AMERICAN
r ASSOCIATION
FIFTH EDITION °J CRITICAL-CARE
NURSES
AACN
Essentials of
Progressive
Care Nursing
Sarah A. Delgado
Mc
Gra w
Hill
, AACN Essentials of Progressive Care Nursing
Fifth Edition
Sarah A. Delgado, MSN, RN, ACNP
Clinical Practice Specialist
American Association of Critical-Care Nurses
Aliso Viejo, California
New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto
Delgado-PC_FM_pi-xviii.indd 1 10/08/23 1:58
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, Contents
Contributors...........................................................................................................................................................................................................................................................xiii
Peer Reviewers....................................................................................................................................................................................................................................................... xv
Preface................................................................................................................................................................................................................................................................ xvii
Section I. The Essentials........................................................................................................................................................................................................................................ 1
1. Assessment of Progressive Care Patients and Their Families........................................................................................................... 3
Lynn Orser
2. Planning Care for Progressive Care Patients and Their Families.................................................................................................. 19
Lynn Orser
3. Interpretation and Management of Basic Cardiac Rhythms.......................................................................................................... 37
Carol Jacobson
4. Hemodynamic Monitoring................................................................................................................................................................. 73
Yana Dilman
5. Airway and Ventilatory Management................................................................................................................................................ 99
Robert E. St. John and Maureen A. Seckel
6. Pain and Sedation Management....................................................................................................................................................... 141
Yvonne D’Arcy and Sara Knippa
7. Pharmacology..................................................................................................................................................................................... 163
Earnest Alexander
8. Ethical and Legal Considerations..................................................................................................................................................... 193
Laura Webster
Section II. Pathologic Conditions..................................................................................................................................................................................................................... 217
9. Cardiovascular System....................................................................................................................................................................... 219
Brook Powell and Barbara Leeper
10. Respiratory System............................................................................................................................................................................. 253
Kiersten N. Henry and Maureen A. Seckel
11. Multisystem Problems....................................................................................................................................................................... 287
Sonya M. Grigsby
12. Neurological System........................................................................................................................................................................... 311
Kathrina Siaron and DaiWai M. Olson
iii
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, iv CONTENTS
13. Hematologic and Immune Systems................................................................................................................................................. 337
Danya Garner
14. Gastrointestinal System..................................................................................................................................................................... 353
Anna M. Alder
15. Renal System....................................................................................................................................................................................... 385
Jie Chen
16. Endocrine System............................................................................................................................................................................... 403
Heather Roff
17. Trauma................................................................................................................................................................................................. 425
Alina Huneke and Jen Miller
Section III. Advanced Concepts........................................................................................................................................................................................................................ 443
18. Advanced ECG Concepts.................................................................................................................................................................. 445
Carol Jacobson
19. Advanced Cardiovascular Concepts................................................................................................................................................ 493
Brook Powell and Barbara Leeper
20. Advanced Neurologic Concepts....................................................................................................................................................... 521
Kathrina Siaron and DaiWai M. Olson
Section IV. Key Reference Information............................................................................................................................................................................................................. 543
21. Normal Laboratory Reference Values.............................................................................................................................................. 545
Sarah A. Delgado
22. Implementing Crisis Standards of Care........................................................................................................................................... 549
Laura Webster
23. Cardiac Rhythms, ECG Characteristics, and Treatment Guide................................................................................................... 551
Carol Jacobson
Index ............................................................................................................................................................................................................... 559
Delgado-PC_FM_pi-xviii.indd 4 10/08/23 1:58
, Contents in Detail
Contributors..............................................................................................................................................................................................................................................................xiii
Peer Reviewers.......................................................................................................................................................................................................................................................... xv
Preface.................................................................................................................................................................................................................................................................... xvii
Section I. The Essentials........................................................................................................................................................................................................................................ 1
1. Assessment of Progressive Care Patients and Their Families........................................................................................................... 3
Lynn Orser
Assessment Framework 3
Prearrival Assessment 4 / Arrival Quick Check 4 / Comprehensive Initial Assessment 4 /
Ongoing Assessment 4 / Patient Safety Considerations in Admission Assessments 4
Prearrival Assessment: Before the Action Begins 5
Admission Quick Check Assessment 6
Airway and Breathing 7 / Circulation and Cerebral Perfusion 7 / Chief Complaint 7 /
Drugs and Diagnostic Tests 7 / Equipment 8
Comprehensive Initial Assessment 8
Past Medical History 9 / Social History 9 / Physical Assessment by Body System 9 /
Transition/Discharge Planning 15
Ongoing Assessment 16
Principles of Management 17
Selected Bibliography 17
Progressive Care Assessment 17 / Evidence-Based Practice 17
2. Planning Care for Progressive Care Patients and Their Families.................................................................................................. 19
Lynn Orser
Interprofessional Plan of Care 20
Planning Care through Staffing Considerations 20
Patient Safety Considerations in Planning Care 21
Prevention of Common Complications 22
Physiologic Instability 22 / Venous Thromboembolism 22 / Hospital-Acquired Infections 22 /
Pressure Injury 24 / Sleep Pattern Disturbance 24 / Falls 25 / Psychosocial Impact 25
Patient and Family Education 27
Assessment of Learning Readiness 27 / Strategies to Address Patient and Family Education 27 /
Outcome Measurement 28
Family-Centered Care 28
Family Visitation 29
Transporting the Progressive Care Patient 30
Assessment of Risk for Complications 30 / Level of Care Required during Transport 31 /
Preparation 32 / Transport 32 / Interfacility Transfers 34
Transitioning to the Next Stage of Care 34
Supporting Patients and Their Families during the Dying Process 34
v
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, vi CONTENTS IN DETAIL
Principles of Management 34
Selected Bibliography 34
Patient and Family Needs 34 / Infection Prevention and Control 35 / Patient and Family
Education 35 / Psychosocial Care 35 / Sleep Deprivation 35 / Transport of Critically Ill Patients 35 /
Evidence-Based Practice 35
3. Interpretation and Management of Basic Cardiac Rhythms.......................................................................................................... 37
Carol Jacobson
Basic Electrophysiology 37
Ecg Waveforms, Complexes, and Intervals 38
P Wave 39 / QRS Complex 39 / T Wave 39 / U Wave 39 / PR Interval 39 / ST Segment 39 /
QT Interval 39
Basic Electrocardiography 39
Cardiac Monitoring 40
Determination of the Heart Rate 41
Determination of Cardiac Rhythm 43
Common Dysrhythmias 43
Rhythms Originating in the Sinus Node 43
Normal Sinus Rhythm 43 / Sinus Bradycardia 43 / Sinus Tachycardia 44 / Sinus Dysrhythmia 44 /
Sinus Node Dysfunction 45 / Sinus Pause and Sinus Arrest (Failure of the Sinus Node to Fire) 45 /
Tachycardia-Bradycardia (Tachy-Brady) Syndrome 45
Dysrhythmias Originating in the Atria 46
Premature Atrial Complexes 46 / Wandering Atrial Pacemaker and Multifocal Atrial Tachycardia 47 /
Atrial Tachycardia 47 / Atrial Flutter 48 / Atrial Fibrillation 51 / Supraventricular Tachycardia 56
Dysrhythmias Originating in the Atrioventricular Junction 57
Premature Junctional Complexes 57 / Junctional Rhythm, Accelerated Junctional Rhythm, and
Junctional Tachycardia 58
Dysrhythmias Originating in the Ventricles 58
Premature Ventricular Complexes 58 / Idioventricular Rhythm and Accelerated Idioventricular
Rhythm 59 / Ventricular Tachycardia 60 / Ventricular Fibrillation 60 / Ventricular Asystole 62
Atrioventricular Blocks 62
First-Degree Atrioventricular Block 62 / Second-Degree Atrioventricular Block 63 / High-Grade
Atrioventricular Block 64 / Third-Degree Atrioventricular Block (Complete Block) 64
Temporary Pacing 65
Indications 65 / Transvenous Pacing 65 / Epicardial Pacing 65 / Components of a Pacing
System 66 / Basics of Pacemaker Operation 66 / Initiating Transvenous Ventricular Pacing 68 /
Initiating Epicardial Pacing 68 / External (Transcutaneous) Pacemakers 69
Defibrillation and Cardioversion 70
Defibrillation 70 / Automatic External Defibrillators 70 / Cardioversion 70
Selected Bibliography 71
Evidence-Based Practice 71
4. Hemodynamic Monitoring................................................................................................................................................................. 73
Yana Dilman
Hemodynamic Parameters 74
Cardiac Output 74 / Components of Cardiac Output/Cardiac Index 76 / Stroke Volume and Stroke
Volume Index 77 / Ejection Fraction 77 / Factors Affecting Stroke Volume/Stroke Volume Index 77 /
Global End-Diastolic Volume as a More Reliable Preload Marker 81
Basic Components of Hemodynamic Monitoring Systems 82
Arterial Catheter 82 / Pressure Tubing 82 / Pressure Transducer 82 / Pressure Amplifier 82 /
Pressure Bag and Flush Device 82 / Alarms 84
Obtaining Accurate Cvp and Arterial Values 84
Zeroing the Transducer 84 / Leveling the Transducer to the Catheter Tip 84 / Ensuring Accurate
Waveform Transmission 84
Insertion and Removal of Catheters 87
Central Venous Catheters 87 / Arterial Catheters 87
Obtaining and Interpreting Hemodynamic Waveforms 88
Patient Positioning 88 / Interpretation 88 / Artifacts in Hemodynamic Waveforms:
Respiratory Influence 90
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, CONTENTS IN DETAIL vii
Tissue Perfusion Markers 91
Central Venous Oxygen (Scvo2) Monitoring 91 / Venoarterial Carbon Dioxide Gap 91 /
Lactate Monitoring 91 / Capillary Refill Time Monitoring 91
Minimally Invasive Hemodynamic Monitoring 91
Pulse Contour Measurement 91
Transpulmonary Thermodilution (PiCCO) 91 / LiDCO 92 / FloTrac/Vigileo 92 / Volume Clamp
Method 92 / Thoracic Bioimpedance/Bioreactance 92 / Esophageal Doppler 93 / Applanation
Tonometry 93 / Pleth Variability Index and End-Tidal Carbon Dioxide Pulse Pressure 93 /
Microcirculatory Targets 93 / Ambulatory Pulmonary Artery Pressure Monitoring 94
Selected Bibliography 95
Hemodynamic Monitoring 95 / Minimally Invasive Hemodynamic Monitoring 96 /
Therapeutics 97 / Evidence-Based Practice Guidelines 98
5. Airway and Ventilatory Management................................................................................................................................................ 99
Robert E. St. John and Maureen A. Seckel
Diagnostic Tests, Monitoring Systems, and Respiratory Assessment Techniques 99
Arterial Blood Gas Monitoring 99 / Venous Blood Gas Monitoring 104 / Pulse Oximetry 104 /
Assessing Pulmonary Function 106
Airway Management 109
Oropharyngeal Airway 109 / Nasopharyngeal Airway 109 / Laryngeal Mask Airway 109 /
Artificial Airways 109 / Endotracheal or Tracheostomy Suctioning 112 / Extubation 114
Decannulation 114
Oxygen Therapy 115
Complications 115 / Oxygen Delivery 115
Basic Ventilatory Management 118
Indications 118 / General Principles 118 / Modes 121 / Complications of Mechanical
Ventilation 123 / Weaning From Short-Term Mechanical Ventilation 125 / Weaning From
Prolonged Mechanical Ventilation 128 / Respiratory Fatigue, Rest, and Conditioning 129 /
Wean Trial Protocols 130 / Other Protocols for Use 131 / Critical Pathways 131 / Systematic
Institutional Initiatives for the Management of the LTMV Patient Population 131 / Troubleshooting
Ventilators 131 / Oral Feedings 132 / Communication 132
Principles of Management 136
Maximizing Oxygenation, Ventilation, and Patient-Ventilator Synchrony 136 / Maintain a Patent
Airway 136 / Monitor Oxygenation and Ventilation Status Frequently 136 / Physiotherapy and
Monitoring 137 / Maintain Oxygenation and Ventilatory Support at All Times 137 / Weaning from
Mechanical Ventilation 137 / Preventing Complications 137 / Maximizing Communication 137 /
Reducing Anxiety and Providing Psychosocial Support 137
Selected Bibliography 137
General Progressive Care 137 / COVID-19 139 / Ventilator Management 139 /
Weaning from Mechanical Ventilation 139 / Communication 139 / Evidence-Based Resources 139
6. Pain and Sedation Management....................................................................................................................................................... 141
Yvonne D’Arcy and Sara Knippa
Physiologic Mechanisms of Pain 141
Peripheral Mechanisms 141 / Spinal Cord Integration 142 / Central Processing 142
Responses to Pain 143
Pain Assessment 144
A Multimodal Approach to Pain Management 144
Nonsteroidal Anti-Inflammatory Drugs 145
Side Effects 145
Opioids 146
Side Effects 146 / Intravenous Opioids 147 / Patient-Controlled Analgesia 147 /
Switching From IV to Oral Opioid Analgesia 148
Epidural Analgesia 148
Epidural Opioids 148 / Epidural Local Anesthetics 151
Non-Pharmacological Pain Management 151
Cutaneous stimulation 151 / Distraction 152 / Imagery 153 / Relaxation Techniques 153 /
Deep Breathing and Progressive Relaxation 153 / Presence 153
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, viii CONTENTS IN DETAIL
Special Considerations For Pain Management In Older Adults 153
Assessment 153 / Interventions 154 / Principles of Pain Management 154
Sedation 154
Analgosedation 154 / Reasons for Sedation 154 / Goals and Management of Sedation 156 /
Sedative Medications 158 / Sedation Considerations During Drug Shortages 158 / Issues Related to
Sedation 158 / Principles of Management for the Use of Sedatives 160
Selected Bibliography 161
Pain Management 161 / Sedation 161 / Evidence-Based Practice Guidelines 161
7. Pharmacology..................................................................................................................................................................................... 163
Earnest Alexander
Medication Safety 163
Medication Administration Methods 164
Intravenous 164 / Intramuscular or Subcutaneous 164 / Oral 164 / Sublingual 165 / Intranasal 165 /
Transdermal 165
Central Nervous System Pharmacology 165
Sedatives 165 / Analgesics 169 / Anticonvulsants 170
Cardiovascular System Pharmacology 173
Parenteral Vasodilators 173 / Antiarrhythmics 176 / Vasodilators and Remodeling Agents 179 /
Soluble Guanylate Cyclase Stimulators 179 / Vasopressor Agents 179 / Inotropic Agents 180
Antibiotic Pharmacology 181
Vancomycin 181
Pulmonary Pharmacology 182
Albuterol 182 / Levalbuterol 182 / Ipratropium 182
Gastrointestinal Pharmacology 182
Stress Ulcer Prophylaxis 182 / Acute Peptic Ulcer Bleeding 183 / Variceal Hemorrhage 183
Renal Pharmacology 183
Diuretics 183
Hematologic Pharmacology 185
Anticoagulants 185 / Factor Xa Inhibitors 187 / Direct Thrombin Inhibitors 187 / Glycoprotein IIb/IIIa
Inhibitor 188 / Thrombolytic Agents 188
Immunosuppressive Agents 189
Cyclosporine 189 / Tacrolimus (FK506) 190 / Sirolimus (Rapamycin) 190
Special Dosing Considerations 190
Drug Disposition in Older adults 190 / Therapeutic Drug Monitoring 190
Selected Bibliography 192
General 192 / Evidence-Based Practice Guidelines 192
8. Ethical and Legal Considerations..................................................................................................................................................... 193
Laura Webster
Foundational Terms: Defining Ethics and Morality 193
Types of Ethical Issues 193
The Foundations for Ethical Decision Making 195
Common Ethical Theories 195 / Professional Codes and Standards for Nurses 195 /
Rule-Based 196 / Institutional Policies 196 / Legal Standards 197 / Principles of Ethics 197 /
Relationship-Focused 198 / Ethic of Care 198 / Casuistry 198 / Outcome-Based 198
Surge Capacity and Crisis Standards of Care 198
Rights 200
Building an Ethical Environment 201
Healthy Work Environments 201
Common Ethical Issues 204
Fidelity 204 / Privacy and Confidentiality 204 / Veracity 205 / Informed Consent 205 / Shared
Decision Making 206 / Substitute Decision Making 206 / Respect for Persons 206 /
End-of-Life Care 207 / Informed Assent 208 / Evolving Technology 211 /
Electronic Health Record 212 / Social Media 212 / Patient Advocacy 212
The Process of Ethical Analysis 213
Selected Bibliography 215
Professional Codes, Standards, and Position Statements 216 / Evidence-Based Guidelines 216 /
Online References of Interest: Related to Legal and Ethical Considerations 216
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, CONTENTS IN DETAIL ix
Section II. Pathologic Conditions..................................................................................................................................................................................................................... 217
9. Cardiovascular System....................................................................................................................................................................... 219
Brook Powell and Barbara Leeper
Special Assessment Techniques, Diagnostic Tests, and Monitoring Systems 219
Assessment of Chest Pain 219 / Coronary Angiography 219
Pathologic Conditions 221
Acute Coronary Syndromes 221 / Principles of Management of Acute Coronary Syndromes 227 /
Percutaneous Coronary Interventions 229 / Other Percutaneous Coronary Interventions 230 /
Surgical Management 231 / Indications 232 / Contraindications 232 / Postoperative Management
232 / Electrophysiology Studies 233
Heart Failure 234
Sympathetic nervous system activation 235 / Ventricular Remodeling 235 /
Neurohormonal Response 236 / The Progression of Heart Failure 237 / Principles of Management
for Heart Failure 240 / Shock 242 / Hypertension 247
Selected Bibliography 250
General Cardiovascular 250 / Coronary Revascularization 250 / Acute Coronary Syndromes 250 /
Heart Failure 250 / Hypertension 251 / Evidence-Based Practice Guidelines 251
10. Respiratory System............................................................................................................................................................................. 253
Kiersten N. Henry and Maureen A. Seckel
Special Assessment Techniques, Diagnostic Tests, and Monitoring Systems 253
Chest X-Rays 253 / Computed Tomography, Magnetic Resonance Imaging, and Bedside
Ultrasonography 258 / CTPA and V/Q Scans 259 / Chest Tubes 259
Thoracic Surgery and Procedures 261
Principles of Management for Thoracic Surgery and Procedures 261
Pathologic Conditions 262
Acute Respiratory Failure 262 / Acute Respiratory Distress Syndrome 266 / Acute Respiratory
Failure in the Patient with Chronic Obstructive Pulmonary Disease 267 / COVID-19
(SARS-CoV-2) 270 / Principles of Management for COVID-19 Infection 272 / Acute Respiratory
Failure in the Patient with Asthma 272 / Principles of Management for Asthma Exacerbations 274 /
Interstitial Lung Disease 274 / Pulmonary Arterial Hypertension 275 / Pneumonia 276 / Pulmonary
Embolism 279
Selected Bibliography 284
Critical Care Management of Respiratory Problems 284 / Chest X-Ray Interpretation 285 /
COVID-19 (SARS-COV-2) 285 / Evidence-Based Practice Resources 285
11. Multisystem Problems....................................................................................................................................................................... 287
Sonya M. Grigsby
Sepsis and Septic Shock 287
Etiology, Risk Factors, and Pathogenesis 287 / Clinical Presentation 289 / Principles of Management
of Sepsis and Septic Shock 292
COVID-19 294
Substance Use Disorders 296
Etiology, Risk Factors, and Pathophysiology 296 / Principles of Management for Overdose 300
Pressure Injury 302
Pressure Injury Stages 302 / COVID-19 Related Pressure Injuries 304 / Principles of Management of
Pressure Injury 304
Healthcare-Associated Infections 305
CAUTI 305 / CLABSI 305 / Selected Infectious Diseases 306 / HAI Prevention 307
Selected Bibliography 307
Sepsis and Septic shock 307 / Overdoses 308 / Pressure Injuries 308 / Healthcare-Associated
Infections 308 / Selected Infectious Diseases 309
12. Neurological System........................................................................................................................................................................... 311
Kathrina Siaron and DaiWai M. Olson
Special Assessment Techniques and Diagnostic Tests 311
Level of Consciousness 311 / Glasgow Coma Scale (GCS) and the Full Outline of Unresponsiveness
(FOUR) Score 312 / Mental Status 313 / Delirium and Dementia 314 / Motor Assessment 315 /
Sensation 315 / Cranial Nerve Assessment and Assessment of Brain Stem Function 316 /
Vital Sign Alterations in Neurologic Dysfunction 318
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