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

DISEASES AND

DISORDERS

DISEASES

A Nursing

Therapeutics Manual

THIRD EDITION

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page i PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK009

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page ii PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK009

DISEASES AND

DISORDERS

DISEASES AND

DISORDERS

A Nursing

Therapeutics Manual

THIRD EDITION

Marilyn Sawyer Sommers, RN, PhD, FAAN

Professor

University of Pennsylvania

Philadelphia, Pennsylvania

Susan A. Johnson, RN, PhD

Program Director & Associate Professor

College of Mount St. Joseph

Cincinnati, Ohio

Theresa A. Beery, PhD, RN

Associate Professor

University of Cincinnati

Cincinnati, Ohio

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page iii PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00

F. A. Davis Company

1915 Arch Street

Philadelphia, PA 19103

www.fadavis.com

Copyright © 2007 by F. A. Davis Company

Copyright © 2007, 2002, 1997 by F. A. Davis Company. All rights reserved. This book is pro￾tected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted

in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise,

without written permission from the publisher.

Printed in the United States

Last digit indicates print number: 1098765432

Acquisitions Editor: Joanne P. DaCunha, RN, MSN

Developmental Editor: Kristin L. Kern

Design Manager: Carolyn O’Brien

As new scientific information becomes available through basic and clinical research, recom￾mended treatments and drug therapies undergo changes. The author(s) and publisher have done

everything possible to make this book accurate, up to date, and in accord with accepted standards

at the time of publication. The author(s), editors, and publisher are not responsible for errors or

omissions or for consequences from application of the book, and make no warranty, expressed

or implied, in regard to the contents of the book. Any practice described in this book should be

applied by the reader in accordance with professional standards of care used in regard to the

unique circumstances that may apply in each situation. The reader is advised always to check

product information (package inserts) for changes and new information regarding dose and con￾traindications before administering any drug. Caution is especially urged when using new or

infrequently ordered drugs.

Library of Congress Cataloging-in-Publication Data

Sommers, Marilyn Sawyer.

Diseases and disorders : a nursing therapeutics manual / Marilyn Sawyer

Sommers, Susan A. Johnson, Theresa A. Beery.—3rd ed.

p. ; cm.

Includes bibliographical references and index.

ISBN-13: 978-0-8036-1337-9

ISBN-10: 0-8036-1337-7

1. Nursing—Handbooks, manuals, etc. 2. Nursing diagnosis—Handbooks, manuals,

etc. 3. Therapeutics—Handbooks, manuals, etc. I. Johnson, Susan A. II. Beery,

Theresa A. III. Title.

[DNLM: 1. Nursing Care—methods—Handbooks. 2. Nursing Process—Handbooks.

WY 49 S697da 2007]

RT51.S66 2007

610.73—dc22

2006019341

Authorization to photocopy items for internal or personal use, or the internal or personal use of

specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clear￾ance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is

paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that

have been granted a photocopy license by CCC, a separate system of payment has been arranged.

The fee code for users of the Transactional Reporting Service is: 8036–0811/ 02 0 $.10.

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page iv PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00

To my girls- Marilyn, Melissa, Abigail, and Sophia- with love

MSS

To Ian, Tara, Shannon, Courtney, Michael, Abigail, and Morgan…you bring much love, joy and

pride to our family.

And to all the nursing students I have encountered…many thanks for all the lessons

you have taught me. May you always strive to make a difference in others, in the profession,

and in yourself.

SAJ

To my dear husband, delightful children and extraordinary grandchildren.

You bring me so much joy!

TAB

Dedication

v

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page v PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK009

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page vi PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00

Preface

vii

The first and second editions of this book were conceived to provide distilled, up-to-date infor￾mation to nursing students and staff nurses about many conditions and diagnoses encountered in

nursing practice. With the third edition, we have responded to the ever-changing health care

environment as well as to the recommendations of our readers and editors. We have held true to

our initial purpose in this third edition: to provide a ready source of information for nurses in a

time of short staffing, brief lengths of stay, and increasing patient acuity in the hospital, in nurs￾ing homes, in rehabilitation centers, and in the home. We have also responded to the ever￾increasing need for nurses to understand the scientific basis of their practice by augmenting the

pathophysiology sections that were in the past two editions.

Perhaps the most significant addition to the third edition is a section entitled Genetic Con￾siderations. Since the completion of the Human Genome Project in 2003, the health care disci￾plines are beginning to understand the enormous significance of the human genome sequence,

which provides foundational information that shows us how genes and proteins work together to

promote human health. This section of the book assists practitioners to consider how the genetic

basis of disease is related to environmental factors in health and disease, and how disease sus￾ceptibility, detection of illness, and drug response are related to people’s genetic make-up. We

are indebted to co-author Dr. Terry Beery for the development of the genetic information con￾tained in this edition.

As in the first edition, we have included relevant information about Gender and Life Span

Considerations, and have enhanced this section with information about racial and ethnic differ￾ences in health and disease. As our society has an ever-increasing diversity, we have developed

this section so that practitioners have a basis from which to develop culturally competent care.

Each entry begins with the Diagnosis Related Group (DRG) category. DRGs were initiated

by the Health Care Financing Administration to serve as an organizing framework to group￾related conditions and to stabilize reimbursements. Because they provide a convenient standard

to evaluate hospital care, DRGs are used by institutions and disciplines to measure utilization

and to allocate resources. We have included DRGs to indicate the expected norms in average

length of stay for each entry. Each entry follows the nursing process, with assessment informa￾tion incorporated in the History and Physical Assessment sections, the Psychosocial Assess￾ment, and Diagnostic Highlights. Based on requests from our readers and reviewers, we have

supplemented information on diagnostic testing from earlier editions to provide normal and

abnormal values for the most important diagnostic tests. We have also added a section to explain

the rationale for the test. These detailed, specific sections provide the foundation needed to per￾form a comprehensive assessment of the patient’s condition so that a Primary Nursing Diag￾nosis can be formulated appropriate to the patient’s specific needs. The Planning and Imple￾mentation section is divided into Collaborative and Independent interventions. The intent of

the Collaborative section is to detail the goals of a multidisciplinary plan of care to manage the

condition or disease. As in the second edition, there is an expanded section on Pharmacologic

Highlights that explores commonly used drugs, their doses, mechanisms of action, and ratio￾nales for use. The Independent section focuses on independent nursing interventions that

demonstrate the core of the art and science of nursing. Each entry then finishes with Documen￾tation Guidelines and Discharge and Home Healthcare Guidelines to help nurses evaluate the

outcomes of care and to prepare hospitalized patients for discharge.

As with the first and second editions, the idea for the book originated with Joanne Patzek

DaCunha, Publisher at F.A. Davis. The authors salute her creativity, perseverance, enthusiasm,

and vision. More importantly, her gracious friendship and support enabled us to accomplish this

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page vii PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00

viii Preface

revision with a minimum of difficulty. We also owe a debt of gratitude to Jeff Sommers for his

assistance with manuscript development, editing, proofreading, and supportive cheerleading.

Finally we acknowledge with gratitude the hard work that a host of contributors made to the first

edition.

The entire reason to revise this book is to provide practicing nurses a concise and yet scien￾tifically sound text to guide the professional practice of nursing. The provision of nursing care in

the 21st century presents us with overwhelming challenges, and yet nursing is the discipline of

choice for millions of practitioners. We hope this book honors the science of nursing and makes

it easier to practice the art of nursing.

MSS

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page viii PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK0

Consultants

ix

Dianne V. Benton, RN, MS

Instructor, Senior Level Medical￾Surgical Nursing

Louise Obici School of Nursing

Suffolk, Virginia

Barbara Dunn, RN, MSN

Professor, Nursing

New Hampshire Technical Institute

Concord, New Hampshire

Mary Taylor Martof, RN, EdD

Associate Professor

Louisiana State Health Sciences

Center

New Orleans, Louisiana

Christine C. Mihal, RN, MSN

Lecturer of Nursing

Associate Director of Baccalaureate

Nursing

Fairleigh Dickinson University

Teaneck, New Jersey

Anne Pithan, RN, MSN

Nursing Faculty

St. Luke’s College of Nursing

Sioux City, Iowa

Sylvia J. Sheffler, RN, DNSc

Associate Professor

Delaware State University

Dover, Delaware

Susan Wilkinson, RN, MSN, PhD(c)

Professional Specialist

Department of Nursing

Angelo State University

San Angelo, Texas

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page ix PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page x PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK009

Contents

xi

Abdominal Aortic Aneurysm 1

Abdominal Trauma 5

Abortion, Spontaneous 11

Abruptio Placentae 15

Acid-Base Imbalances: Metabolic Acidosis

and Alkalosis; Respiratory Acidosis and

Alkalosis 19

Acquired Immunodeficiency

Syndrome 25

Acromegaly 31

Acute Adrenal Crisis 34

Acute Alcohol Intoxication 37

Acute Respiratory Distress Syndrome 41

Adrenal Insufficiency

(Addison’s Disease) 44

Air Embolism 48

Alcohol Withdrawal 51

Allergic Purpura 56

Alzheimer’s Disease 58

Amputation 62

Amyloidosis 66

Amyotrophic Lateral Sclerosis 69

Anaphylaxis 73

Angina Pectoris 76

Anorectal Abscess and Fistula 81

Anorexia Nervosa 84

Aortic Valve Insufficiency 88

Aortic Valve Stenosis 91

Aplastic Anemia 94

Appendicitis 98

Arterial Occlusive Disease 102

Asthma 106

Atelectasis 110

Atrial Dysrhythmias 113

Basal Cell Carcinoma 119

Benign Prostatic Hyperplasia

(Hypertrophy) 122

Bladder Cancer 126

Blood Transfusion Reaction 130

Bone Cancer 135

Botulism 139

Brain Cancer 142

Breast Cancer 148

Bronchiolitis (Respiratory Syncytial

Viral Infection) 155

Bronchitis 158

Bulimia Nervosa 161

Burns 165

Calculi, Renal 171

Candidiasis (Moniliasis) 174

Cardiac Contusion (Myocardial

Contusion) 177

Cardiac Tamponade 181

Cardiogenic Shock 185

Cardiomyopathy 189

Carpal Tunnel Syndrome 193

Cataract 196

Cerebral Aneurysm 199

Cerebral Concussion 203

Cerebrovascular Accident 207

Cervical Cancer 212

Cervical Incompetence 216

Chlamydial Infections 219

Cholecystitis and Cholelithiasis 223

Chorioamnionitis 227

Chronic Fatigue Immune Dysfunction

Syndrome 230

Cirrhosis 233

Cleft Lip; Cleft Palate 237

Colorectal Cancer 240

Cor Pulmonale 245

Coronary Artery Disease

(Arteriosclerosis) 248

Crohn’s Disease 252

Cushing’s Syndrome 256

Cystic Fibrosis 260

Cystitis 264

Cystocele; Rectocele 268

Cytomegalovirus Infection 271

Degenerative Joint Disease (DJD) 275

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page xi PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00

xii Contents

Diabetes Insipidus 279

Diabetes Mellitus 282

Diffuse Axonal Injury 288

Dislocation; Subluxation 291

Disseminated Intravascular

Coagulation 295

Diverticular Disease 299

Dysfunctional Uterine Bleeding 303

Ectopic Pregnancy 307

Emphysema 310

Encephalitis 314

Endometriosis 318

Epididymitis 322

Epidural Hematoma 325

Epilepsy 329

Esophageal Cancer 333

Esophageal Diverticula 337

Fat Embolism 341

Fetopelvic Disproportion 344

Fibrocystic Breast Condition 348

Gallbladder and Biliary Duct

(Biliary System) Cancer 353

Gastric Cancer 356

Gastritis 360

Gastroenteritis 364

Gastroesophageal Reflux Disease

(GERD) 368

Glaucoma 371

Glomerulonephritis, Acute 374

Goiter 378

Gonorrhea 381

Guillain-Barré Syndrome 384

Gunshot Wound 388

Heart Failure 395

Hemophilia 400

Hemorrhoids 403

Hemothorax 406

Hepatitis 410

Herniated Disk 415

Herpes Simplex Virus 418

Herpes Zoster (Shingles) 421

Hodgkin’s Disease 424

Hydronephrosis 429

Hypercalcemia 433

Hyperchloremia 437

Hyperglycemia 439

Hyperkalemia 443

Hyperlipoproteinemia 447

Hypermagnesemia 451

Hypernatremia 454

Hyperparathyroidism 458

Hyperphosphatemia 462

Hypertension 465

Hyperthyroidism 469

Hypocalcemia 473

Hypochloremia 477

Hypoglycemia 480

Hypokalemia 483

Hypomagnesemia 487

Hyponatremia 490

Hypoparathyroidism 494

Hypophosphatemia 498

Hypothyroidism 501

Hypovolemic/Hemorrhagic Shock 505

Idiopathic Thrombocytopenia Purpura 511

Infective Endocarditis 514

Influenza 518

Inguinal Hernia 521

Intestinal Obstruction 524

Intracerebral Hematoma 527

Intrauterine Fetal Demise 531

Intussusception 534

Iron Deficiency Anemia 538

Irritable Bowel Syndrome 541

Junctional Dysrhythmias 545

Kidney Cancer 549

Laryngeal Cancer 553

Laryngotracheobronchitis (Croup) 556

Legionnaires’ Disease 560

Leukemia, Acute 563

Leukemia, Chronic 567

Liver Failure 572

Lung Cancer 576

Lupus Erythematosus 581

Lyme Disease 585

Lymphoma, Non-Hodgkin’s 589

Mallory-Weiss Syndrome 595

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page xii PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00

Contents xiii

Mastitis 598

Melanoma Skin Cancer 601

Meningitis 605

Migraine Headache 609

Mitral Insufficiency

(Regurgitation) 612

Mitral Stenosis 616

Mononucleosis, Infectious 620

Multiple Myeloma 623

Multiple Organ Dysfunction

Syndrome 627

Multiple Sclerosis 633

Muscular Dystrophy 636

Musculoskeletal Trauma 641

Myasthenia Gravis 646

Myocardial Infarction 650

Myocarditis 655

Nephrotic Syndrome 659

Neurogenic Bladder 662

Osteomyelitis 669

Osteoporosis 672

Otitis Media 676

Ovarian Cancer 680

Paget’s Disease 685

Pancreatic Cancer 688

Pancreatitis 693

Parkinson’s Disease 697

Pelvic Fractures 701

Pelvic Inflammatory Disease 705

Peptic Ulcer Disease 709

Pericarditis 713

Peritonitis 717

Pernicious Anemia 720

Pheochromocytoma 724

Pituitary Tumor 728

Placenta Previa 732

Pneumocystis carinii Pneumonia 736

Pneumonia 740

Pneumothorax 743

Polycystic Kidney Disease 746

Polycythemia 750

Postpartum Hemorrhage 754

Preeclampsia 758

Premature Rupture of Membranes 763

Pressure Ulcer 767

Preterm Labor 771

Prostate Cancer 776

Prostatitis 781

Psychoactive Substance Abuse 784

Pulmonary Embolism 789

Pulmonary Fibrosis 793

Pulmonary Hypertension 796

Pyelonephritis 800

Renal Failure, Acute 805

Renal Failure, Chronic 810

Retinal Detachment 815

Rheumatic Fever, Acute 818

Rheumatoid Arthritis 822

Rocky Mountain Spotted

Fever 826

Salmonella Infection

(Salmonellosis) 831

Sarcoidosis 834

Septic Shock 837

Sickle Cell Disease 842

Sjögren’s Syndrome 845

Skin Cancer 848

Spinal Cord Injury 853

Subarachnoid Hemorrhage 857

Subdural Hematoma 861

Sudden Infant Death Syndrome 865

Syndrome of Inappropriate Antidiuretic

Hormone (SIADH) 868

Syphilis 871

Tendinitis 877

Testicular Cancer 879

Tetanus 883

Thoracic Aortic Aneurysm 887

Thrombophlebitis 891

Thyroid Cancer 895

Tonsillitis 899

Toxoplasmosis 902

Tuberculosis 906

Ulcerative Colitis 911

Urinary Tract Infection 914

Urinary Tract Trauma 918

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page xiii PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK00

xiv Contents

Uterine Cancer 923

Vaginal Cancer 929

Vaginitis 932

Varicose Veins 935

Ventricular Dysrhythmias 938

Volvulus 944

Selected Bibliography 949

Index 951

FABK009-FM-i-xviii.qxd 11/7/06 10:47 AM Page xiv PMAC-291 PMAC-291:Books:DAMS/DART/ARCHIVE:FABK0