GNRS 588

Professor B. Richards

AZUSA PACIFIC UNIVERSITY

SCHOOL OF NURSING
GNRS 588: ADVANCED NURSING CARE FOR ADULTS
CARE MAP #: __1_______

Student: Jennifer Bustamante

Instructor: Professor B. Richards
Date of Care: 02/13/2015
Date of Submission: 02/27/2015

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Professor B. Richards

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)

T. L.
58
Female
Cardiovascular
Respiratory
Neurologic
Urinary
Digestive
Endocrine
Musculoskeletal
Hema/Oncology
Infectious
Integumentary
Reproductive
Psychiatric
Other
Breast Implants

HTN
Pneumonia
Stroke
UTI
Ulcer
DM

MI
COPD
Parkinsons
ESRD
Diverticulosis
Hyperthyroidism

Dysrhythmias
TB
Guillain-Barre
Renal Failure
Dysphasia
Hypothyroidism

Hyperlipidemia
HF
Respiratory Failure
Glaucoma
Cataract

Anemia
Shingles

Cancer:
Hepatitis

Meningitis

STI

PVD

Depression Anxiety
Prior accident

Tetracyclines
Marital status
Education level
Social resources
Spiritual resources
Occupation
Employment
Smoking
Alcohol
Recreational Drugs

Married
Unknown
Family at bedside
Christian
Unknown
Unknown
Heavy Smoker
Occasional Drinker
Labs showed positive for methamphetamine but patient denied upon admission

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GNRS 588
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)

Professor B. Richards

Patient was brought to the ED on 2/7/15 by her husband. She was having difficulty walking and breathing. The
patient and her husband explained that she got out of her car and left it in drive. When she tried to stop the
car, she got crushed between her car and an SUV. Onlookers helped move the car.

Onset: 2/7/15; Location: Chest; Duration: since time of accident; Characteristic: SOB
Aggravating Factors: Movement Relieving Factors: non-movement Treatment; came into ED

Cardiac Contusion, Rib fracture (L) 3-9 & (R) 3-5; pneumothorax (No signs of pneuomothorex on chest xray and L
pleural effusion with L lower lobe confirmed)
Physical Exam
course rubbing in RUL; diminished breath sound in LLL

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

Diagnostic Tests
2/7/15:
CPK 4.7
Troponin 0.22
2/7/15:
AB/Pelvis CT
Brain and chest CT
Chest xrayfractured ribs on left side 3-9 and
right side 3-5.
2/9: myocardial perfusion scan large inferior
wall reversible defect; EF 55% ; reversible
ischemia

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Professor B. Richards

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)

85.6 kg and 52; Blood type AB+; Full code;

Time

0730

100.0

1045
1300
alarm
Neurologic & Pupils (0.5)
Head, Face, & Neck (0.5)
ENT (0.5)
Cardiovascular (1.0)

Pulmonary (1.0)

Gastrointestinal (0.5)
Genitourinary (0.5)
Skin (wounds) (0.5)
Musculoskeletal (0.5)

RR

HR

NIBP

ABP

MAP

CO

CVP

SVR

PAP

SpO2

17

70

165/86

112

98

100.1

33

96

125/54

77

100

100.1

29

66

159/83

108

96

0/30

120/40

160/90

IC
P

100/90

Pupil R 3/2 L 3/2 PERRLA; Ramsay scale of 4; GCS: Eyes 1; Motor ; Verbal ETT: Total GCS: 9
Facial erythema ; no JVDs
Endotracheal @ lips 22 cm; size 7.5: NG (L) nare 18 French receiving vital 1.2 cal at feed rate of 40 ml/hr
placement checked- sounds heard from stomach.
S1S2--- NSR; Cap refill <3 seconds; Pedal Pulses 1+;
Thick tan secretions upon suctioning course crackles in RUL; diminished breath sound in LLL
Patient had a chest x ray on 2/7 and 2/12
ETCO2: 34
Ventilator
VT
RR
FiO2
PEEP
I: E Ratio
Mode
A/C
500
16
40%
10
1:2.1
pH
PaO2
PaCO2
HCO3BE
SpO2
7.44
73 (L)
36.1
23.8
98
Firm abdominal in all four quadrants with active bowel sounds and passing gas
Foley catheter 16 French - yellow urine with sediments: output: 310 cc
Picc (RUA) ; red patches scattered along chest wall, slight edema on hands and feet; skin is warm and moist.
Patient in arm restraints removed to assess: skin intact; no reddening. (R) IV on forearm: no infiltration or
warmth.
Patient UE weak but will slightly squeeze hands upon prompting. weak LE

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PATHOPHYSIOLOGY
On your worn words, describe the: (Total 6.0 points)
Pathophysiology of the admitting diagnosis (4.0 points):
Patient admitted for trauma to the chest area (rib fractures, cardiac contusion & suspected pneumothorax)
-Trauma occurs to the body when excess energy is applied and the tissues are able to absorb it. The amount of damage to the tissue will depend
on how much energy was applied. Patients are at risk for hypovolemic shock RBC -2/8 4.16 L 2/9 3.89 L 2/13 3.23 L Hgb 2/8 13.1 2/9 11.7
2/13 9.9 and PT 10.5 / INR 1.0 / PLT 32.2. The body responds to the trauma by requiring an increase in O2 and glucose (glucose 127) for
energy production and to perfuse vital organs. During trauma the body can experience electrolyte imbalances such as potassium being high:
2/12 6.1 DH; 2/12 5.9 H; 2/13 3.6. The excess energy resulted in chest wall injuries with patients such as rib fractures (a disruption or break in
the continuity of the structure of bone) to both the left (3-9) and right (3-5) ribs with cardiac contusion (troponin 0.226 and CPK 4.7). Cardiac
contusion is caused by a force that is placing direct pressure on the myocardium and can cause increased intra-thoracic pressure with sheer
stress happening at the same time. The RV is typically injured due to location and LV output can fall due to reduced preload. Cardiac output
can drop up to 40% and can persist for several weeks. This injuries can make it difficult for the patient to breathe which can impair oxygenation.
No cath until patient is stable.
-In addition, after the CXR showed no signs of pneumothorax and pneumonia was confirmed. Pneumonia is an infection (WBC: 2/8 13.1 H;
2/9 15.7 H; 2/13 14.0 H and bronch lavage with an endotracheal spectrum for cultures) that causes inflammation of the lung parenchyma,
resulting in the alveoli filling up with liquid. Patient can have chills, fever (101 to 102 degrees Fahrenheit), productive cough (thick, tan
secreations), tachypnea (RR 29-33), pleuritic chest pain, dyspnea, and cyanosis. Combining patients chest trauma with her current state of
pneumonia impairs gas exchange. Patient has low PaO2 73 which is oxygen that is dissolved in the blood unattached. The SaO2 is the binding
sites for oxygen which is also slightly low at 94.5.
Correlation between medical/surgical history and admitting diagnosis (2.0 point):
Patient arrived to the ED complaining of pain in the chest area and hunched over when walking according to the RT
Patient has a medical history of breast implants which helped decrease some of the trauma to the chest area. In addition, patient has a history of
COPD and HTN. The history of HTN during a trauma can increase the risk of bleeding. The patients history of COPD increases patient
morbidity with the pneumonia requiring critical care as patient is more susceptible to sepsis, septic shock, and respiratory failure.

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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

Chest xray

Pleural effusion
w/ LLL

None

Possible Pneumothorax but

indicted pneumonia

Myocardial
perfusion
scan

Large inferior
wall reversible
defect.
(L) ventricle
abnormal- lateral
inferior lateral
and anterolateral
wall EF=55%
Respiratory
culture: gram
negative rod
yeast, not
cryptococc.
Neofor
- Lavage large
mucous plug
- RULKlebsiella
Pneumoniae;
Haemophilus
Species

Normal scan
would be no
defects.
EF: 50-75%

Cardiac Contusion

Screen the patient for contraindications to

performing the valsava maneuver such as
myocardial infarction. If present then teach
the patient how to hold breath without bearing
down.
Hydration for patient to flush kidneys
Rest
Close monitoring

Negative for
any cultures

The reliable specimens to identify

infecting organism.

Place patient in fowlers position

Monitoring of O2 saturation
Monitoring of vitals

Negative for
any cultures

Identifies infecting organism

Fowlers position
Close monitoring of ECG during procedure
Sterile procedure
Hyperoxygenation of patient (inspired O2
considered in COPD patients)

Bronch
Lav. LUL

Sputum
Endotrach

Normal Range

Patient-Specific Etiology

Nursing Implications

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Professor B. Richards

CK-MB

4.7 (High)

<3.5%

Cardiac contusion

Troponin

0.226 (High)

<0.03 ng/ml

Cardiac contusion

WBC

2/8 13.1 H
2/9 15.7 H
2/13 14.0 H
2/8 4.16 L
2/9 3.89 L
2/13 3.23 L

5.0 11.0

infection (pneumonia)

- 5 ml venous blood sample without hemolysis.

- If enzymes are present in the heart.
- 5 ml blood sample
- Results are normally available within 4 hours
- Positive for myocardial injury
- indicative of infection in patient

4.7 6.0

Possible hemorrhage

2/8 13.1
2/9 11.7
2/13 9.9
2/12 6.1 DH
2/12 5.9 H
2/13 3.6

5.0 11.0

3.5-5.0 mEq/L

- potassium may be elevated with crush

injuries

Chloride

2/13 109 H

95-105

Electrolyte imbalance

Glucose

2/13 127 H

70 115

Baseline and assess for alterations

as glucose is usually elevated after
injury.

Electrolyte imbalance

RBC

Hgb

Potassium

Phosphorus

2/12 1.5 L
2/13 2.1 L

2.5 4.0 mg/dl

Assess for blood loss

Possible active bleed and needs constant

monitoring.
Cardiac output might be decreased leading to a
loss of perfusion.
Deoxygenated blood

Observe patient for signs and symptoms of

fluid volume excess or deficient.
Continued monitoring of K+ levels.
Monitor ECG for ventricular arrhythmias.
Evaluate cognitive status (impaired mentation,
hypotension, and cardiac dysrhythmias.
Glucose is increased to meet bodys energy
needs.
Watch for hyperglycemia as it produces
insulin resistance and delays the healing
process.
Low phosphorus levels interferes with the
functioning of WBC.

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GNRS 588

Professor B. Richards

ECG STRIP

HR
Rhythm
P wave
75
Regular
Upright
Interpretation: Normal Sinus Rhythm

PR
0.16

QRS
0.08

P:Q ratio
1:1

ST segment
0.32

T-wave
upright

Q-T
0.40

Ectopy
none

SIX SCHELUED MEDICATIONS AND IV FLUIDS

Include all scheduled medications and the PRN if administered. Total 6.0 points.
Medication (Name, Dose, And Route): Fentanyl-NS 1,000 MCG/100 ML IV--- initial: 25 mcg/hr titrate 25 mcg q 30 mins to a max of 100
mcg/hr to a ramsay of 2. Rate currently at 50 mcg/hr
Classification
OPIOID AGONISTS
Mechanism of Action
BINDS TO OPIATE RECEPTORS IN THE CNS, ALTERING THE RESPONSE TO AND
PERCEPTION OF PAIN.
Patient-Specific Indication
PAIN
Side Effects and Adverse Effects
CONFUSION, PARADOXICAL EXCITATION/DELIRIUM, POSTOPERATIVE DEPRESSION,
POSTOPERATIVE DROWSINESS, BLURRED/DOUBLE VISION, ALLERGIC
BRONCHOSPASM, RESPIRATORY DEPRESSION, ARRHYTHMIAS, BRADYCARDIA,
CIRCULATORY DEPRESSION, HYPOTENSION, BILIARY SPASM, NAUSEA/VOMITING,
FACIAL ITCHING, SKELETAL AND THORACIC MUSCLE RIGIDITY. APNEA,
LARYNOGOSPASM
Nursing Implications
AVOID USE IN PATIENT WHO HAVE RECEIVED MAO INHIBITOR WITHIN THE
PREVIOUS 14 DAYS

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Patient/family Education

MONITOR RESPIRATORY RATE AND BP FREQUENTLY THROUGHOUT THERAPY.

REPORT SIGNIFICANT CHANGES IMMEDIATELY. THE RESPIRATORY
DEPRESSANT EFFECTS OF FENTANYL MAY LAST LONGER THAN THE
ANALGESIC EFFECTS. INITIAL DOSES OF OTER OPIODS SHOULD BE REDUCED
BY 24-33% OF USUALLY RECOMMENDED DOSE. MONITOR CLOSELY.
MAY CAUSE INCREASE SERUM AMYLASE AND LIPASE CONCENTRATIONS
SYMPTOMS OF TOXICITY INCLUDE RESPIRATORY DEPRESSION, HYPOTENSION,
ARRHYTHMIAS, BRADYCARDIA, AND ASYSTOLE. ATROPINE MAY BE USED TO
TREAT BRADYCARDIA. IF RESPIRATORY DEPRESSION PERSISTS, PROLONGED
MECHANICAL VENTILATION MAY BE REQUIRED. IF OPIOID ANTAGOINIST IS
REQUIRED TO REVERSE RESPIRATORY DEPRESSION OR COMA, NALOXONE
(NARCAN) IS THE ANTIDOE. DILUTE 0.4 MG AMPULE OF NALOXONE IN 10 ML OF
0.9% NACL AND ADMINISTER 0.5 ML BY DIRECT IV PUSH Q. 2 MIN.
DISCUSS THE USE OF ANESTHETIC AGENTS AND THE SENSATIONS TO EXPECT
WITH PATIENT
EXPLAIN PAIN ASSESSMENT SCALE TO PATIENT
CAUTION PATIENT TO CHANGE POSITIONS SLOWLY TO MINIIZE ORTHSTATIC
HYPOTENSION.
CAUSES DROWSINESS AND DIZZINESS.

Medication (Name, Dose, And Route): Dobutamine 250mg/250ml premix IV---- initial: 2mcg/kg/min to a max of 30 mcg/kg/min --- titrate
1 mcg q. 15 min. to get a map greater than 65 and HR less 140 BPM.
Classification
ADRENERGICS
Mechanism of Action
STIMULATES BETA1 (MYOCARDIAL)-ADRENERGIC RECEPTORS WITH RELATIVELY
MINOR EFFECT ON HEART RATE OR PERIPHERAL BLOOD VESSELS. IT WILL
INCREASE CARDIAC OUTPUT WITHOUT SIGNIFICANTLY INCREASED HEART RATE.
Patient-Specific Indication
REDO: SHORT TERM (<48 HR) MANAGEMENT OF HEART FAILURE CAUSED BY
DEPRESSED CONTRACTILITY FROM ORGANIC HEART DISEASE OR SURGICAL
PROCEDURES
Side Effects and Adverse Effects
HEADACHE, SHORTNESS OF BREATH, ANGINA PECTORIS, ARRHYTHMIAS,
HYPOTENSION, PALPITATIONS, NAUSEA, VOMITING, PHLEBITIS, HYPERSENSITIVITY
REACTIONS INCLUDING SKIN RASH, FEVER, BRONCHOSPASM OR EOSINOPHILIA,
NONANGINAL CHEST PAIN. HYPERTENSION, INCREASED HEART RATE, PREMATURE
VENTRICULAR CONTRACTIONS

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GNRS 588

Nursing Implications

Professor B. Richards

Patient/family Education

IV VASOACTIVE MEDICATION HAVE SECOND PRACTTIONER

INDEPENDENTLY CHECK ORDER, DOSAGE CALCULATIONS AND INFUSION
PUMP SETINGS
ADMINISTER INTO A LARGE VEIN AND ASSESS ADMINISTRATION SITE
FREQUENTLY. EXTRAVASATION MAY CAUSE PAIN AND INFLAMMATION.
MONITOR BP, HEART RATE, ECG, PULMONARY CAPILLARY WEDGE PRESSURE
(PCWP), CARDIAC OUTPUT, CVP, AND URINARY OUTPUT CONTINOUSLY
DURING ADMINISTRATION.
REPORT SIGNIFICANT CHANGES IN VITAL SIGNS OR ARRHYTHMIAS. CONSULT
PHYSICIAN FOR PARAMETERS FOR PULSE, BP, OR ECG CHANGES FOR
ADJUSTING DOSE OR DISCONTINUING MEDICATION.
PAPATE PERIPHERAL PULSES AND ASSESS APPEARANCE OF EXTREMITIES
ROUNTINELY THORUGHOUT DOBUTAMINE ADMINISTRATION. NOTIFY
PHYSICIAN IF QUALITY OF PULSE DETERIORATES OR IF EXTREMITIES
BECOME COLD OR MOTTLED.
MONITOR POTASSIUM CONCENTRATIONS DURING THERAPY; MAY CAUSE
HYPOKALEMIA
EXPLAIN TO PATIENT THE RATIONALE FOR INSTITUTING THIS MEDICATION
AND THE NEED FOR FREQUENT MONITORING
ADVISE PATIENT TO INFORM NURSE IMMEDIATELY IF CHEST PAIN; DYSPNEA;
OR NUMBNESS, TINGLING, OR BURNING OF EXTREMITIES OCCURS.

Medication (Name, Dose, And Route): Diprivan (propofol) 1000mg/100 ml IV; Initial 5mcg/kg/min --- titrate by 5 mcg/kg q. 5 min to a
max of 50 mcg to a ramsay score of 4.
Classification
GENERAL ANESTHETICS
Mechanism of Action
INDUCTION AND MAINTENANCE OF ANESTHESIA
Patient-Specific Indication
Side Effects and Adverse Effects

Nursing Implications

SEDATION OF INTUBATED, MECHANICALLY VENTILATED PATIENTS IN ICU

DIZZINESS, HEADACHE, APNEA, COUGH, HYPERTENSION, ABDOMINAL CRAMPING,
HICCUPS, NAUSEA, VOMITING, FLUSHING, COLDNESS, NUMBNESS, TINGLING AT IV
SITE, INVOLUNTARY MUSCLE MOVEMENTS, PERIOPERATIVE MYOCLONIA,
DISCOLORATION OF URINE (GREEN); FEVER. BRADYCARDIA, HYPOTENSION,
BURING, PAIN, STINGING, PROPOFOL INFUSION SYNDROME
ASSESS RESPIRATORY STATUS, PULSE, AND BP CONTINUOUSLY
THROUGHOUT PROPOFOL THERAPY. FREQUENTLY CAUSES APNEA LASTING
GREATER BUT EQUAL TO 60 SEC.

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Patient/family Education

11

MAINTAIN PATENT AIRWAY AND ADEQUATE VENTILATION. PROPOFOL

SHOULD BE USED ONLY BY INDIVIDUALS EXPERIENCED IN ENDOTRACHEAL
INTUBATION, AND EQUIPMENT FOR THIS PROCEDURE SHOULD BE READILY
AVAILABLE.
ASSESS LEVEL OF SEDATION AND LEVEL OF CONSCIOUSNESS THROUGHOUT
AND FOLLOWING ADMINISTRATION. [WHEN USING OF RICU 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 SNDROME (SEVERE METABOLIC
ACIDOSIS, HYPERKALEMIA, LIPEMIA, RHABDOMYOLYSIS, HEPATOMEGALY,
CARDIAC AND RENAL FAILURE). MOST FREQUENT WITH PROLONG, HIGH
DOSE INFUSIONS (>5MG/KG/HR FOR >48 HR) BUT HAS ALSO BEEN REPORTED
FOLLOWING LARGE DOSE, SHORT-TERM INFUSIONS DURING SURGICAL
ANESTHESIA. IF PROLONGED SEDATION OR INCREASING DOSE IS REQUIRED,
OR METABOLIC ACIDOSIS OCCURS, CONSIDER ALTERNATIVE MEANS OF
SEDATION.
IF OD OCCURS, MONITOR PULSE, RESPIRATION AND BP CONTINUOUSLY.
MAINTAIN PATENT AIRWAY AND ASSIST VENTILATION AS NEEDED. IF
HYPOTENSION OCCURS, TREATMENT INCLUDES IV FLUIDS, REPOSITIONING,
AND VASOPRESSORS.
INFORM PATIENT THAT THIS MEDICATION WILL DECREAE MENTAL RECALL
OF THE PROCEDURE. [MAY CAUSE DROWSINESS OR DIZZINESS. ADVISE
PATIENT TO REQUEST ASSISTANCE PRIOR TO AMBULATION AND TRANSFER
AND TO AVOID DRIVING OR OTHER ACTIVITIES REQUIRING ALERTNESS FOR
24 HR FOLLOWING ADMINISTRATION.
ADVISE PATIENT TO AVOID ALCOHOL OR OTHER CNS DEPRESSANTS
WITHOUT THE ADVICE OF A HEALTH CARE PROFESSIONAL FO R24 HR
FOLLOWING ADMINISTRATION.

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Professor B. Richards

Medication (Name, Dose, And Route): Dexmedetomidine (Precedex) 400mcg IV: start at 0.5 mcg/kg/hr to max dose of 1.8 mcg/kg/hr
Classification
SEDATIVE / HYPNOTICS
Mechanism of Action
ACTS AS A RELATIVELY SELECTIVE ALPHA-ADRENERGIC AGONIST WITH SEDATIVE
PROPERTIES. ---SEDATION
Patient-Specific Indication
SEDATION OF INITIALLY INTUBATED AND MECHANICALLY VENTILATED PATIENTS
DURING TREATMENT IN AN INTENSIVE CARE SETTING; SHOULD NOT BE USED FOR
>24 HR.
Side Effects and Adverse Effects
HYPOXIA, TRANSIENT HYPERTENSION, DRY MOUTH, NAUSEA, VOMITING, ANEMIA,
FEVER. BRADYCARDIA, SINUS ARREST, HYPOTENSION.
Nursing Implications
ASSESS LEVEL OF SEDATION THROUGHOUT THERAPY. DOSE IS ADJUSTED
BASED ON LEVEL OF SEDATION.
MONITOR ECG AND BP CONTINUOUSLY THROUGHOUT THERAPY. MAY CAUSE
HYPOTENSION, BRADYCARDIA, AND SINUS ARREST.
TOXICITY AND OVERDOSE: ATROPINE IV MAY BE USED TO MODIFY THE
VAGAL TONE.
Patient/family Education
EXPLAIN TO PATIENT AND FAMILY THE PURPOSE OF THE MEDICATION.
Medication (Name, Dose, And Route): Potassium Chloride 40 MEQ/100ML IV @ 25MLS/HR to be administrated over 4 hours
Classification
MINERAL AND ELECTROLYTE REPLACEMENTS / SUPPLEMENTS
Mechanism of Action
MAINTAIN ACID-BASE BALANCE, ISOTONICITY, AND ELECTROPHYSIOLOGIC
BALANCE OF THE CELL. POTASSIUM IS THE ACTIVATOR IN MANY ENZYMATIC
REACTIONS; ESSENTIAL TO TRANSMISSION OF NERVE IMPULSES; CONTRACTION OF
CARDIAC, SKELETA;, AND SMOOTH MUSCLE; GASTRIC SECRETION; RENAL
FUNCTION; TISSUE SYNTHESIS; AND CARBOHYDRATE METABOLISM.
Patient-Specific Indication
TREATMENT OF POTASSIUM DEPLETION
Side Effects and Adverse Effects
CONFUSION, RESTLESSNESS, WEAKNESS, ECG CHANGES, IRRITATION AT IV SITE,
PARALYSIS, PARESTHESIA. ARRHYTHMIAS
Nursing Implications
HIGH ALERT: MEDICATION ERRORS INVOLVING TOO RAPID INFUSION OR
BOLUS IV ADMINISTRATION OF KCL HAVE RESULTED IN FATALITIES.
MAX INFUSION RATE IN MONITORED SETTING 40 MEQ/HR IN ADULTS. RCH
POLICY MAX INFUSION 20 MEQ/HR CENTRAL LINE AND 10 MEQ/HR INTO A
PERIPHERAL LINE.
ASSESS FOR SIGNS AND SYMPTOMS OF HYPOKALEMIA (WEAKNESS, FATIGUE,
U WAVE ON ECG, ARRHYTHMIAS, POLYURIA, POLYDIPSIA) AND
HYPERKALEMIA

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Patient/family Education

13

MONITOR PULSE, BP, AND ECG PERIODICALLY DURING IV THERAPY

MONITOR SERUM POTASSIUM BEFORE AND PERIODICALLY DURING THERAPY.
MONITOR RENAL FUNCTION, SERUM BICARBONATE, AND PH.
DETERMINE SERUM MAGNESIUM LEVEL IF PATIENT HAS REFRACTORY
HYPOKALEMIA, HYPOMAGNESEMIA SHOUL DBE CORRECTED TO FACILITATE
EFFECTIVE OF POTASSIUM REPLACEMENT. MONITOR SERUM CHLORIDE
BECAUSE HYPOCHLOREMIA MAY OCCUR IF REPLACING POTASSIUM WITHOUT
CONCURRENT CHLORIDE.
TOXICITY AND OVERDOSE: SYMPTOMS TOXICITY ARE THOSE OF
HYPERKALEMIA (SLOW, IRREGULAR HEARTBEAT; FATIGUE; MUSCLE
WEAKNESS; PARESTHESIA; CONFUSION; DYSPNEA; PEAKED T WAVES;
DEPRESSED ST SEGMENTS; PROLONGED QT SEGMENTS; WIDENED QRS
COMPLEXES; LOSS OF P WAVES; AND CARDIAC ARRHYTHMIAS).
TREATMENT INCLUDES DISCONTINUATION OF POTASSIUM, ADMINISTRATION
OF SODIUM BICARBONATE TO CORRECT ACIDOSIS, DEXTROSE AND INSULIN
TO FACILITATE PASSAGE OF POTASSIUM INTO CELLS, CALCIUM SALTS TO
REVERSE ECG EFFECTS, SODIUM POLYSTYRENE USED AS AN EXCHANGE
RESIN, AND/OR DIALYSIS FOR PATIENT WITH IMPAIRED RENAL FUNCTION.
ADVISE PATIENT REGARDING SOUCES OF DIETARY POTASSIUM. ENCOURAGE
COMPLIANCE WITH RECOMMENDED DIET.
INSTRUCT PATIENT TO REPORT DARK, TARRY, OR BLOODY STOOLS;
WEAKNESS; UNUSUAL FATIGUE; OR TINGLING OF EXTREMITIES, NOTIFY
HEALTH CARE PROFESSIONAL IF NAUSEA, VOMITING, DIARRHEA, OR
STOMACH DISCOMFORT PERSISTS. DOSAGE MAY REQUIRE ADJUSTMENT.
EMPHASIZE THE IMPORTANCE OF REGULAR FOLLOW UP EXAMS TO MONITOR
SERUM LEVELS AND PROGRESS.

Medication (Name, Dose, And Route): Neutra-Phos 2 powder packets NG Tube TID
Classification
MINERAL AND ELECTROLYTE REPLACEMENTS / SUPPLEMENTS
Mechanism of Action
PHOSPHATE IS PRESENT IN BONE AND IS INVOLVED IN ENERGY TRANSFER AND
CARBOHYDRATE METABOLISM.
Patient-Specific Indication
TREATMENT OF PHOSPHATE DEPLETION IN PATIENTS (PHOSPHORUS 2.1)
Side Effects and Adverse Effects
RELATED TO HYPERPHOSPHATEMIACONFUSION, DIZZINESS, HEADACHE,
WEAKNESS, BRADYCARDIA, ECG CHANGES (ABSENT P WAVES, WIDENING OF THE
QRS COMPLEX WITH BIPHASIC CURVE, PEAKED T WAVES), EDEMA, ABDOMINAL

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Nursing Implications

Patient/family Education

Professor B. Richards
PAIN, N/V, HYPERKALEMIA, HYPERNATREMIA, HYPERPHOSPHATEMIA,
HYPOCALCEMIA, HYPOMAGNESEMIA, MUSCLE CRAMPS, FLACCID PARALYSIS,
HEAVINESS OF LEGS, PARESTHESIAS, TREMORS. DIARRHEA, ARRHYTHMIAS,
CARDIAC ARREST
DISSOLVED IN A FULL GLASS OF WATER AND ALLOW MIXTURE TO STAND
FOR 2-5 MIN TO ENSURE IT IS FULLY DISSOLVED.
ADMINISTER AFTER MEALS TO MINIMIZE GASTRIC IRRITATION AND
LAXATIVE EFFECT.
DO NOT ADMINISTER SIMULTANEOUSLY WITH ANTACIDS CONTAINING
ALUMINUM, MAGNESIUM, OR CALCIUM.
ASSESS PATIENT FOR S/S OF HYPOKALEMIA (WEAKNESS, FATIGUE,
ARRHYTHMIAS, PRESENCE OF U WAVES ON ECG, POLYURIA, POLYDIPSIA)
AND HYPOPHOSPHATEMIA (ANOREXIA, WEAKNESS, DECREASED REFLEXES,
BONE PAIN, CONFUSION, BLOOD DYSCRASIAS) THOUGHOUT THERAPY.
MONITOR INTAKE AND OUTPUT RATIOS AND DAILY WEIGHT. REPORT
SIGNIFICANT DISCREPANCIES.
LAB TEST: MONITOR SERUM PHOSPHATE, POTASSIUM, SODIUM, AND
CALCIUM LEVELS PRIOR TO AND PERIODICALLY THROUGHOUT THERAPY.
INCREASE PHOSPHATE MAY CAUSE HYPOCALCEMIA.
MONITOR RENAL FUNCTION STUDIES PRIOR TO AND PERIODICALLY
THOUGHOUT THERAPY.
MONITOR URINARY PH IN PATIENTS RECEIVING POTASSIUM AND SODIUM
PHOSPHATE AS A URINARY ACIDIFIER.
EXPLAIN PURPOSE OF MEDICATION AND THE NEED TO TAKE AS DIRECTED.
TAKE MISSED DOSES AS SOON AS REMEMBERED UNLESS WITHIN 1 TO 2
HOURS OF THE NEXT DOSE. EXPLAIN THAT THE TABLETS SHOULD NOT BE
SWALLOWED WHOLE AND SHOULD BE DISSOLVED IN WATER.
INSTRUCT PATIENTS IN LOW SODIUM DIET
ADVISE IMPORTANCE OF MAINTAINING A HIGH FLUID INTAKE TO PREVENT
KIDNEY STONES
INSRUCT TO PROMPTLY REPORT DIARRHEA, WEAKNESS, FATIGUE, MUSCLE
CRAMPS, UNEXPLAINED WEIGHT GAIN, SWELLING OF LOWER EXTREMITIES,
SOB, UNUSAL THIRST, OR TREMORS.

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Medication (Name, Dose, And Route): Celecoxib (Celebrex) 200 mg (1 tab) NG tube Daily
Classification
COX 2 INHIBITORS
Mechanism of Action
INHIBITS THE ENZYME COX-2. THIS ENZYME IS REQUIRED FOR THE SYNTHESIS OF
PROSTAGLANDINS. HAS ANALGESIC, ANTI-INFLAMMATORY, AND ANTIPYRETIC
PROPERTIES.
Patient-Specific Indication
RIB FRACTURE
Side Effects and Adverse Effects
DIZZINESS, HEADACHE, INSOMNIA, EDEMIA, ABDOMINAL PAIN, DIARRHEA,
DYSPEPSIA, FLATULENCE, NAUSEA, RASH. MYOCARDIAL INFARCTION, STROKE,
THROMBOSIS, GI BLEEDING, EXFOLIATIVE DERMATITIS, STEVENS-JOHNSON
SYNDROME, TOXIC EPIDERMAL NECROLYSIS
Nursing Implications
CAPSULES MAY BE OPENED AND SPRINKLED ON APPLESAUCE AND INGESTED
IMMEDIATELY WITH WATER. MIXTURE MAY BE STORED IN THE
REFRIGERATOR FOR UP TO 6 HR.
ASSESS PATIENT FOR SKIN RASH FREQUENTLY DURING THERAPY; MAY BE
LIFE-THREATENING. STEVENS-JOHNSON SYNDROME MAY DEVELOP. TREAT
SYMPTOMATICALLY; MAY RECUR ONCE TREATMENT IS STOPPED.
ASSESS ROM, DEGREE OF SWELLING, AND PAIN IN AFFECTED JOINTS BEFORE
AND PERIODICALLY THROUGHOUT THERAPY.
ASSESS PATIETN FOR ALERGY TO SULFONAMIDES, ASPIRIN, OR NSAIDS.
PATIENT WITH THESE ALLERGIES SHOULD NOT RECEIVE CELECOXIB.
LABS: MAY CAUSE INCREASE AST AND ALT LEVELS.
MAY CAUSE HYPOPHOSPHATEMIA AND INCRAESE BUN.
Patient/family Education
INSTRUCT PATIENT TO TAKE CELECOXIB EXACTLY AS DIRECTED. DO NOT
TAKE MORE THAN PRESCRIBED DOSE.
ADVISE PATIENT TO NOTIFY HCP PROMPTLY IF S/S OF GI TOXICITY, SKIN
RASH, UNEXPLAINED WEIGHT GAIN, EDEMA, OR CHEST PAIN OCCURS.
PATIENT SHOULD DISCONTINUE AND NOTIFY HCP IF S/S OF HEPATOTOXICITY
OCCUR (NAUSEA, FATIGUE, LETHARGY, PRURITUS, JAUNDICE, URQ
TENDERNESS, FLU-LIKE SYMPTOMS.

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Medication (Name, Dose, And Route): Ceftriaxone (Rocephin) 2 GM (1 Vial) IV q. 24 hrs over 30 mins. Dilute in NS or D5/W 50 ml
Classification
ANTI-INFECTIVES
Mechanism of Action
BINDS TO THE BACTERIAL CELL WALL MEMBRANE, CAUSE CELL DEATH.
Patient-Specific Indication
RESPIRATORY INFECTION
Side Effects and Adverse Effects
DIARRHEA, CHOLELITHIASIS, GALLBLADDER SLUDGING, RASHES, URTICARIA,
BLEEDING, EOSINOPHILIA, HEMOLYTIC ANEMIA, LEUKOPENIA, THROBOCYTOSIS,
SUPERINFECTION. PAIN AT IM SITE, PHLEBITIS AT IV SITE SEIZURES (HIGH DOSES),
PSEUDOMEMBRANOUS COLITIS, ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS.
Nursing Implications
ASSESS FOR INFECTION (VITAL SIGNS; APPEARANCE OF WOUND, SPUTUM,
URNE, AND STOOL; WBC) AT BEGINNING OF AND THROUGHOUT THERAPY.
BEFORE INITIATING THERAPY, OBRAIN A HISTORY TO DETERMINE PREVIOUS
USE OF AND REACTIONS TO PENICILLINS OR CEPHALOSPORINS. PERSONS WIT
A NEGATIVE HISTORY OF PENCILLIN SENSITIVITY MAY STILL HAVE AN
ALLERGIC RESPONSE.
OBTAIN SPECIMENS FOR CULTURE AND SENSITIVITY BEFORE INITIATING
THERAPY. FIRST DOSE MAY BE GIVEN BEFORE RECEIVING RESULTS.
OBSERVE PATIEN FOR S/S OF ANAPHYLAXIS (RASH, PRURITUS, LARYNGEAL
EDEMA, WHEEZING). DISCONTINUE THE DRUG AND NOTIFY HCP
IMMEDIATLEY IF SYMPTOMS OCCUR. KEEP EPINEPHRINE, AN ANTIHISTAMINE
AND RESUSCITATION EQUIPMENT CLOSE BY IN THE EVENT OF AN
ANAPHYLACTIC REACTION.
MONITOR BOWEL FUNCTION. DIARRHEA, ABDOMINAL CRAMPING, FEVER,
AND BLOODY STOOLS SHOULD BE REPORTED TO CHP PROMPTLY AS A SIGN
OF PSEUDOMEMBRANOUS COLITIS. MAY BEGIN UP TO SEVERAL WEEKS
FOLLOWING CESSATION OF THERAPY.
LAB: MAY CAUSE POSITIVE RESULTS FOR COOMBS TEST
MAY CAUSE INCREASED SERUM AST, ALT, ALKALINE PHOSPHATASE,
BILIRUBIN, LDH, BUN, AND CREATININE.
MAY RARELY CAUSE LEUKOPENIA, NEUTROPENIA, AGRANULOCYTOSIS,
THROMBOCYTPENIA, EOSINOPHILIA, LYMPHOCYTOSIS, AND
THROMBOCYTOSIS.
Patient/family Education
ADVISE PATIENT TO REPORT SIGNS OF SUPERINFECTION (FURRY
OVERGROWTH ON THE TONGUE, VAGINAL ITCHING OR DISCHARGE, LOOSE
OR FOUL SMELLING STOOLS) AND ALLERGY

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INSTRUCT PATIENT TO NOTIFY HCP IF FEVER OR DIARRHEA DEVELOP,

ESPECIALLY IF DIARRHEA CONTAINS BLOOD, MUCUS, OR PUS. ADVISE
PATIENT NOT TO TREAT DIARRHEA WITHOUT CONSULTING HCP.

Medication (Name, Dose, And Route): Lidocaine (Lidoderm) 2 ea (2 adhesion patch) Topical apply to L and R rib cage. 12 hr on and 12
hr off
Classification
ANESTHETIC
Mechanism of Action
PRODUCES LOCAL ANESTHESIA BY INHIBITING TRANSPORT OF IONS ACROSS
NEURONAL MEMBRANES, THERBY PREVENTING INITIATION AND CONDUCTION OF
NORMAL NERVE IMPULSES.
Patient-Specific Indication
RIB FRACTURES-- ANESTHETIC
Side Effects and Adverse Effects
SIDE EFFECTS APPLIES MAINLY TO SYSTEMIC USE
SIDE EFFECTS FOR LOCAL: BURNING, CONTACT DERMATITIS, ERYTHEMA, STINGING
Nursing Implications
MONITOR FOR PAIN INTENSITY IN AFFECTED AREA PERIODICALLY DURING
THERAPY.
Patient/family Education
APPLY LIDODERM PATCH TO INTACT SKIN TO COVER THE MOST PAINFUL
AREA. PATCH MAY BE CUT TO SMALLER SIZES WITH SCISSORS BEFORE
REMOVING RELEASE LINER. CLOTHING MAY BE WORN OVER PATCH. IF
IRRITATION OR BURNIN GSENSATION OCCURS DURING APPLICATION,
REMOVE PATCH UNTIL IRRITAION SUBSIDES. WASH HANDS AFTER
APPLICATION; AVOID CONTACT WITH EYES, DISPOSE OF USED PATCH TO
AVOID ACCESS BY CHILDREN OR PETS.

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SYNTHESIS, CRITICAL THINKING, AND PRIRITIZING

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.

Patient brought to the ED on 2/7/15 after being crushed between two cars. CT scans, CXR, CBC with diff, CMP, troponin and CK-MB labs,
perfusion scan done. Patient had cardiac contusion and fractured ribs on both sides. It was thought that patient might have pneumothorax but
that was ruled out and pleural effusion on left lower lobe. Bronical lavage with a mucus plug sucked up and culture. Lab results pneumonia.
Client placed on ventilator. Patient is having high WBC and febrile of 102 F. MD would like to extubate but patient keeps bearing down and
having episodes of bradycardia (dropping down into the 20s). Patient gets agitated and is currently has wrist restraints.

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
Support patient with oral hygiene care related to patient having an NG tube and preventing further
complications with pneumonia.
Health Promotion and Education
Readiness for enhanced family coping related to family member describing impact of crisis.
Physiological Needs (high priority)
Clear suctions from airway by performing endotracheal suctioning as needed.
Physiological Needs (low priority)
Thermoregulation with acetaminophen and ice packs.
Psychological Needs
Support patient in anxiety due to confusion from fentanyl.
Pharmacological Considerations
Precedex; Fentanyl; Dobutamine; Propofol
Safety and Infection Control
ROM and skin care where wrist restraints are applied every hour.
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 r/t inadequate oxygenation AEB pleural effusion, cardiac contusion, and ABG
2.
Risk for infection related to respiratory compromise present with pneumonia AEB increased WBC and thick tan secretions
Two Medium Priority Nursing Diagnoses (at least one of them should be spiritual or psychosocial diagnosis):
1.
Ineffective tissue perfusion r/t ischemia AEB by high Troponin and CK-MB enzymes
2.
Risk for Post-Trauma Syndrome r/t inadequate coping ability due to physical and emotional stress AEB hospitalization from a motor
vehicle accident.
One Low Priority Nursing Diagnosis:
1.
Risk for injury to self r/t confusion from fentanyl AEB attempting to pull out ventilator tube.

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Nursing Diagnosis I: Impaired gas exchange r/t inadequate oxygenation AEB pleural effusion, cardiac contusion, and ABG
*

Relevant Assessment:
o Course crackles in RUL
o Thick tan secretions upon suctioning
o Diminished breath sound in LLL
o RR going as high as 33
* Relevant Diagnostic Tests:
o ABG
o CXR
* Relevant Medications and Therapies:
o Ipratropium / Albuterol Sulfate 3 ml (1 UD) Nebulization q. 4 hrs
o Mechanical ventilation
* Expected Outcomes:
o Patient have adequate gas exchange as evidenced by PaO2 80 mm Hg, PaCO2 35 to 45 mm Hg, pH 7.35 to 7.45, presence of
normal breath sounds and absence of adventitious breath sounds; RR is 12-20 breaths/min with normal pattern and depth.
* Nursing Interventions with Rationales:
o Monitor respiratory rate, depth, and ease of respiration. Watch for use of accessory muscles and nasal flaring. Normal respiratory
rate is 10-20 breaths/min in the adult. A study demonstrated that when the respiratory rate exceeds 30 breaths/min along with
other physiological measures, a significant cardiovascular or respiratory alteration exists.
o Auscultate breath sounds every 1 to 2 hours. Listen for diminished breath sounds, crackles, and wheezes. The presence of crackles
and wheezes may alert the nurse to airway obstruction, which may lead to or exacerbate existing hypoxia. In severe exacerbations
of chronic obstructive pulmonary disease (COPD), lung sounds may be diminished or distant with air trapping.
o Monitor oxygen saturation continuously using pulse oximetry. Correlate arterial oxygen saturation blood gas results with pulse
oximetry. An oxygen saturation of less than 90% (normal: 95% to 100%) or a partial pressure of oxygen of less than 80 mm Hg
(normal: 80 to 100 mm Hg) indicates significant oxygenation problems. Pulse oximetry is useful for tracking and/or adjusting
supplemental oxygen therapy for clients with COPD.
o Observe for cyanosis of the skin; especially note color of the tongue and oral mucous membranes. Central cyanosis of the tongue
and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in the extremities maybe due
to activation of the central nervous system or exposure to cold and may or may not be serious.
o Position the client in a semirecumbent position with the head of the bed at a 30 to 45 degree angle to decrease the aspiration of
gastric, oral, and nasal secretions. Evidence shows that mechanically ventilated clients have a decreased incidence of VAP if the
client is placed in a 30-45 degree semirecumbent position as opposed to a supine position.
o Monitor the effects of sedation and analgesics on the clients respiratory pattern; use judiciously. Both analgesics and medications
that cause sedation can depress respiration at times. However, these medications can be very helpful for decreasing the SNS
discharge with physical and psychological distress that accompanies hypoxia.

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o

o
o
* Evaluation
o
o

Professor B. Richards

Administer humidified oxygen through an appropriate device; aim for an O2 saturation level of 90% oxygen saturation or above.
Watch for onset of hypoventilation as evidenced by increased somnolence. There is a fine line between ideal or excessive oxygen
therapies; increasing somnolence is caused by retention of carbon dioxide leading to CO2 narcosis. Promote oxygen therapy
during a COPD exacerbation. Supplemental oxygen should be titrated to improve the clients hypoxemia with a target of 88%
to 92% oxygen saturation.
Assess and monitor oxygen indices such as PF ration (FIO2:pO2), venous oxygen saturation/oxygen consumption (SVO2 or
ScVO2)
Turn client every 2 hours. Monitor mixed venous oxygen saturation closely after turning. If it drops below 10% or fails to return
to baseline promptly, turn the client back into the supine position, check vital signs, and evaluate oxygen status. If the client does
not tolerate turning, consider use of a kinetic bed that rotates the client form side to side in a turn of at least 40 degrees.
Patient O2 Saturation remained 96% during shift.
Patient pH 7.44 / PaO2 73 (L) / CO2: 36.1 / HCO3: 23.8 during shift

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Nursing Diagnosis II: Risk for infection related to respiratory compromise present with pneumonia AEB increased WBC and

thick tan secretions

* Relevant Assessment: Increased WBC count and Thick tan secretions from suctioning
* Relevant Diagnostic Tests:
o CBC w. differential
o CXR
o Sputum endotracheal
o Bronchial lavage
* Relevant Medications and Therapies:
o Ceftriaxone (Rocephin) 2 GM (1 Vial) IV q. 24 hrs over 30 mins. Dilute in NS or D5/W 50 ml
o Suctioning q. 4 hr
o Oral care BID with chlorhexidine gluconate 15 ml.
* Expected Outcomes:
o Patient remains free of infection reflected by normothermia and negative cultures; WBC count is within normal limits for patient;
and sputum is clear to white in color.
* Nursing Interventions with Rationales:
o Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature. Change in mental
status, fever, shaking, chills, and hypotension are indicators of sepsis.
o Oral or tympanic thermometers may be used to assess temperature in adults. The use of thermometers to obtain temperatures is
supported.
o Note and report laboratory values (white blood cell count and differential, serum protein, serum albumin, and cultures). While the
WBC may be in normal range, an increased number of immature bands may be present.
o Assess skin for color, moisture, texture, and turgor (elasticity). Keep accurate, ongoing documentation of changes. Hospitalacquired pressures areas, skin tears, and infections are associated with pain, reduced mobility, increased risk of in-hospital
complications, and increased health care costs.
o Use strategies to prevent further complications for pneumonia: assess lung sounds, and sputum color and characteristics; use
sterile water for mouth care; use sterile technique when suctioning; suction secretions above tracheal tube before suctioning; drain
accumulated condensation in ventilator tubing in to a fluid trap or other collection device before repositioning the client; assess
patency and placement of nasogastric tubes; elevate the clients head to 30 degrees or higher to prevent gastric reflux of organisms
in the lung. Ventilator-associated pneumonia is the most common health care-acquired infection seen in the ICU.
* Evaluation
o Indwelling catheters; endotracheal tubes; venous or arterial access devices will be assessed during each shift and remain pathogen
free for patient stay in the hospital.
o Continuous monitoring of WBC, temperature and monitor for signs of infection such as redness, swelling, increased pain, or
purulent drainage at exit site of tubes and catheters. Color of respiratory secretions could be indicative of respiratory infection.
Notify MD of any changes to patients condition.

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REFERENCES
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care.
Baird, M. S., & Bethel, S. (2011). Manual of critical care nursing: Nursing interventions and collaborative management
(6th ed.). St. Louis, MO: Elsevier Mosby.
Chernecky, C. C., & Berger, B. J. (2013). Laboratory tests and diagnostic procedures (6th ed.). St. Louis, MO:
Elsevier/Saunders.
Deglin, PharmD, J. H., Vallerand, PhD, RN, FAAN, A. H., & Sanoski, BS, PharmD, FCCP, BCPS, C. A. (2012, June 15).
DrugGuide.com | Davis's Drug Guide Online + Mobile. Retrieved February 22, 2015, from http://www.drugguide.com/ddo/ub
Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology (5th ed.). St. Louis, Mo: Elsevier.
Kaye, P., & O'Sullivan, I. (2002). Myocardial contusion: emergency investigation and diagnosis. Emergency Medicine Journal,
19(1), 8-10. doi:10.1136/emj.19.1.8
Urden, L. D., Stacy, K. M., & Lough, M. E. (2012). Priorities in critical care nursing (6th ed.). St. Louis, MO: Elsevier/Mosby.

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