
membranes, poor skin turgor, shocklike
symptoms)
- Check for glycosuria: increased sugar in urine
could indicate presence of hyperglycemia,
which increases serum osmolality.
- Check serum sodium, urea, and glucose for
increased values. Calculate serum osmolality
by doubling serum sodium
- Report urinary output less than 25 ml/hr or 600
ml/day. Urea is excreted by the kidneys, and
with decreased urine output, urea accumulates
in the blood.
- Check vital signs: fast pulse, decreased BP and
increased respiration could indicate
dehydration leading to shock.
- Determine the hydration status of the client.
Elevated BUN may be attributed to
hemoconcentration.
- Monitor ICP and report significant or sudden
changes immediately.

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1
1

(ICP)

Urine
output

29 ml/hr

> 30 ml/hr

of the CSF surrounding the brain and

spinal cord. Increased ICP can injure
and damage the brain. In this case, it is
caused by an ICH and its extension
into the ventricles.
Low urine output is called oliguria.
This can be suggestive of dehydration
or fluid shifts from the vascular space
to interstitial, or third spaces. This fluid
imbalance is likely related to this
patients hypertonic infusion therapy to
decrease ICP. New physician orders
are to hold the 3% NS in order to
prevent over-diuresis, which could
result in AKI.

- Maintain an ICP <20 using various measures

including keeping the HOB > 30 degrees,
maintaining a body temperature < 98.8F,
decreasing stimuli, maintaining a SBP < 160,
etc.
- Report urinary output less than 25 ml/hr or 600
ml/day.
- Check vital signs: fast pulse, decreased BP and
increased respiration could indicate
dehydration leading to shock.
- Determine the hydration status of the client
(Kee, 2014).

ECG STRIP

HR
48 bpm

Rhythm
Regular

P wave
SA (on
monitor)

PR
Unable to
assess d/t
interference

QRS
0.09

P:Q ratio
Unable to
assess d/t
interference

ST segment
Unable to
assess d/t
interference

T-wave
Unable to
assess d/t
interference

Q-T
Unable to
assess d/t
interference

Ectopy
N/A

Interpretation:
Sinus bradycardia

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SIX SCHEDULED MEDICATIONS AND IV FLUIDS

Include all scheduled medications and the PRN if administered. Total 6.0 points.
Medication (Name, Dose, And Route): fentanyl citrate (Sublimaze) 1000 mcg/100 ml IV as dir PRN pain, currently @ 100 mcg (10 ml)/hr
Classification
Opioid analgesic
Mechanism of Action
Binds to opiate receptors in CNS, altering the response to and perception of pain. Produces CNS
depression. Metabolized mostly by liver; ~ 2-4 hr half life in adults.
Patient-Specific Indication
Decreases pain and supplements in anesthesia
Side Effects and Adverse Effects
Confusion, postoperative depression and drowsiness, blurred vision, bronchospasm, respiratory
depression, arrhythmias, bradycardia, hypotension, biliary spasm, N/V, facial itching, skeletal and
thoracic muscle rigidity c/rapid IV infusion, apnea, laryngospasm
Nursing Implications
Initial rate: 25 mcg/hr
Titrate by: 25 mcg/hr q 30 min
Maximum rate: 200 mcg/hr
Goal: Ramsay 4
- Intermittent infusion: may be diluted in D5W or 0.9% NaCl. Up to 50 mcg/ml.
- Monitor respiratory rate and BP frequently throughout therapy. Report significant changes
immediately. Respiratory depressant effects of fentanyl may last longer than the analgesic
effects. Initial doses of other opioids should be reduced by 25-33% of usual recommended
dose.
- Assess fall risk and implement fall prevention strategies.
- Symptoms of toxicity include respiratory depression, hypotension, arrhythmias, bradycardia,
asystole. Atropine may be used to treat bradycardia. Mechanical ventilation may be required to
treat respiratory depression. Narcan can be used to reverse respiratory depression or coma.
Patient/family Education
- Educate family that this medication is to decrease pain and also supplements in anesthesia.
- Medication causes dizziness and drowsiness.
- Caution patient to change positions slowly to minimize orthostatic hypotention after weaned
off of drug for at least 24 hours after completion of medication (Deglin, Vallerand 2015).
Medication (Name, Dose, And Route): diprivan (Propofol) 100mg/100 ml IV as dir PRN, currently @ 50 mcg/kg/min
Classification
General anesthetics
Mechanism of Action
Short-acting hypnotic. MOA is unknown. Produces amnesia. Has no analgesic properties. Crosses BBB
well. Metabolized by liver. Half life of 3-12 hrs (Blood-brain equilibration half-life 2.9 min).
Patient-Specific Indication
Induction and maintenance of anesthesia; sedation of intubated, mechanically ventilated patient in ICU
Side Effects and Adverse Effects
Bradycardia, hypotension, burning, pain, stinging at IV site, dizziness, headache, apnea, cough, HTN,
abdominal cramping, N/V, flushing, cold/numb/tingling IV site, discoloration or urine (green), fever,

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Nursing Implications

Patient/family Education

1
3
involuntary muscle movement, perioperative myoclonia, propofol infusion syndrome.
Initial rate: 5 mcg/kg/min
Titrate by: 5 mcg/kg/min q 15 min
Maximum rate: 50 mcg/kg/min Goal: Ramsay 5
- Additive CNS and respiratory depression w/ETOH, antihistamines, opioids analgesics, and
sedative/hypnotics. Decreased dosage may be required. Dose is titrated to patient response.
- Propofol has no effect on pain threshold. Adequate analgesia should always be used when
propofol is used as an adjunct to surgical procedures
- Discard after 12 hr if administered directly from vial or after 6 hr if transferred to syringe or
other catheter.
- Aseptic technique is essential: solution is capable of rapid growth of bacterial contaminants.
- Intermittent/continuous infusion: administer undiluted. Allow 3-5 minutes btwn dose
adjustments to allow for and assess clinical effects. 10 mg/ml. Rate based on patients weight.
- Assess respiratory status, pulse, BP continuously throughout therapy. Frequently causes apnea
lasting > 60 sec. Maintain patent airway and adequate ventilation. Propofol should be used only
by individuals with endotracheal intubation.
- Assess level of sedation and level of consciousness throughout and following administration.
- When using for ICU sedation, wake-up and assessment of CNS function should be done daily
during maintenance to determine minimum dose required for sedation. Maintain a light level of
sedation during these assessments; do not discontinue. Abrupt discontinuation may cause rapid
awakening with anxiety, agitation, and resistance to mechanical ventilation
- Monitor for propofol infusion syndrome (severe metabolic acidosis, hyperkalemia, lipemia,
rhabdomyolysis, hepatomegaly, cardiac and renal failure).
- Inform family that this medication is for sedation and will decrease the patients mental recall
of procedures and events during medication administration.
- Teach family that when patients are on this medication, it is necessary for them to be on
mechanical ventilation since it depresses the respiratory drive.
- After patient is awake, advise patient to request assistance with ambulation and transfer and to
avoid driving or other activities requiring alertness for a minimum of 24 hours following
administration (Deglin, Vallerand 2015).

Medication (Name, Dose, And Route): 3% Sodium Chloride 500 ml IV q 16 h 40 min @ 30 mls/hr
Classification
Mineral and electrolyte replacements/supplements; hypertonic
Mechanism of Action
Sodium is a major cation in extracellular fluid and helps maintain water distribution, fluid and
electrolyte balance, acid-base equilibrium, and osmotic pressure. Chloride is the major anion in

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Dr. Alomari

Patient-Specific Indication
Side Effects and Adverse Effects
Nursing Implications

Patient/family Education

extracellular fluid and is involved in maintaining acid-base balance. Solutions of NaCl resemble
extracellular fluid.
Replacement in deficiency states and maintenance of homeostasis. Infusion of hypertonic solution
causes fluid shift from interstitial spaces into extravascular space to reduce ICP.
HF, pulmonary edema, edema, hypernatremia, hypervolemia, hypokalemia, irritation at IV site.
Parameters: hold and call Dr. Dekermanjian if Na>154 or if serum osmolality >320
- Administer via large vein and prevent infiltration. After the first 100 mL, sodium, chloride, and
bicarbonate concentrations should be re-evaluated to determine the need for further
administration
- Rate of hypertonic NaCl solutions should not exceed 100ml/hr or 1 mEq/kg/hr
- Excessive amounts of NaCl may partially antagonize effects of antihypertensives
- Assess fluid balance (I/O, daily weight, edema, lung sounds) throughout therapy
- Monitor serum osmolarity in patients receiving hypertonic saline solutions
- Explain to patients family the purpose of infusion.
- (Deglin, Vallerand 2015)

Medication (Name, Dose, And Route): levetiracetam (Keppra) 500 mg/100 ml NaCl q 12 h IV over 15 min @ 400 ml/hr
Classification
Anticonvulsants, pyrrolidines
Mechanism of Action
Appears to inhibit burst firing without affecting normal neuronal excitability and may selectively
prevent hypersynchronization of epileptiform burst firing and propogation of seizure activity.
Patient-Specific Indication
Decreased incidence/severity of seizures that may occur d/t swelling and injury in brain.
Side Effects and Adverse Effects
Aggression, agitation, anger, anxiety, apathy, depersonalization, depression, dizziness, hostility,
irritability, personality disorder, weakness, drowsiness, dyskinesia, fatigue, coordination difficulties,
suicidal thoughts, stevens-johnson syndrome, toxic epidermal necrolysis
Nursing Implications
- Dilute dose (500 mg) in 100 ml of 0.9% NaCl, D5W or LR. Infuse over 15 min.
- Assess patient for CNS adverse effects throughout therapy: somnolence, fatigue (asthenia),
coordination difficulties, and behavioral abnormalities.
- Assess location, duration, characteristics of seizure activity
- Assess for rash periodically during therapy. May cause SJS. D/C therapy if severe or if
accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions,
conjunctivitis, hepatitis, and/or eosinophilia.
- May cause decreased RBC and WBC and abnormal LFTS.
Patient/family Education
- Advise family that this medication is being given to prevent seizure activity that could be

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1
5

caused by the injury to the patients brain

Advise family that once patient is off of sedation, this medication may cause dizziness and
somnolence. The patient should not resume driving until physician gives clearance (Deglin,
Vallerand 2015).

Medication (Name, Dose, And Route): atorvastatin calcium (Lipitor) 20 mg qd PO (GTube)

Classification
Lipid-lowering agents; hmg coa reductase inhibitors
Mechanism of Action
Inhibits HMG-CoA reductase, an enzyme which is responsible for catalyzing an early step in the
synthesis of cholesterol
Patient-Specific Indication
Lowers total and LDL cholesterol and triglycerides. Slightly increases HDL cholesterol. Reduction of
lipids/cholesterol reduces risk of MI and stroke sequelae.
Side Effects and Adverse Effects
Amnesia, confusion, dizziness, headache, weakness, rhinitis, bronchitis, chest pain, peripheral edema,
abdominal cramps, constipation, diarrhea, flatus, heartburn, altered taste, drug-induced hepatitis,
pancreatitis, nausea, hyperglycemia, ED, rashes, pruritis, arthralgia, arthritis, myalgia, myositis,
immune-mediated necrotizing myopathy, rhabdomyolysis, hypersensitivity reactions including
angioneurotic edema
Nursing Implications
- May be administered without regard to food
- Avoid grapefruit juice during therapy; may increase risk of toxicity.
- Crush tablet and dissolve in sterile water before administering via GTube
- Monitor liver function tests prior to initiation of therapy and as clinically indicated.
Patient/family Education
- Educate family that this medication is for the treatment of hyperlipidemia.
- Educate family and patient that drinking grapefruit juice can increase levels and risk of
medication toxicity and rhabdomyolysis (Deglin, Vallerand 2015).
Medication (Name, Dose, And Route): lisinopril (Prinivil) 40 mg qd GTube
Classification
Antihypertensive, ACE inhibitor
Mechanism of Action
Angiotensin-converting enzyme inhibitors block the conversion of angiotensin I to the vasoconstrictor
angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory
prostaglandins. ACE inhibitors also increase plasma rennin levels and decrease aldosterone levels. Net
result is systemic vasodilation.
Patient-Specific Indication
Lowering of BP in hypertensive patients.
Side Effects and Adverse Effects
Dizziness, fatigue, headache, weakness, cough, hypotension, CP, abdominal pain, N/V/D, ED, impaired
renal function, rashes, hyperkalemia, angioedema

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Nursing Implications

Patient/family Education

Monitor BP and pulse frequently during initial dosage adjustment and periodically during
therapy
Assess for signs of angioedema (dyspnea, facial swelling)
Monitor renal function. May cause increase in BUN and serum creatinine
Inform family that this medication is for the treatment of the patients uncontrolled
hypertension.
Once awake, advise patient regarding importance of compliance with this medication.
Encourage patient to comply with additional interventions for hypertension (weight reduction,
low sodium diet, d/c smoking, moderation of ETOH consumption, regular exercise, and stress
management).
Instruct patient and family on correct technique for measuring BP. Advise them to check BP at
least once weekly and to report any abnormal findings or significant changes to health care
professional (Deglin, Vallerand 2015).

Medication (Name, Dose, And Route): amlodipine besylate (Norvasc)10 mg qd GTube

Classification
Antihypertensives, calcium channel blockers (CCB)
Mechanism of Action
Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition
of excitation-contraction coupling and subsequent contraction.
Patient-Specific Indication
Systemic vasodilation resulting in decreased BP.
Side Effects and Adverse Effects
Dizziness, fatigue, peripheral edema, angina, bradycardia, hypotension, palpitations, gingival
hyperplasia, nausea, flushing.
Nursing Implications
- May be administered without regard to food
- Monitor BP and pulse before therapy, during dose titration, and periodically during therapy.
Monitor ECG periodically during prolonged therapy
- Monitor intake/output ratios and daily weight
Patient/family Education
- Inform family that this medication is for the treatment of hypertension in addition to lisinopril.
- Advise patient to avoid large amounts of grapefruit juice during therapy
- Instruct patient and family on correct technique for monitoring pulse. Instruct to contact HCP if
heart rate < 50 bpm (Deglin, Vallerand 2015).

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Medication (Name, Dose, And Route): enalapril (Vasotec) 1.25 mg q 4 hr PRN IV when SBP >160 mmHg
Classification
Antihypertensives, ACE inhibitor
Mechanism of Action
Angiotensin-converting enzyme inhibitors block the conversion of angiotensin I to the vasoconstrictor
angiotensin II. ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory
prostaglandins. ACE inhibitors also increase plasma rennin levels and decrease aldosterone levels. Net
result is systemic vasodilation.
Patient-Specific Indication
Lowering of BP in hypertensive patients.
Side Effects and Adverse Effects
Dizziness, fatigue, headache, vertigo, weakness, cough, hypotension, CP, abdominal pain, N/V/D,
proteinuria, impaired renal function, rashes, hyperkalemia, dyspnea, angioedema
Nursing Implications
Parameters: give 1.25 mg q 4 hrs IV when SBP >160 mmHg
- May be administered undiluted; administer over at least 5 minutes
- Monitor BP and pulse frequently during therapy.
- Assess patient for signs of angioedema (swelling of face, extremities, eyes, lips, or tongue, or
difficulty in swallowing or breathing)
- Monitor renal function. May cause increase in BUN serum creatinine.
Patient/family Education
- Inform family that this medication is used to control hypertension if the systolic value increases
to greater than 160 mmHg
- Instruct family to notify HCP if rash, mouth sores, fever, swelling of hands or feet, irregular
heartbeat, or swelling of face occurs (Deglin, Vallerand 2015).
Medication (Name, Dose, And Route): labetalol HCl (Trandate) 10 mg q 6 hr prn IV when SBP > 180 mmHg
Classification
Antianginals, antihypertensives, beta blockers
Mechanism of Action
Blocks stimulation of beta1 (myocardial) and beta2 (pulmonary, vascular, and uterine)-adrenergic
receptor sites. Also has alpha1-adrenergic blocking activity which may result in more orthostatic
hypotension.
Patient-Specific Indication
Decreases BP.
Side Effects and Adverse Effects
Fatigue, weakness, anxiety, depression, dizziness, insomnia, memory loss, mental status changes,
nightmares, blurred vision, dry eyes, nasal stuffiness, bronchospasm, wheezing, arrhythmias,
bradycardia, CHF, pulmonary edema, orthostatic hypotension, constipation, diarrhea, nausea, ED,
decreased libido, itching, rashes, hyper/hypoglycemia, arthralgia, back pain, muscle cramps,
paresthesia.
Nursing Implications
Parameters: give 10 mg q 6 hrs when SBP > 180 mmHg
- Administer undiluted 5 mg/ml slowly over 2 minutes
- Monitor BP and pulse frequently during therapy.

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Patient/family Education

Patients receiving labetalol IV must be supine during and for 3 hr after administration. Vital
signs should be monitored every 5-15 min during and for several hours after administration
Monitor intake and output rations and daily weight. Assess patient routinely for evidence for
fluid overload (peripheral edema, dyspnea, rales/crackles, fatigue, weight gain, JVD)
Monitor for signs of overdose (bradycardia, severe dizziness/fainting, dyspnea, bluish
fingernails/palms)
Inform family that this medication is given to treat hypertension if the systolic value increases
to greater than 180 mmHg.
Other education similar to that of other antihypertensive medications (Deglin, Vallerand 2015).

Medication (Name, Dose, And Route): nicardipine HCl (Cardene) sodium chloride 25/250 mg/ml as dir IV
Classification
Antianginal, antihypertensive, CCB
Mechanism of Action
Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition
of excitation-contraction coupling and subsequent contraction.
Patient-Specific Indication
Systemic vasodilation resulting in decreased BP.
Side Effects and Adverse Effects
Abnormal dreams, anxiety, confusion, drowsiness, headache, jitteriness, psychiatric disturbances,
weakness, blurred vision, disturbed equilibrium, epistaxis, tinnitus, cough, dyspnea, SOB, arrhythmias,
HF, peripheral edema, bradycardia, CP, hypotension, palpitations, syncope, tachycardia, increased
LFTS, anorexia, N/V/D/C, dry mouth, dyspepsia, dysuria, sexual dysfunction, dermatitis, erythema
multforme, flushing, increased sweating, pruritis, gynecomastia, anemia, weight gain, muscle cramps,
tremor, SJS
Nursing Implications
Parameters: Give if SBP >160 mmHg
Initial rate: 5 mg/hr
Titrate by: 2.5 mg/hr q 15 min
Maximum rate: 15 mg/hr
Goal: SBP 160-180, DBP 90-105
- Additive hypotension may occur with used concurrently with fentanyl and other
antihypertensives
- Grapefruit juice increases serum levels and effect
- Dilute each 25-mg ampule with 240 ml D5W, D5/0.45% NaCL, or 0.9% NaCL. Infusion is
stable for 24 hr at room temp.
- Administer through large peripheral veins or central veins to reduce risk of venous thrombosis,
phlebitis, swelling, extravastation. Change infusion site every 12 hrs to minimize risk of
irritation to site.
- Monitor BP and pulse prior to and during therapy. Monitor ECG periodically during prolonged
therapy.

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Patient/family Education

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-

Monitor I/O ratios.

Assess for SJS rash periodically during therapy.
Monitor serum calcium, potassium, and renal and hepatic functions
Inform family that this medication is for the treatment of hypertension as needed, if SBP > 160
mmHg.
Advise patient to avoid large amounts of grapefruit juice during therapy
Instruct patient and family on correct technique for monitoring pulse. Instruct to contact HCP if
heart rate < 50 bpm (Deglin, Vallerand 2015).

Additional Medications:
0.9% Sodium Chloride 1000 ml IV q 24 h @ 35 mls/hr
Acetaminophen 650 mg PR q 6 hr PRN when temperature is greater than 101F/38.3C
Chlorhexidine gluconate 15 ml BID in oral cavity
Mupirocin (Bactroban) 1 applic BID in nares
Dextrose/water 25 ml as dir PRN IV if BS < 70 and NPO or unconscious (infuse @ 3ml/min)
Pantoprazole sodium 40 mg QD Gtube
Docusate sodium 200 mg BID Gtube
Insulin, Regular PRN AC/HS SQ, per Mild Scale, to keep serum glucose between 140-180 mg/dL for optimal healing:
For blood sugar:
121-180 = 0 units
181-200 = 2 units
201-250 = 4 units
251-300 = 6 units
301-350 = 8 units
351-400 = 10 units
>400 = CALL MD

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SYNTHESIS, CRITICAL THINKING, AND PRIORITIZING

Provide a synopsis of your patients hospitalization story. Briefly highlight the acute physiological and psychological alterations and the
needs of your patient. Total 3.0 Points.
Mrs. JV is a 42-year old Hispanic female with a history of uncontrolled hypertension and a family history of hypertension. She and her
three siblings were all diagnosed with high blood pressure in their 20s. Due to her lack of medical insurance, this patient has been noncompliant
with antihypertensive medications for quite some time. On the evening of February 6, 2015, JV began experiencing right hand numbness and was
unable to hold onto her cell-phone while at a parent-teacher conference at her daughters school. Subsequently, she began to experience right-sided
facial drooping, right arm and leg paresthesia and paresis, and a decreased LOC. She was taken to the hospital where a CT of her brain revealed a
left-sided thalamic intracranial hemorrhage (ICH). Surgeons were unable to insert a ventriculostomy, and after four attempts, resorted to placing a
subdural Camino bolt in the right frontal area to monitor ICP. The patient experienced respiratory failure S/P surgery and is still intubated. She is
kept sedated in the SICU to achieve and maintain acceptable ICP levels and blood pressures. Daily sedation-vacations are scheduled, but each
attempt is met with dangerously increased ICP and BP readings and the patient is consequently re-sedated. Since the ventriculostomy drain could
not be placed to relieve pressure in the brain, other measures are being taken to lower ICP. Plan of care includes keeping patients hemodynamic
values within the prescribed parameters and weaning off of sedation once tolerated.
Physiological alterations and needs: Due to her recent intracranial bleed related to uncontrolled HTN, Mrs. JV needs close hemodynamic
monitoring to prevent further complications and to restore appropriate perfusion and homeostasis. Mrs. JV has increased ICP, and because
attempts made to insert a drain were not successful, she requires other measures to lower ICP. These ICP-lowering measures include adherence to
the following parameters:
- Temperature: < 98.8F (cooling blanket in place to decrease bloodflow and prevent neurogenic fever)
- ICP: < 20 (Call MD if > 20 for 5+ minutes)
- SBP < 160 mmHg (if > 160, nicardipine or vasotec PRN)
- Keep HOB > 30 degrees
- Serum Na 140-150 (if >154 hold 3% NS and call MD)
- Serum Osmolality < 320 mOsm/kg (if >320, hold 3% NS and call MD)
- EtCO2: 30-34 (CO2 increases cerebral blood flow and increases pressure in brain; therefore, blowing off CO2 with hyperventilation
decreases ICP)
- Minimize external and environmental stimuli (cluster care when possible)
- Osmotic diuresis; hypertonic solution: 3% NS drip (watch overdiuresis to avoid AKI)
This patient requires oral (via NG tube) antihypertensive medications to control her hypertension as well as diprivan and fentanyl to control ICP
by keeping her sedated and pain-free. Being on a mechanical ventilator puts Mrs. JV at risk for acquiring pneumonia, therefore ventilator acquired
pneumonia (VAP) protocol, including oral care every 4 hours, must be followed. Because of her prolonged bedrest, she requires heel protectors

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and frequent turning every 2 hours to prevent the formation of ulcers. She is also wearing sequential compression devices (SCDs) to encourage
lower extremity blood flow. Mrs. JVs body is recovering from an acute and debilitating event, therefore she needs rest and hydration in order to
heal.
Psychological alterations and needs: Mrs. JV is currently sedated. However, she was admitted because of uncontrolled HTN and needs
education on the vital importance of antihypertensive medication compliance. She needs teaching about other self-care and preventative measures
including dietary, exercise, and lipid control.
Based on your analysis, list the needs of your patient in each of the following areas. Total 7.0 Points (1 point per area).
Basic Care and Comfort
Sedation, pain medication, oral care
Health Promotion and Education
Medication and disease process teaching once weaned off sedation; teaching family
Physiological Needs (high priority)
Ventilation support, sedation and other ICP reducing measures
Physiological Needs (low priority)
Ulcer prevention (turn pt Q2hrs), VAP prevention protocol (oral care Q4hrs)
Psychological Needs
Medication and disease process teaching once weaned off sedation; teaching family; support of family
Pharmacological Considerations
Sedation, antihypertensives, antiepileptics, antihyperlipidemia and pain medications
Safety and Infection Control
Continual monitoring and prevention of further IICP and subsequent complications
Synthesize the patient needs and generate nursing diagnoses. Total 5.0 Points (1 point per diagnosis).
Two High Priority Nursing Diagnoses:
1.
Impaired gas exchange and ineffective airway clearance R/T altered level of consciousness secondary to CVA and sedation AEB mild
interstitial pulmonary edema on CXR and ventilator settings of 16/550/30/5 with intolerance to daily weaning attempts.
2.
Decreased intracranial adaptive capacity R/T increased intracranial pressure AEB ICPs >15 and midline cerebral shift.
Two Medium Priority Nursing Diagnoses (at least one of them should be spiritual or psychosocial diagnosis):
1.
Fluid volume imbalance (excess) R/T hypertonic solution infusion therapy and oliguria AEB urine output 29 ml/hr, I&O balance of 1197
ml over 24 hrs, serum osmolality of 314 mOsm/kg, and +2 edema in all extremities.
2.
Interrupted family processes R/T situational crisis and role change AEB patients sister stating, she did everything for her family: now
everything is chaotic and they dont know what to do or where to find things [medical records, etc].
One Low Priority Nursing Diagnosis:
1.
R/F ineffective thermoregulation R/T trauma associated with injury to or pressure on the hypothalamus AEB CT images of thalamic ICH
and midline cerebral shift.
(Ackley & Ladwig, 2014; Baird & Bethel, 2011)

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NURSING DIAGNOSIS
Total 25.0 Points
Nursing Diagnosis I:
Impaired gas exchange and ineffective airway clearance R/T altered level of consciousness secondary to CVA and sedation AEB mild
interstitial pulmonary edema on CXR and ventilator settings of 16/550/30/5 with intolerance to daily weaning attempts.
* Relevant Assessment: Patient sedated and intubated. Does not tolerate attempts to wean off of sedation. Loss of consciousness prior to
ventriculostomy attempt and respiratory failure S/P bolt placement. Diminished lung sounds bilaterally.
* Relevant Diagnostic Tests: CXR to check ET tube placement revealed mild interstitial pulmonary edema
* Relevant Medications and Therapies: mechanical ventilation @ 16/550/30/5 via ET tube
* Expected Outcomes: By the time of discharge from the ICU, this patient will have adequate gas exchange without ventilator support as
evidenced by appropriate mental status and orientation, SpO2 > 94%, respiratory rate 12-20 breaths per minute with normal depth and pattern; and
absence of adventitious breath sounds.
* Nursing Interventions with Rationales:
- Assess patients respiratory rate, depth, and rhythm. Auscultate lung fields for breath sounds every 1-2 hours and as needed. Auscultate
upper chest over artificial airway to assess for leaks. Monitor for abnormal respiratory patterns. Be alert to IICP. The presence of crackles
and wheezes may alert the nurse to airway obstruction, which may lead to exacerbate existing hypoxia.
- Monitor oxygen saturation continuously using pulse oximetry. Correlate arterial oxygen saturation blood gas results with pulse oximetry.
An oxygen saturation less than 90% or a partial pressure of oxygen of less than 80 mmHg indicates significant oxygenation problems.
Pulse oximetry is useful for tracking and/or adjusting supplemental oxygen therapy.
- Monitor serial ABG values. Be alert to levels indicative of hypoxemia (PaO2 < 80 mmHg) and to PaCO2 > 35 mmHg (levels higher than
this may increase ICP).
- Observe for cyanosis of the skin; especially note color of tongue and oral mucous membranes. Central cyanosis of the tongue and oral
mucosa is indicative of serious hypoxia and is a medical emergency.
- Assist with turning every 2 hours to promote lung drainage, expansion, and alveolar perfusion. Raise HOB 30 degrees to enhance gas
exchange and decrease risk of aspiration of oral, nasal, and gastric secretions. Evidence shows that a mechanically ventilated client has a
decreased incidence of VAP if client is placed in a 30- to 40- degree semi-recumbent position as opposed to supine position.
- Assess ventilator for proper functioning and parameter settings, including FiO2, tidal volume, rate, mode, peak inspiratory pressure, and
temperature of inspired gases. Ensure connections are tight and alarms are set. Assessing the ventilator for proper function and the
patients response to therapy is most often a collaborative effort between nursing and respiratory therapist (Ackley & Ladwig, 2014;
Baird & Bethel, 2011).
* Evaluation: Goal not yet met. Patient still dependent on mechanical ventilator with 16 supported breaths per minute at 30% FiO2.

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Nursing Diagnosis II:

Decreased intracranial adaptive capacity R/T increased intracranial pressure AEB ICPs >15 and midline cerebral shift.
* Relevant Assessment: Decreased LOC secondary to CVA and sedation; pupils pinpoint and sluggish bilaterally; minimal motor response to pain
* Relevant Diagnostic Tests: Brain CT showing midline cerebral shift, elevated ICP levels 8-24 mmHg
* Relevant Medications and Therapies: Sedation; antihypertensive medications; maintenance of temperature < 98.8F (cooling blanket and fans if
necessary), SBP < 160 mmHg (if > 160, nicardipine or vasotec PRN), Serum Na 140-150, serum osmolality < 320 mOsm/kg, EtCO2 between 3034; keep HOB > 30 degrees; minimize external and environmental stimuli (cluster care when possible); osmotic diuresis
* Expected Outcomes: Patient will have equal and normoreactive pupils, ICP 0-15 mmHg, and absence of headache, vomiting, and other clinical
indicators of IICP by time of discharge from ICU.
* Nursing Interventions with Rationales:
- Monitor pupils, LOC, and motor activity; also perform cranial nerve assessments. A decrease in LOC is an early indicator of IICP.
Changes in the size and reaction of the pupils, a decrease in motor function, and cranial nerve palsies are also signs of IICP. Pupil size
and reactivity are predictive of outcome; nonreactive and dilated pupils are associated with a mortality as high as 80% compared with a
mortality of 24% in traumatic brain-injured clients with pupils that react to light.
- Maintain a patent airway, and ensure precise delivery of oxygen to promote optimal cerebral perfusion. Maintain optimal oxygenation and
ventilation, applying PEEP as needed and avoiding hyperventilation. PEEP levels of 10 cm H2O have been found to produce no
significant changes in ICP, especially when combined with HOB elevation of 30 degrees. Hyperventilation has been found to worsen
outcomes in TBI clients and should be avoided, especially in the first 24 hours post injury.
- Facilitate cerebral venous drainage by maintaining neck in neutral position. Elevate HOB 30-45 degrees. Elevating the head of the bed
allows for increased venous drainage that decreases ICP.
- Premedicate clients with adequate sedation and limit endotracheal suction passes to two in order to limit ICP increases. In well-sedated or
paralyzed clients, elevations in ICP are attenuated, but increases in ICP may be cumulative with each suction pass.
- Induce moderate hypothermia (32-35 degrees C) per collaborative protocol. A recent meta-analysis suggests that hypothermia maintained
for 48 hours reduces mortality and results in favorable neurological outcomes, but only in clients who do not receive barbiturates.
- To help prevent fluid volume excess, which could add to cerebral edema, ensure precise delivery of IV fluids at consistent rates.
- Maintain glycemic control per collaborative protocol. Maintain glucose levels between 140-180 mg/dL utilizing insulin therapy in braininjured clients.
- Monitor hemodynamic status to evaluate BP, MAP, ICP; document hourly and notify physician of any sudden changes or if values exceed
preestablished ranges. Perform ongoing calibration and zeroing of transducer to ensure accuracy of readings.
- Maintain ICP < 20 mmHg. Treat elevations in ICP immediately. The guidelines for the Management of Severe Brain Injury established
the treatment threshold for ICP as greater than 20 mmHg (Ackley & Ladwig, 2014; Baird & Bethel, 2011).
* Evaluation: Goal not yet met. Many interventions appropriately in place but patients pupils are still pinpoint and sluggish and ICP occasionally
increases to greater than 15 mmHg.

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REFERENCES

Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An evidence-based guide to planning care (10th ed.). Maryland Heights,
Mo: Mosby Elsevier.
Baird, M. S. & Bethel, S. (2011). Manual of critical care nursing: Nursing interventions and collaborative management (6th edition). St. Louis,
MO: Elsevier.
Chernecky, C. C. & B. J. Berger (2004). Laboratory tests & diagnostic procedures. Philadelphia, PA, Saunders.
Deglin, Pharm D, J. H., & Vallerand, PhD, Rn, FAAN, A. H. (Ed.). (2015). Davis' Drug Guide for Nurses (13th ed.). F.A. Davis Co.
Dirksen, S. R. (2011). Clinical companion to Medical-surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis,
Mo: Elsevier/Mosby.
Kee, J. L. (2014). Laboratory and diagnostic tests with nursing implications (9th ed). Upper Saddle River, NJ., Pearson Education Inc.
S. E. Huether & McCance, K. L. (2012). Pathophysiology: The biologic basis for disease in adults and children. Maryland Heights, Mo., Mosby
Elsevier.
Potter, P. A., A. G. Perry, et al. (2009). Fundamentals of nursing. St. Louis, Mo., Mosby Elsevier.

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