AACN Core Curriculum for Progressive and Critical Care Nursing, 8th Edition (2023)

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REGISTER TODAY!2019v1.0YOU’VE JUST PURCHASEDMORE THANA TEXTBOOK!YOU’VE JUST PURCHASEDMORE THANA TEXTBOOK!You can now purchase Elsevier products on Evolve!Go to evolve.elsevier.com/shop to search and browse for products.Enhance your learning with Evolve Student Resources.These online study tools and exercises can help deepen yourunderstanding of textbook content so you can be moreprepared for class, perform better on exams, and succeedin your course.Activate the complete learning experience that comes with eachNEW textbook purchase by registering athttp://evolve.elsevier.com/AACN/corecurriculum/If your school uses its own Learning Management System, your resources may bedelivered on that platform. Consult with your instructor.

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AACNCore CurriculumforProgressiveandCritical CareNursingTONJA M. HARTJES, EditorDNP, APRN, CNS, CCRN, CNEcl, FAANPOwner, Nurse Practitioner and ConsultantNursing DepartmentCoastal Consultants and Education LLCSt. Augustine Beach, FloridaEdition8

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3251 Riverport LaneSt. Louis, Missouri 63043AACN CORE CURRICULUM FOR PROGRESSIVEISBN: 978-0-323-77808-4AND CRITICAL CARE NURSING, EIGHTH EDITIONCopyright © 2023 by Elsevier, Inc. All rights reserved.No part of this publication may be reproduced or transmitted in any form or by any means, electronic ormechanical, including photocopying, recording, or any information storage and retrieval system, withoutpermission in writing from the publisher. Details on how to seek permission, further information aboutthe Publisher’s permissions policies and our arrangements with organizations such as the CopyrightClearance Center and the Copyright Licensing Agency, can be found at our website:www.elsevier.com/permissions.This book and the individual contributions contained in it are protected under copyright by the Publisher(other than as may be noted herein).NoticePractitioners and researchers must always rely on their own experience and knowledge in evaluatingand using any information, methods, compounds or experiments described herein. Because of rapidadvances in the medical sciences, in particular, independent verification of diagnoses and drug dos-ages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors,editors or contributors for any injury and/or damage to persons or property as a matter of productsliability, negligence or otherwise, or from any use or operation of any methods, products, instructionsor ideas contained in the material herein.Previous editions copyrighted 2018, 2006, 1998, 1991, 1985, 1981, 1975.Executive Content Strategist: Lee HendersonSenior Content Development Manager: Lisa NewtonSenior Content Development Specialist: Laura SelkirkPublishing Services Manager: Deepthi UnniSenior Book Production Executive: Manchu MohanSenior Book Designer: Amy BuxtonPrinted in India.Last digit is the print number:987654321Elsevier

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iiiBimbola Fola Akintade, PhD, MBA, MHA, ACNP-BC, NEA-BC, FAANPAssociate Professor and Associate Dean for the MSN ProgramOrganizational Systems and Adult HealthUniversity of Maryland, School of Nursing;Acute Care Nurse PractitionerSurgical Intensive Care UnitUniversity of Maryland Medical CenterBaltimore, MarylandChapter 2: Psychosocial Aspects of Critical CareJenny G. Alderden, PhD, APRN, CCRN, CCNSAssociate ProfessorBoise State University, School of NursingBoise, IdahoChapter 16: Older Adult PatientsAngela Benefield, DNP, RN, AGCNS-BC, CCRN-CSC-CMCClinical Education Specialist/Clinical ConsultantEducation and Professional DevelopmentIndependent Clinical Education ConsultantTemecula, CaliforniaChapter 15: Bariatric PatientsPatricia A. Blissitt, PhD, ARNP-CNS, CCRN, CNRN, SCRN, CCNS, CCM, ACNS-BCNeuroscience Clinical Nurse SpecialistProfessional Development and Nursing ExcellenceHarborview Medical Center;Associate Professor, Clinical FacultyUniversity of Washington, School of Nursing;Neuroscience Clinical Nurse SpecialistClinical Education and PracticeSwedish Medical CenterSeattle, WashingtonChapter 5: Neurologic SystemBryan Boling, DNP, AG-ACNP, CCRN-CSC, CENAdvanced Practice ProviderAnesthesiology, Critical Care MedicineUniversity of KentuckyLexington, KentuckyAdjunct FacultyAGACNP ProgramGeorgetown UniversityWashington, District of ColumbiaChapter 4: Cardiovascular SystemChapter 6: Renal SystemContributors

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ivContributorsNicole Brumfield, DNP, APRN, FNP-BC, AG-ACNP-BCAnesthesiology, Critical Care MedicineUniversity of KentuckyLexington, KentuckyChapter 8: Hematologic and Immunologic SystemsDeborah Chapa, PhD, ACNP-BC, FAANP, ACHPNAssociate Professor, NursingMarshall UniversityHuntington, West VirginiaChapter 2: Psychosocial Aspects of Critical CareCatrina Cullen, RN, BSN, CCRNUniversity of Colorado, College of NursingDenver, ColoradoChapter 19: SedationAnna Dermenchyan, MSN, RN, CCRN-K, CPHQDirector of QualityDepartment of MedicineUniversity of California – Los Angeles HealthLos Angeles, CaliforniaChapter 1: Professional Caring and Ethical PracticeAndrea Efre, DNP, ARNP, ANP, FNPOwner, Nurse Practitioner and ConsultantHealthcare Education ConsultantsTampa, FloridaChapter 4: Cardiovascular SystemCarrol Graves, MSN, RN, CCRN, CNLClinical Nurse LeaderCritical CareNorth Florida/South Georgia Veterans Health SystemGainesville, FloridaChapter 13: HypothermiaRenee M.Holleran,FNP-BC, PhD, CCRN (Alumnus), CEN, CFRN, CTRN(Retired), FAENNurse PractitionerAnesthesia Chronic PainVeterans Health Administration;Former Manager of Adult TransportIntermountain Life FlightIntermountain Health CareSalt Lake City, Utah;Former Chief Flight NurseUniversity Air CareUniversity HospitalCincinnati, Ohio;Family Nurse PractitionerHope Free ClinicMidvale, UtahChapter 11: Multisystem Trauma

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ContributorsvJennifer MacDermott, MS, RN, ACNS-BC, NP-C, CCRNNurse PractitionerHospital MedicineSt. Luke’s Health SystemBoise, IdahoChapter 7: Endocrine SystemMary Beth Flynn Makic, PhD, RN, CCNS, CCRN-K, FAAN, FNAP, FCNSProfessorUniversity of Colorado, College of NursingAurora, Colorado;Research ScientistDenver HealthDenver, ColoradoChapter 19: SedationDiane McLaughlin, DNP, AGACNP-BC, CCRNAcute Care Nurse PractitionerNeurocritical CareUniversity of Florida Health - Jacksonville;Acute Care Nurse PractitionerCritical Care MedicineMayo ClinicJacksonville, Florida;LecturerCase Western Reserve University, School of NursingCleveland, OhioChapter 10: Sepsis and Septic ShockShana Metzger, MS, FNP-BC, AG-ACNP-BCAdjunct InstructorSchool of Nursing and Health StudiesGeorgetown UniversityWashington, District of ColumbiaChapter 14: Toxin ExposureDenise O’Brien, DNP, RN, ACNS-BC, CPAN, CAPA, FASPAN, FCNS, FAANPerianesthesia Clinical Nurse SpecialistConsultantSelf-EmployedYpsilanti, MichiganChapter 22 Perioperative CareJan Odom-Forren, PhD, RN, CPAN, FASPAN, FAANAssociate ProfessorUniversity of Kentucky, College of NursingLexington, Kentucky;Perianesthesia Nursing ConsultantLouisville, KentuckyChapter 22 Perioperative Care

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viContributorsPatricia Radovich, PhD, CNS, FCCMDirectorNursing ResearchLoma Linda University Health Hospitals;Assistant ProfessorLoma Linda University, School of NursingLoma Linda, California;Assistant ProfessorCalifornia State University – Fullerton, School of NursingFullerton, California;Adjunct ProfessorCalifornia State University - San Bernardino, School of NursingSan Bernardino, CaliforniaChapter 9: Gastrointestinal SystemTonya Sawyer-McGee, DNP, MBA, MSN, BSN, RN, ACNP-BCDean of NursingCollege of Nursing and Advanced Health ProfessionsThe Chicago School of Professional PsychologyRichardson, Texas;Adjunct ProfessorAbilene Christian University, College of NursingAbilene, TexasChapter 20: PainKarah Cripe Sickler, RN, DNP, AG-ACNP-BCNurse PractitionerSurgical Critical CareUniversity of Florida HealthGainesville, FloridaChapter 12: BurnsDaniel N. Storzer, DNP, ACNPC, ACNP-BC, CNRN, CCRN, CCEMT-P, FCCP, FCCMAcute Care Nurse PractitionerPulmonary/Critical CareFox Valley Pulmonary MedicineNeenah, Wisconsin;Clinical InstructorAcute Care Nurse Practitioner ProgramWalden University;Critical Care ParamedicWaushara County EMSWautoma, WisconsinChapter 3: Pulmonary SystemJennifer T.N. Treacy, MSN, APRN, FNPWomen, Infant, & Children UnitRiverside Regional Medical CenterNewport News, VirginiaChapter 17: High-Risk Obstetric PatientsClareen Wiencek, PhD, RN,ACNP, ACHPN, FAANAssociate ProfessorDirector of Advanced PracticeUniversity of Virginia, School of NursingCharlottesville, VirginiaChapter 21: Palliative and End-of-Life Care

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viiStaccie Anne Allen, DNP, BSBA, APRN, AGACNP-BC, FNP-C, CFRN, EMT-PNurse Practitioner/ParamedicShandsCair Critical Care Transport ProgramUniversity of Florida Department of Emergency MedicineUniversity of Florida Health Shands HospitalGainesville, FloridaAngie Atwood, PhD, RNAssistant Professor of NursingCampbellsville UniversityCampbellsville, KentuckyMichele Beatty Bachmann, MSN, RNInstructorDepartment of Primary CareSouthern Illinois University – EdwardsvilleEdwardsville, IllinoisBeverly L. Banks, BSN, MSN, RNSenior Full-Time FacultyNursingAlpena Community CollegeAlpena, MichiganDebra J. Behr, DNP, RN, CCRN-KDirector of Professional Development and Magnet ProgramLutheran Medical CenterWheat Ridge, ColoradoCollin Bowman-Woodall, MSN, RNAssistant ProfessorSamuel Merritt University, School of NursingSan Mateo, CaliforniaMary Ann “Cammy” Christie, APRN, MSN, CCRN, CMC-CSC, PCCNAcute Care Nurse PractitionerDepartment of Critical Care Medicine and SurgeryUniversity of FloridaGainesville, FloridaReviewers

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viiiReviewersJudy E. Davidson, DNP, RN, MCCM, FAANNurse ScientistUniversity of California – San Diego Health Sciences;ScientistDepartment of PsychiatryUniversity of California – San Diego, School of MedicineLa Jolla, California;Associate EditorJournal of Nursing ManagementTina Deatherage, DNP, RN, CCNS, CCRN, CNRN, NEA-BCHospital Accreditation Program SurveyorThe Joint Commission;Adjunct Faculty, NursingQueens UniversityCharlotte, North CarolinaChristina Flint, MSN, MBA, RNAssistant ProfessorUniversity of Indianapolis, School of NursingIndianapolis, IndianaMatthew J. Fox, MSN, RN-BCAssistant ProfessorNursingOhio UniversityZanesville, OhioKeble Frazer, BSN, RN-BC, CCRN, PCCNRegistered NurseMedical and Surgical Intensive Care UnitsOrange Regional Medical CenterMiddletown, New York;Montefiore Medical CenterBronx, New YorkKelly A. Gaiolini, RNStaff Nurse, Neuro/Surgical Intensive Care UnitLawnwood Regional Medical CenterFort Pierce, FloridaCharles R. Gold, BSN, RN, CCRNRegistered NurseNeurosurgical Intensive Care UnitAtrium Health’s Carolinas Medical CenterCharlotte, North Carolina

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ReviewersixAmi Grek, DNP, APRN, ACNP-BCLead Advanced Practice ProviderDepartment of Critical CareAssociate DirectorNP/PA Critical Care Fellowship ProgramAssistant Professor of MedicineMayo Clinic School of MedicineJacksonville, FloridaChristopher Guelbert, DNP, RN, CCRN, CNMLAssistant ProfessorNursingBarnes Jewish CollegeSt. Louis, MissouriStephanie A. Gustman, BSN, MSN, DNP, RNAssociate ProfessorFerris State UniversityBig Rapids, MichiganChristian Guzman, MS, CCRN, ACNPC-AG, APRNFacility Director, Advanced Practice ProvidersIntensivist Nurse PractitionerIntensive Care ConsortiumGainesville, FloridaJillian Hamel, MS, RN, ACNP-BCAcute Care Nurse PractitionerEmergency Department Observation UnitProvidence Regional Medical CenterEverett, WashingtonSonya Renae Hardin, PhD, MBA/MHA, CCRN, ACNS-BC, NP-C, FAANDean and ProfessorUniversity of Louisville, School of NursingLouisville, KentuckyKiersten Henry, DNP, ACNP-BC, CCNS, CCRN-CMCChief Advanced Practice ClinicianMedStar Montgomery Medical CenterOlney, MarylandCheryl Holsworth, MSA, RN, CBN, CMSRNSenior Specialist for Bariatric SurgerySharp Memorial HospitalSan Diego, California

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xReviewersRobert C. Ingram, BSN, MSN, MHA, DNPc, RN, CENAssistant ProfessorLourdes University, College of NursingSylvania, OhioTonia Kennedy, MSN, EdD, RN-BC, CCRN-KAssociate ProfessorLiberty University, School of NursingLynchburg, VirginaSara Knippa, MS, RN, CCRN, PCCN, ACCNS-AGClinical Nurse Specialist and EducatorCardiac ICUUniversity of Colorado HospitalCHealthAurora, ColoradoMarianna LeCron Presley, MSN, RN, CCRNCritical Care NurseMedical Intensive CareAtrium Health PinevilleCharlotte, North CarolinaKellyAnne Lee, MSN, MBA, RN, CCRNHealthcare ConsultantCoasta Consulting Group, LLCMount Pleasant, South CarolinaTanaya C. Lindstrom, MSN, RN, CCRN, CNLClinical Nurse EducatorSurgical/Medical Intensive Care UnitsNorth Florida South Georgia Veterans Health SystemGainesville, FloridaYvette Lowery, MSN/Ed, DNP, FNP-c, CCRN, CEN, PCCNFamily Nurse PractitionerEmergency DepartmentMemorial HospitalJacksonville, FloridaKaren A. Matos, MSN, RN, CCRNClinical Nurse Expert of Medical and Surgical Intensive Care Units and TelemetryNursing EducationRalph H. Johnson Veterans Administration HospitalCharleston, South CarolinaPaige McCraney, DNP, APRNAdult Health Nurse PractitionerAssistant ProfessorUniversity of North Georgia Department of NursingDahlonega, Georgia

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ReviewersxiDenise M. McEnroe-Petitte, AS, BSN, MSN, PhD, RNAssociate Professor NursingKent State University – TuscarawasNew Philadelphia, OhioKatina M. Meyer, BSN, RNRegistered NurseMedical Intensive Care UnitStormont Vail HealthTopeka, KansasSamantha Palmer Noah, MSN, APRN, FNP-BC, AGACNP-BCNurse PractitionerFlourish Health NetworkGainesville, FloridaDaiWai M. Olson, PhD, RN, CCRN, FNCSProfessor of Neurology & NeurotherapeuticsProfessor of NeurosurgeryDistinguished Teaching ProfessorUniversity of Texas Southwestern Medical CenterDallas, TexasSarah Peacock, DNP, APRN, ACNP-BCLead Advanced ProviderDepartment of Critical Care MedicineMayo ClinicJacksonville, FloridaDeidra Pennington, MSN, RNAssistant ProfessorNursingJefferson College of Health SciencesRoanoke, VirginiaRuthie Robinson, PhD, RN, CNS, FAEN, CEN, NEA-BCDirector, Graduate Nursing StudiesJoAnne Gay Dishman School of NursingLamar UniversityBeaumont, TexasEmily Rogers, DNP, AGACNP-BC, CCRN, APRNNurse Practitioner, Department of Critical CareMayo ClinicJacksonville, Florida

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xiiReviewersJanet Czermak Russell, DNP, RN, APN-BCAssociate Professor of NursingNursing/BiologyEssex County CollegeNewark, New JerseyPeter D. Smith, BA, MSN, RNClinical Education SpecialistNursing EducationKindred HealthcareSt. Louis, MissouriDiane Fuller Switzer, DNP, ARNP, FNP-BC, ENP-BC, ENP-C, CCRN, CEN, FAENAssistant Clinical ProfessorSeattle University, College of NursingSeattle, WashingtonAshley N. Thompson, DNP, AGACNP-BCAcute Care Nurse Practitioner, Assistant ProfessorUF Health/University of FloridaGainesville, Florida

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xiiiSince the early 1970s, the American Association of Critical-Care Nurses (AACN) and itsAACN Core Curriculumhave stood at the forefront of the continuing evolution of criti-cal care nursing to better meet the highly specialized needs of the patients and familiesthey serve. TheAACN Core Curriculumhas now undergone eight editions, during whichtime it has maintained its reputation as the source of all things critical care. Among sev-eral steps we took to help prepare for this edition, AACN and I issued a reader survey andgathered together a cross-section of expert clinicians for a focus group during the organi-zation’s National Teaching Institute & Critical Care Exposition in 2019. Our goal was togather information to ensure that this newest edition kept pace with the expanding roleof nurses in the critical care profession. Participants confirmed the many ways theAACNCore Curriculumis used: as a clinical reference in caring for progressive and critical carepatients, as a resource for CCRN certification exam preparation, for the creation of criticalcare courses and curricula, as a cornerstone for new nurse orientation, and in the develop-ment of competency content. Several nurses with whom we spoke stated that theAACNCore Curriculumwas their “critical care bible,” affirming that after all these years it is still anactively sought-after resource within critical care nursing practice.As we listened to readers and collected information from multiple sources, we confirmedthat the purpose of theAACN Core Curriculumremains, as it always has been, to articulatethe knowledge base that underlies progressive and critical care nursing practice. Each edi-tion of this work attempts to redefine that knowledge base for nurses who practice in thisever-expanding specialty area.The eighth edition has been retitledAACN Core Curriculum for Progressive and CriticalCare Nursing. Critical care practice and nursing have evolved over the past decade. Acutelyill patients are treated in many units of the hospital, from the Medical-Surgical departmentsto progressive and intermediate care units and elsewhere. Patients requiring critical carealso are found outside the intensive care unit. Specialty nursing units have been created tomeet these evolving health care needs; critical care nurses and patients are found in car-diac catheterization labs, emergency departments, and tele-ICUs. Sometimes they are evenfound at home awaiting heart transplant with inotropic medications and a left ventricularassist device. Changing the title of the text as we have done brings the resource more inline with the varied settings in which we find critically ill patients, and it signals to readersoutside the traditional ICU that they are included in our base of readers.Several similarities still exist between the seventh and eighth editions. The current edi-tion continues to use the CCRN Examination blueprint and task statements as a startingpoint for determining relevant content and its apportionment throughout the book. Wecontinue with the embellished outline format, and body systems are again used to dividethe major content areas into chapters. Subsections related to physiologic anatomy, patho-physiology, and patient assessment; generalized patient care; and unique characteristics ofspecific disorders also have been retained.Readers can still find the AACN Synergy Model for Patient Care woven throughout thisedition. When it was developed in the late 1990s, the Synergy Model became the conceptualframework for certified practice in critical care and has since been widely incorporatedacross the discipline. Chapter 1 describes the model in detail, and each chapter includes inthe assessment section a reminder of the model’s prevalence. A key premise of the SynergyModel is that patient characteristics drive the competencies that nurses need in order toPreface

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xivPrefaceprovide holistic, healing care that achieves optimal patient outcomes. A knowledge base ofcritical care nursing underlies clinical practice and reflects a foundational requirement forthe development of these nursing competencies.AACN’s Competency Based Assessment (CBA) framework was incorporated as “lev-eling” guidance using the Synergy Model for Patient Care and the expanded outline formatand embellishment items within the text. The termsnovice, advanced beginner, proficient,andexpertwere used to operationalize the nurse competency and leveling of content withintheAACN Core Curriculum.The Novice or Advanced Beginner is encouraged to focus on the following content forfoundational knowledge:Section 1: System Wide Elements•Anatomy and Physiology Review•Assessment•Patient Care•The new “Key Concept” highlight boxes have been expanded throughout the text,and replace “Key Points” from the seventh editionProficient or Expert learners are encouraged to focus on the following content forexpert knowledge:Section 2: Specific Patient Health Problems•Health Problems•Pathophysiology, Etiology, Signs and Symptoms, Diagnostic Findings, Managementof Patient Care, Complications, End Organ Diseases•The new “Expert Tip” highlight boxes have been expanded throughout the text, andreplace the “Clinical Pearls” from the seventh editionTo keep pace with the expanding role of progressive and critical care nursing practiceand the evolving health care arena, the following items have been added or updated:•Reorganization of content into four sections:Part I: Foundations of Progressive and Critical Care NursingPart II: Critical Care of Patients with Issues Affecting Specific Body SystemsPart III: Critical Care of Patients with Multisystem IssuesPart IV: Critical Care of Patients with Special Needs•Removal of all subchapters•A new Perioperative Care chapter•The text features improved navigation, format, and usability with a new, full-color, user-friendly interior design that uses high-contrast text colors and a larger font.•A Crosswalk was created at the beginning of each chapter that interfaces or maps foun-dational nursing content within key educational and clinical documents including thefollowing:•Quality and Safety in Nursing Education (QSEN) competencies•National Patient Safety Goals•American Nurses Association (ANA) Standards for Professional Nursing Practice•American Association of Critical-Care Nurses (AACN) Standards for Progressive andCritical Care Nursing Practice•American Association of Critical-Care Nurses Healthy Work Environments•Progressive and Critical Care Nursing Certification•All chapters, tables, figures, boxes, and terminology are based on the most recently pub-lished AACN/ANA Scope of Practice and Standards of Care.•QSEN content has been incorporated within chapters of the text.•The newest sepsis guidelines content has been added to Chapter 10.

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Prefacexv•All references complement and reinforce current AACN and critical care standards andguidelines of care.•References and bibliographies for all chapters are now available online on the Evolve siteathttp://evolve.elsevier.com/AACN/corecurriculum/.•Each chapter was carefully reviewed by AACN clinical practice specialists as well as bya nurse in current critical care practice. A clinical pharmacist also reviewed all medica-tions for correct indication and dosages.The contributors, reviewers, AACN clinical practice specialists, and I have worked tire-lessly and made every attempt to provide the most current and relevant knowledge baseof information related to progressive and critical care nursing. I welcome your commentsabout this edition and your suggestions for future editions of theAACN Core Curriculum.Tonja M. Hartjes, DNP, APRN, CNS, CCRN, CNEcl, FAANPEditor of theAACN Core Curriculum for Progressiveand Critical Care Nursing, 8th editiontonjahartjes@gmail.com

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xviiThis eighth edition of theAACN Core Curriculumis possible only because of the tirelessdedication and professionalism of many others, whose commitment to this project madeall the difference.First, I would like to thank the devoted readers of theAACN Core Curriculum, who pro-vided their time and thoughtful comments over the years regarding the use of the text andsuggestions for its evolution as nursing practice has evolved. Improvements in content anddesign come in large part from their recommendations.Many thanks to the contributors and reviewers whose enthusiasm, expertise, and expe-riences have been shared with the readers. Their continued strength and resilience duringthis especially important time (during the pandemic) is a testament to their commitmentto nursing. Development of this resource is made possible through the sustained efforts ofeach contributor, whose insightful comments created an effective and useful clinical refer-ence and CCRN review.Sincere thanks and special recognition go to AACN’s publishing staff, Michael Muscatand Katie Spiller, and the clinical practice specialists who provided endless time and dedi-cation to me, to the contributors, to critical care nurses, and to the patients and familieswe serve. Special thanks to Linda Bell, Julie Miller, Mary Stahl, Cindy Cain, and MarianAltman for painstakingly reading through each chapter to offer suggestions.I also wish to acknowledge those involved directly with the publication process. TheElsevier staff provided considerable administrative support, and their organizational skillsand resources were a tremendous asset in the planning, preparation, and execution of thistext: Lee Henderson, Laura Selkirk, and Manchu Mohan.Special thanks to my friend and mentor Suzanne Burns, without whose prior contribu-tions to critical care nursing I would not be in this position. She has served as a role modeland mentored me throughout my career and the publishing process.As always, I thank my family and friends who have been patient with my necessaryabsences and whose love, support, and encouragement have inspired me throughout thisjourney.Acknowledgments

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xixPART IFoundations of Progressive and Critical Care NursingChapter 1Professional Caring and Ethical Practice1Anna Dermenchyan, MSN, RN, CCRN-K, CPHQAmerican Association of Critical-Care Nurses Mission, Vision, and Values(AACN, 2020 a,b,c)1Mission1Vision2Values2Synergy of Caring2Key Responsibilities of Registered Nurses (American Nurses Association [ANA], 2020)2What Acute and Critical Care Nurses Do (AACN, 2019)2The Environment of Progressive and Critical Care Nurses (AACN, 2019)2The AACN Synergy Model for Patient Care5AACNSynergy Model for Patient Care (AACN, 2020a,b,c)5Origin of the Synergy Model5Purpose5Overview of the Synergy Model5Application of the Synergy Model15Family Presence: Visitation in the Adult ICU (AACN Practice Alert, 2016)16Healthy Work Environment Standards (AACN, 2016)17General Legal Considerations Relevant to Critical Care Nursing Practice17National Governing Bodies17State Nurse Practice Acts (Russell, 2017)17Scope of Practice18Standards of Care18Certification in a Specialty Area19Professional Liability19Documentation22Good Samaritan Laws24Ethical Clinical Practice24Foundation of Ethical Nursing Practice24Emergence of Clinical Ethics24Standard Ethical Theory25Ethical Principles (ANA, 2015b)25Common Ethical Distinctions26Advance Care Planning27The Law in Clinical Ethics (Department of Health & Human Services, 2020)29Clinical Ethics Assessment34Nurse’s Role as Patient Advocate and Moral Agent36Chapter 2Psychosocial Aspects of Critical Care38Deborah Chapa, PhD, ACNP-BC, FAANP, ACHPN; Bimbola Fola Akintade, PhD, MBA, MHA, ACNP-BC, NEA-BC, FAANPSystemwide Elements38Review of Psychosocial Concepts38Assessment43Contents

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xxContentsPain, Agitation, Delirium, Immobility and Sleep Disruption (PADIS) (Devlin et al., 2018)44Sleep Deprivation46ASD and PTSD46Delirium (Acute Confusional State)48Powerlessness50Anxiety51Depression53Substance Misuse, Dependence, and Withdrawal55Aggression and Violence57Suicide59Dying Process and Death61PART IICritical Care of Patients with Issues Affecting Specific BodySystemsChapter 3Pulmonary System63Daniel N. Storzer, DNP, ACNPC, ACNP-BC, CNRN, CCRN, CCEMT-P, FCCP, FCCMSystemwide Elements63Anatomy and Physiology Review63Assessment85Diagnostic Studies105Patient Care109Specific Patient Health Problems136Acute Respiratory Failure (ARF)136Chest Trauma139Acute Respiratory Distress Syndrome (ARDS)139Vaping141Transfusion-Related Lung Injury142Pulmonary Embolism142Chronic Obstructive Pulmonary Disease (COPD)146Asthma and Status Asthmaticus150Pneumonia153Ventilator-Associated Pneumonia and Event157Drowning158Pulmonary Problems in Surgical/Thoracic Surgery Patients160Air Leak Syndromes162Acute Pulmonary Inhalation Injuries163Neoplastic Lung Disease163Pulmonary Fibrosis167Obstructive Sleep Apnea168End-Stage Pulmonary Conditions: Lung Transplantation169Chapter 4Cardiovascular System176Andrea Efre, DNP, ARNP, ANP, FNP and Bryan Boling, DNP, AG-ACNP, CCRN-CSC, CENSystemwide Elements176Anatomy and Physiology Review176Assessment190Diagnostic Studies201Patient Care232Specific Patient Health Problems235Acute Coronary Syndrome235Acute Myocardial Infarction—ST-Segment Elevation Myocardial Infarction235

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ContentsxxiNon—ST Elevation Myocardial Infarction (See Acute Coronary Syndrome(NSTEMI- Acute Coronary Syndrome and Unstable Angina))247Chronic Stable Angina Pectoris251Coronary Artery Disease253Heart Failure257Pericardial Disease266Myocarditis271Infective Endocarditis274Cardiomyopathy280Cardiac Rhythm Disorders286Mitral Regurgitation301Mitral Stenosis304Aortic Regurgitation307Aortic Stenosis310Atrial Septal Defect313Ventricular Septal Defect316Patent Ductus Arteriosus319Coarctation of the Aorta322Hypertensive Crises325Aortic and Peripheral Arterial Disease330Shock337Mechanical Circulatory Support Devices344End-Stage Heart Disease: Cardiac Transplantation350Cardiac Trauma353Chapter 5Neurologic System354Patricia A. Blissitt, PhD, ARNP-CNS, CCRN, CNRN, SCRN, CCNS, CCM, ACNS-BCSystemwide Elements354Anatomy and Physiology Review354Assessment390Diagnostic Studies406Patient Care408Specific Patient Health Problems417Increased Intracranial Pressure or Intracranial Hypertension417Stroke426Brain Tumor455Spinal and Spinal Cord Tumors459Intracranial Infections461Neuromuscular/Autoimmune Disease468Seizure Disorders476Encephalopathy483Coma486Brain Death487Neurosurgical Procedures488Chapter 6RenalSystem490Bryan Boling, DNP, AG-ACNP, CCRN-CSC, CENSystemwide Elements490Anatomy and Physiology Review490Assessment504

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xxiiContentsDiagnostic Studies507Patient Care511Specific Patient Health Problems520Renal Trauma520Acute Kidney Injury520Chronic Kidney Disease534Electrolyte Imbalances—Potassium Imbalance: Hyperkalemia540Electrolyte Imbalances—Potassium Imbalance: Hypokalemia546Electrolyte Imbalances—Sodium Imbalance: Hypernatremia547Electrolyte Imbalances—Sodium Imbalance: Hyponatremia549Electrolyte Imbalances—Calcium Imbalance: Hypercalcemia551Electrolyte Imbalances—Calcium Imbalance: Hypocalcemia553Electrolyte Imbalances—Phosphate Imbalance: Hyperphosphatemia554Electrolyte Imbalances—Phosphate Imbalance: Hypophosphatemia556Electrolyte Imbalances—Magnesium Imbalance: Hypermagnesemia557Electrolyte Imbalances—Magnesium Imbalance: Hypomagnesemia558Rhabdomyolysis559End-Stage Renal Condition: Renal Transplant560Chapter 7Endocrine System564Jennifer MacDermott, MS, RN, ACNS-BC, NP-C, CCRNSystemwide Elements564Anatomy and Physiology Review564Hypothalamus565Pituitary Gland (Also Called Hypophysis)565Thyroid Gland568Parathyroid Glands568Adrenal Glands569Pancreas570Pineal Gland and Thymus Gland571Gonadal Hormones (Testosterone, Estrogen, Progesterone)571Assessment571Diagnostic Studies574Patient Care575Specific Patient Health Problems576Altered Glucose Metabolism576Altered Antidiuretic Hormone Production584Altered Thyroid Hormone Production587Acute Adrenal Insufficiency or Crisis591Acute Hyperparathyroidism and Hypoparathyroidism592Chapter 8Hematologic and Immunologic Systems593Nicole Brumfield, DNP, APRN, FNP-BC, AG-ACNP-BCSystemwide Elements593Anatomy and Physiology Review593Assessment of Hematologic and Immunologic Systems597Diagnostic Studies599Patient Care602Specific Patient Health Problems604

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ContentsxxiiiThrombocytopenia604Disseminated Intravascular Coagulation606Medication-Induced Coagulopathy608Thromboembolic Disorders611Anemia613Sickle Cell Anemia616Neutropenia618Acute Leukemia619Malignant Pericardial Effusion621Hematopoietic Stem Cell Transplantation622Organ Transplant Rejection624Human Immunodeficiency Virus Infection626Anaphylactic Reaction629Chapter 9Gastrointestinal System631Patricia Radovich, PhD, CNS, FCCMSystemwide Elements631Anatomy and Physiology Review631Accessory Organs of Digestion (Fig. 9.4)639Patient Assessment644Diagnostic Studies648Patient Care650Specific Patient Health Problems652Abdominal Trauma652Bowel Infarction (Obstruction, Perforation)652Functional Gastrointestinal Disorders (Obstruction, Motility [Ileus, Diabetic Gastroparesis,GERD, Inflammatory Bowel Syndrome])654Gastrointestinal Infections(Clostridium Difficile)656Abdominal Compartment Syndrome657Acute Abdomen659Acute Liver Failure661Gastrointestinal Bleeding663Gastrointestinal Bariatric Surgery667Chronic Liver Failure: Decompensated Cirrhosis667Carcinoma of the Gastrointestinal Tract672Acute Pancreatitis675Hepatitis678End-Stage Gastrointestinal System Condition: Liver Transplantation682Nutritional Support in the Critically Ill Patient683PART IIICritical Care of Patients with Multisystem IssuesChapter 10Sepsis and Septic Shock686Diane McLaughlin, DNP, AGACNP-BC, CCRNSystemwide Elements686Anatomy and Physiology Review686Assessment698Patient Care700

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xxivContentsChapter 11Multisystem Trauma706Renee M. Holleran, FNP-BC, PhD, CCRN (Alumnus), CEN, CFRN, CTRN (Retired), FAENSystemwide Elements706Trauma Concepts and Physiology Review706Assessment712Patient Care718Head and Spinal Trauma721Thoracic Trauma: Pulmonary and Cardiac734Pulmonary Trauma734Cardiac Trauma737Abdominal Trauma741Chapter 12Burns745Karah Cripe Sickler, RN, DNP, AG-ACNP-BCSystemwide Elements745Anatomy and Physiology Review745Assessment754Patient Care760Chapter 13Hypothermia764Carrol Graves, MSN, RN, CCRN, CNLSystemwide Elements764Anatomy and Physiology Review764Assessment769Patient Care772Chapter 14Toxin Exposure776Shana Metzger, MS, FNP-BC, AG-ACNP-BCSystemwide Elements776Anatomy and Physiologic Review776Assessment787Patient Care790Interventions for Ingestion of Toxic Substance (Fig. 14.1)792General Management Strategies for Gastric Decontamination794Treatment for Body Stuffing/Body Packing795Additional Interventions for the Purposeful Ingestion795Envenomation796PART IVCritical Care of Patients With Special NeedsChapter 15Bariatric Patients799Angela Benefield, DNP, RN, AGCNS-BC, CCRN-CSC-CMCSystemwide Elements799Anatomy and Physiology Review799Assessment800Patient Care804Care of the Bariatric Surgery Patient806Related Bariatric Care Issues807

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ContentsxxvChapter 16Older Adult Patients809Jenny G. Alderden, PhD, APRN, CCRN, CCNSAge-Related Biologic and Behavioral Differences809Age-Related Changes in Medication Action and Clinical Implications809The Four Ms of Age-Friendly Health Care814Chapter 17High-Risk Obstetric Patients820Jennifer T.N. Treacy, MSN, APRN, FNPSystemwide Elements820Anatomy and Physiology Review820Specific Patient Health Problems823Postpartum Hemorrhage823Hypertensive Disorders of Pregnancy824Hemolysis, Elevated Liver Enzymes, Low Platelet Count Syndrome830Amniotic Fluid Embolism831Acute Fatty Liver of Pregnancy832Special Considerations833Trauma833Cardiopulmonary Concerns in Pregnant Patients835Chapter 18Patient Transport836Renee M. Holleran, FNP-BC, PhD, CCRN (Alumnus), CEN, CFRN, CTRN (Retired), FAENMembers of the Transport Team837Indications for Transport837Modes of Interfacility Transport838Risks and Stresses of Transport839Overriding Priorities in Patient Transport841Preparation for Transport841Patient Care During Transport844Legal and Ethical Issues Related to Transport845Chapter 19Sedation846Mary Beth Flynn Makic, PhD, RN, CCNS, CCRN-K, FAAN, FNAP, FCNS and Catrina Cullen, RN, BSN, CCRNSystemwide Elements846Considerations Before Sedation846Practice Considerations During Administration of Sedation848Specific Patient Health Problems855Procedural Sedation and Analgesia for the Patient in High Acuity Settings855

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xxviContentsChapter 20Pain860Tonya Sawyer-McGee, BSN, MSN, MBA, RN, DNP, ACNP-BCSystemwide Elements860Anatomy and Physiology Review860Background865Assessment869Patient Care873Patient Education880Specific Clinical Problems Related to Pain Therapy885Specific Patient Health Problems886Chapter 21Palliative and End-of-Life Care888Clareen Wiencek, PhD, RN, ACNP, ACHPN, FAANSystemwide Elements888Concept Review888Assessment for Palliative Care, Hospice, or End-of-Life Care Services893Patient Care893Transitioning Goals of Care to End-of-Life (Box 21.3)895Additional Considerations (See Ch. 2, Psychosocial Aspects of Critical Care)897Chapter 22Perioperative Care898Jan Odom-Forren, PhD, RN, CPAN, FASPAN, FAAN and Denise O’Brien, DNP, RN, ACNS-BC, CPAN, CAPA, FASPAN, FCNS, FAANSystemwide Elements898Anatomy and Physiology Review898Assessment899Patient Care901Initial Arrival in Postanesthesia Care Unit or Intensive Care Unit914Ongoing Postanesthesia Care—Emergence from Anesthesia914Specific Patient Health Problems917Index923

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1CROSSWALK•Quality and Safety in Nursing Education (QSEN):Patient-centered care, Teamwork andcollaboration, Evidence-based practice, Quality improvement, Safety, Informatics•National Patient Safety Goals:Identifies patients correctly, Improve staff communication, Usemedicines safely, Uses alarms safely, Prevents infection, Identify patient safety risks, Preventsmistakes in surgery•American Nurses Association (ANA) standards for Professional Nursing Practice:Standard 1. Assessment, Standard 2. Diagnosis, Standard 3. Outcomes identification, Standard4. Planning, Standard 5. Implementation, Standard 6. Evaluation, Standard 7. Ethics, Standard 8.Culturally congruent practice, Standard 9. Communication, Standard 10. Collaboration, Standard11. Leadership, Standard 12. Education, Standard 13. Evidence-based practice and research,Standard 14. Quality of practice, Standard 15. Professional practice evaluation, Standard 16.Resource utilization, Standard 17. Environmental health•AACN Scope and Standards for Progressive and Critical Care Nursing Practice:Standard 1. Quality of practice, Standard 2. Professional practice evaluation, Standard 3.Education, Standard 4. Communication, Standard 5. Ethics, Standard 6. Collaboration, Standard7. Evidence-based practice/research/clinical inquiry, Standard 8. Resource utilization, Standard 9.Leadership, Standard 10. Environmental health•AACN Standards for Establishing and Sustaining Healthy Work Environments (HWE):Skilled communication, True collaboration, Effective decision-making, Appropriate staffing,Meaningful recognition, Authentic leadership•PCCN content:Professional Caring and Ethical Practice—All items•CCRN content:Professional Caring and Ethical Practice—All itemsPART IFoundations of Progressive and Critical Care NursingCHAPTER1Professional Caringand Ethical PracticeAnna Dermenchyan, MSN, RN, CCRN-K, CPHQAMERICAN ASSOCIATION OF CRITICAL-CARE NURSES MISSION,VISION, AND VALUES (AACN, 2020a,b,c)MISSION1.Patients and their families rely on nurses at the most vulnerable times of their lives.Acute and critical care nurses rely on AACN for expert knowledge and the influenceto fulfill their promise to patients and their families. AACN drives excellencebecause nothing less is acceptable.

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2PART IFoundations of Progressive and Critical Care NursingVISION1.AACN is dedicated to creating a healthcare system driven by the needs of patientsand families where acute and critical care nurses make their optimal contribution.VALUES1.As AACN works to promote its mission and vision, it is guided by values that arerooted in, and arise from, the Association’s rich history, traditions, and culture.AACN’s members, volunteers, and staff will honor the following:a.Ethical accountability and integrityin relationships, organizational decisions, andstewardship of resources.b.Leadership to enable individuals to make their optimal contributionthrough lifelonglearning, critical thinking, and inquiry.c.Excellence and innovationat every level of the organization to advance theprofession.d.Collaborationto ensure quality patient- and family-focused care.SYNERGY OF CARINGKEY RESPONSIBILITIES OF REGISTERED NURSES (AMERICAN NURSESASSOCIATION [ANA], 2020)1.Perform physical examinations and health histories before making critical decisions.2.Provide health promotion, counseling, and education.3.Administer medications and other personalized interventions.4.Coordinate care, in collaboration with a wide array of healthcare professionals.WHAT ACUTE AND CRITICAL CARE NURSES DO (AACN, 2019)1.Restore, support, promote, rehabilitate, or palliate to maintain the physiologic andpsychosocial stability of patients of all ages across the life span.2.Synthesize and prioritize information to take immediate and decisive evidence-based, patient-focused action using clinical judgment and clinical inquiry.3.Anticipate and respond with confidence, and adapt to rapidly changing patientconditions.4.Respond to the unique needs of patients and families coping with unanticipatedillness or injury and treatment, and advocate for their choices in quality-of-life andend-of-life decisions.5.Establish and maintain a healthy work environment that is safe, respectful,healing, and caring for nurses, peers, patients, families, and the interprofessionalteam.6.Demonstrate the financial contribution of nursing through appropriate resourceutilization, cost effectiveness, innovation, and efficiency, resulting in optimal safetyand quality outcomes.7.Demonstrate the contribution of nursing to the quality and financial stability of thefacility through stewardship of resources.8.Promote and maintain care for self and coworkers to foster resilience.9.Ensure the delivery of safe, compassionate, and high-quality patient care.THE ENVIRONMENT OF PROGRESSIVE AND CRITICAL CARE NURSES(AACN, 2019)1.Acutely and critically ill patients require complex assessment and therapies, high-intensity interventions, and continuous vigilance.

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