Copyright © 2007 by F. A. Davis.
Copyright © 2007 by F. A. Davis.
UNDERSTANDING
Medical Surgical
Nursing
THIRD EDITION
LINDA S. WILLIAMS, MSN, RNBC
Professor of Nursing
Jackson Community College
Jackson, Michigan
PAULA D. HOPPER, MSN, RN
Professor of Nursing
Jackson Community College
Jackson, Michigan
00William & Hopper (F)-FM 11/2/06 2:59 PM Page iii
Copyright © 2007 by F. A. Davis.
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2007 by F. A. Davis Company
Copyright © 2003, 1999 by F. A. Davis Company. All rights reserved. This product is protected 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 of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Acquisitions Editors: Lisa B. Deitch/Jonathan Joyce
Director of Content Development: Darlene D. Pedersen
Special Projects Editor: Shirley A. Kuhn
Senior Project Editor: Ilysa H. Richman
Art and Design Manager: Carolyn O’Brien

Disclaimer:
Some images in the original version of this book are not
available for inclusion in the eBook.
Copyright © 2007 by F. A. Davis.
To our students, this is for you. We hope it helps you achieve
your dreams.
Linda and Paula
In memory of my mother who was so proud of the book that
she took it everywhere to show to people. I will miss her joy in
seeing this edition. To my dad who has always been supportive
and kept me company on my breaks from writing during this
revision.
To Garland,
with love, whose support I needed more than ever before
during this past year. Thank you.
To Jami and Anthony, who’s joy in life are their wonderful
children, Dimitri, Alex, and Ayla who also bring me joy.
To my sister Lisa and her family Ken, Michael, and Nathan
for their ongoing support.
To Christine, Anna, and Suzee for encouragement and a
listening ear when it was needed most.
L
INDA S. WILLIAMS
To Dave, with love, for his continued love and support.
To Dan and Libby, my two other favorite people in the
world. I am so proud of you both.
And to my Dad, who proudly displays our books even
though he doesn’t have to read them.
PAULA D. HOPPER
00William & Hopper (F)-FM 11/2/06 2:59 PM Page v

little assistance to students. Literature suggests that
comprehension increases when students read guid-
ing questions before reading the text. So we have
provided a series of questions that students should
keep in mind as they read. These questions can be
translated easily back into objectives by instructors
who prefer this format.
• Special features written by actual patients, called
Patient Perspectives, were added in the second edi-
tion. Many more have been added to this edition.
These stories help to make patients’ experiences
with illness more meaningful and personal for stu-
dents.
• Web links are included in the text to help students
do further research on topics of interest. Every
effort was made to use only major established web
sites that are unlikely to change in the near future.
• One of our most popular features, Critical Thinking
Exercises, has been expanded to help students prac-
tice and think about what they are learning. We
have added more math calculations and documenta-
tion practice to Critical Thinking Exercises where
applicable.
• Review questions at the end of each chapter have
been updated and include alternate format items to
reflect NCLEX-PN.
• Suggested Answers for the Critical Thinking
Exercises and Review Questions are included.
Research supports the importance of immediate
feedback to reinforce learning, so we feel strongly

beginning of each chapter.
• A review of anatomy and physiology is presented at
the beginning of each unit.
• Word-building footnotes are found throughout the
chapters to make complex medical terminology eas-
ier to understand.
• Nursing care plans with geriatric considerations
have been updated.
• Boxed presentations of Cultural Considerations,
Gerontological Issues, Home Health Hints, Ethical
Considerations, and Nutrition Notes provide valu-
able supplemental information and help students
relate text material to real life situations.
• Many new photographs and drawings have been
added to illustrate important concepts.
• A comprehensive, updated glossary of new words is
included in the appendix.
TO STUDENTS: HOW TO USE
THIS BOOK
As you begin each chapter, carefully read the section labeled
Questions to Guide your Reading. Then, when you are fin-
ished reading each chapter, go back and make sure you can
answer each question.
You will find a list of new words and their pronuncia-
tions at the beginning of each chapter. These words appear
in bold at their first use in a chapter, and they also appear in
the glossary at the end of the book. By learning the mean-
ings of these words as you encounter them, you will increase
your understanding of the material.
You also will encounter other learning tips to increase

ence:
• NANDA nursing diagnoses
• Lab values
• Common medical abbreviations (Although it is still
important to know the abbreviations, many can
increase risk of errors. Check www.JCAHO.org for
a list of abbreviations to avoid.)
• Common prefixes and suffixes to help learn word
building techniques
SUPPLEMENTAL MATERIALS
• A new Electronic Student Guide is included with
the book. This provides practice in the form of
objective (fill-in, labeling, and flashcard) exercises,
and case studies. There are also review questions
and a practice NCLEX test. We have also included a
brief math tutorial using Unit Analysis, and practice
calculation problems. Answers are provided to all
exercises for immediate feedback.
• A paperback Student Workbook is available to pro-
vide the student additional contact and practice with
the material. Each chapter includes vocabulary prac-
tice, objective exercises, a case study or other criti-
cal thinking practice and review questions written in
NCLEX-PN format. Answers provide immediate
feedback. Rationales are provided for non-anatomy
review question answers.
• An Instructor’s Resource Disk includes an
Electronic Instructor’s Guide that provides materi-
als for use in the classroom. Each chapter has a
chapter outline with suggested classroom activities.

instructor’s convenience, there is a comprehensive
Power Point program for classroom presentations.
Images from the text have been added for the third
edition. Each presentation can be modified, reduced,
or expanded by individual instructors to suit their
needs.
Preface ix
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Copyright © 2007 by F. A. Davis.
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Copyright © 2007 by F. A. Davis.
Acknowledgements
Many people helped us make this book a reality. First and
foremost are our students, who provided us with the inspira-
tion to undertake this project. We hope that they continue to
find this text worth reading.
The F.A. Davis Company has been an exceptional pub-
lishing partner. We feel fortunate to have had their continued
enthusiasm and confidence in our book. The staff at F.A.
Davis has guided us through this project for three editions to
help us create a student-friendly book that truly promotes
understanding of medical-surgical nursing.
Lisa Deitch, Shirley Kuhn, Ilysa Richman, Darlene
Pedersen, Doris Wray, and many others have been extremely
patient and kind as we worked hard to provide a quality text
and meet deadlines.
We thank the staff of W.A. Foote Memorial Hospital in
Jackson, Michigan for allowing us access to their facility
and patients for a great photo shoot. Our photographer,

Instructor and Program Coordinator
University of Central Florida
Cocoa, Florida
Brenda Anderson
St. Bernards Medical Center
Patient Care Manager-Education
Jonesboro, Arizona
Debra Aucoin-Ratcliff, RN, BSN, MN, DNPc
Nursing Faculty
American River College
Sacramento, California
Cynthia Francis Bechtel, MS, RN, CNE, CEN, EMT-I
Associate Professor
Anna Maria College
Paxton, Massachusetts
Virginia Birnie, RN, BScN, MSN
Nursing Instructor
Camosun College
Victoria, British Columbia
Canada
Janice L. Bradford, MS
Assistant Professor
Jackson Community College
Jackson, Michigan
Lucy L. Colo, RN, MSN
Faculty
Huron School of Nursing
East Cleveland, Ohio
Linda Hopper Cook RN, MN, PhD Candidate
Instructor

Winnipeg, Manitoba
Canada
Lynn Keegan, RN, PhD, AHN-BC, FAAN
Director
Holistic Nursing Consultants
Port Angeles, Washington
xiii
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Copyright © 2007 by F. A. Davis.
Marty Kohn, RN, BSN, MS, FNP-CWOCN
Nurse Practitioner Wound Care Center
Foote Hospital
Jackson, Michigan
Linda Marie Lowe, RN, BSN
Assistant Professor
University of Northern British Columbia
Prince George, British Columbia
Canada
Carroll Lutz, BSN, MA, RN
Associate Professor Emerita
Jackson Community College
Jackson, Mississippi
Marina Martinez-Kratz, RN, BSN, MS
Professor
Jackson Community College
Jackson, Michigan
Maureen McDonald, MS, RN
Professor
Massasoit Community College
Brockton, Massachusetts

University of Massachusetts, Lowell
Lowell, Massachusetts
Patrick M. Shannon, JD, EdD, MPH
Attorney
Bay Mills Community College
Brimley, Michigan
Susan Smith, BS, MS, RNC, CAN
President/Educator
SK Smith Consulting
Warriors Mark, Pennsylvania
Rita Bolek Trofino, MNEd, RN
Director of Healthcare Programming and Initiatives
Pennsylvania Highlands Community College
Johnstown, Pennsylvania
Deborah L. Weaver, RN, PhD
Associate Professor
Valdosta State University
Valdosta, Georgia
Jennifer Whitley, RN, MSN, CNOR
Educator
Huntsville Hospital
Huntsville, Alabama
Bruce K. Wilson, PhD, RN, CNS
Professor
University of Texas-Pan American
Edinburg, Texas
xiv Contributors
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Copyright © 2007 by F. A. Davis.
Contributors to

Educator, Surgical Services
Swedish Medical Center
Englewood, Colorado
Vera Dutro, RN, BSN, OCN
Infusion Nurse
Zanesville Infusion Therapy
Zanesville, Ohio
Rowena Elliott, MS, RN, CNN, C, CLNC
Assistant Professor
University of Mississippi
Jackson, Mississippi
Mary Friel Fanning, RN, MSN, CCRN
Director, Adult Cardiac Nursing Units
West Virginia University Hospitals
Morgantown, West Virginia
Donna D. Ignatavicius, MS, RN, CM
Clinical Nurse Specialist in
Medical/Surgical/Gerontological Nursing
Calvert Memorial Hospital
Owner/Consultant, DI Associates
Prince Frederick, Maryland
Cheryl L. Ivey, RN, MSN
Department Director
Emory University Hospital
Atlanta, Georgia
Josephine Whitney Johns, RN, OCN, CRNI
South Mississippi Home Health
Oncology Specialty Nurse
Board of Director, Mississippi Cancer Pain Initiative
Co-founder, Mississippi Gulf Coast Chapter

Memorial Hospital at Gulfport
Gulfport, Mississippi
Cindy Meredith, MSN, RN
Director and Instructor of Nursing
Spring Arbor University
Spring Arbor, Michigan
Marsha A. Miles, RN, MSN, CCRN
Instructor
Valdosta State University
College of Nursing
Valdosta, Georgia
Debbie Millar, MEd, BScN, RN, MBA Candidate
Clinical Educator
Humber River Regional Hospital
Toronto, Ontario
Canada
Kathy Neeb, ADN, BA
RN Consultant
North Memorial Occupational Health Clinic
Robbinsdale, Minnesota
Winifred J. Ellenchild Pinch, EdD, MEd, MS, RN, BS
Professor
Creighton University
Omaha, Nebraska
Larry Purnell, PhD, MSN, BSN, FAAN
Professor
University of Delaware
Sudlersville, Maryland
Deborah L. Roush, RN, MSN
Assistant Professor

Rogersville, Missouri
Kathleen Kelley Walsh, RN, MS
Professor of Nursing
Jackson Community College
Jackson, Mississippi
JoAnn Widner, RN, MS
Health Educator
Central North Alabama Health Services, Inc.
Huntsville, Alabama
xvi Contributors to Previous Editions
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Copyright © 2007 by F. A. Davis.
Reviewers
Deborah L. Benns, MSN, BSN, BA, RN
Nursing Professor
Rend Lake College
Ina, Illinois
William Beiswenger, RN, MA, CDE
Certified Diabetes Educator
W.A. Foote Memorial Hospital Diabetes Center
Jackson, Michigan
Nicholle Bieberdorf, RN, BAN
Practical Nursing Instructor
Northwest Technical College
Bemidji, Minnesota
L. Adrienne Bowlus, MSN, RN
Instructor
Apollo School of Practical Nursing
Lima, Ohio
Rosemary Brown, RN, MSN, FNP-C

Foote Hospital
Addison, Michigan
Andi Foley, RN, BSN, CEN
Charge RN
Lakeland Regional Medical Center
Lakeland, Florida
Madeline Gervase, MSN, CCRN, FNP, RN
Assistant Professor
Union County College
Plainfield, New Jersey
Tracey A. Hartke, MSN, RN
Front Range Community College
Westminster, Colorado
Dorothy A. Hogan, RN, MN
Nursing Faculty
Wayne Community College
Goldsboro, North Carolina
xvii
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Copyright © 2007 by F. A. Davis.
Phyllis Sue Howard, RN, BSN
Administrator, PN Program
Ashland Community & Technical college
Ashland, Kentucky
Connie Hunt, RN, BSN
Instuctor, Practical Nursing
Indian Capital Technology Center
Stilwell, Oklahoma
Theresa Isom, AD, BS, MS
Nursing Coordinator

Augusta, GA 30906
Linda K. Maranville, RN, BSN, PHN
Instructor
American Career College
Los Angeles, California
Patricia Marrow, RN, BSN, MA
Nursing Educator, LPN Program
Daytona Beach Community College
Daytona Beach, Florida
Mary Patricia Norrell, RNC, BSN, MS
Chair, Practical Nursing Program
Ivy Tech State College
Columbus, Indiana
Darlene D. Pedersen, MSN, APRN, BC
Director and Psychotherapist
PsychOptions
Philadelphia, Pennsylvania
LuAnn J. Reicks, RNBC, BS, MSN
Professor; PN Coordinator
Iowa Central Community College
Fort Dodge, Iowa
Carleen J. Ronchetti, RN, MS
Nursing Instructor
Lake Superior College
Duluth, Minnesota
Denise Root, RN, ADN, BSN, MSN
Director, Nursing Department
Otero Junior College
LaJunta, Colorado
Glynda Renee Sherrill, RN, BSN,

Martha Williams, BA, RN
Professor
Central Texas College
Brady, Texas
Christina Wilson, RN, BAN, PHN
Faculty, Practical Nursing Department
Anoka Technical College
Anoka, Minnesota
Reviewers xix
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Copyright © 2007 by F. A. Davis.
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Copyright © 2007 by F. A. Davis.
Contents
UNIT ONE
Understanding Health Care Issues 1
Chapter 1 Critical Thinking and the Nursing Process 2
Paula D. Hopper and Linda S.Williams
Critical Thinking and Safe Care 3
Critical Thinking Attitudes 3
Knowledge Base 3
Critical Thinking Skills 4
Nursing Process 5
Role of the Licensed Practical Nurse and Licensed
Vocational Nurse 5
Data Collection 6
Nursing Diagnosis 7
Plan of Care 8
Implementation 9

Review Questions 28
Chapter 3 Cultural Influences on Nursing Care 30
Nancy Ahern
Case Study 31
Concepts Related to Culture 31
Health-Care Values, Beliefs, and Practices 33
Nursing Assessment and Strategies 33
Characteristics of Cultural Diversity 34
Communication Styles 34
Space 34
Time Orientation 35
Social Organization 35
Environmental Control 36
Health-Care Practitioners 37
Biological Variations 37
Death and Dying and End of Life Issues 38
Ethnic and Cultural Groups 38
Cultural Groups in the United States 38
African Americans/Blacks 40
American Indians/Alaskan Natives 45
Arab Americans 45
Asian Americans/Pacific Islanders 45
Culturally Competent Care 46
Reflections on Case Study 47
Review Questions 47
Chapter 4 Alternative and Complementary
Therapies 49
Lynn Keegan
Alternative or Complementary:
What’s the Difference? 50

Movement of Fluids and Electrolytes in the Body 59
Fluid Gains and Fluid Losses 60
Fluid Imbalances 60
Dehydration 60
Fluid Excess 62
Electrolyte Balance 64
Electrolyte Imbalances 64
Sodium Imbalances 65
Potassium Imbalances 67
Calcium Imbalances 69
Magnesium Imbalances 72
Acid-Base Balance 72
Sources of Acids and Bases 72
Control of Acid-Base Balance 72
Acid-Base Imbalances 73
Respiratory Acidosis 73
Metabolic Acidosis 73
Respiratory Alkalosis 74
Metabolic Alkalosis 74
Compensation 74
Review Questions 74
Chapter 6 Nursing Care of Patients Receiving
Intravenous Therapy 76
Lynn Dianne Phillips
Case Study 77
Indications for Intravenous Therapy 77
Types of Infusions 77
Continuous Infusion 77
Intermittent Infusion 77
Bolus 78

Causative Agents 93
Mode of Transmission 94
Portal of Entry 95
Susceptible Host 95
Portal of Exit 95
The Human Body’s Defense Mechanisms 96
Skin and Mucous Membranes 96
Cilia 96
Gastric Juices 96
Immunoglobulins 96
Leukocytes and Macrophages 96
Lysozymes 96
Interferon 96
Inflammatory Response 96
Immune System 96
Infectious Disease 97
General Clinical Manifestations of Infections 97
Laboratory Assessment 97
Immunity 97
Types of Diseases 97
Infection Control in the Community 98
xxii Contents
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Copyright © 2007 by F. A. Davis.
Infection Control in Health-Care Agencies 98
Asepsis 98
Infection Prevention Guidelines 99
Prevention of Respiratory Tract Infections 100
Prevention of Genitourinary Tract Infections 100
Prevention of Surgical Wound Infections 102

Chapter 9 Nursing Care of Patients in Pain 122
Karen P. Hall
The Pain Puzzle 123
Definitions of Pain 125
Myths and Barriers to Effective Pain
Management 126
More Pain-Related Definitions 126
Mechanisms of Pain Transmission 127
Types of Pain 127
Options for Treatment of Pain 128
Analgesics 128
Other Interventions 131
Routes for Medication Administration 132
Nondrug Therapies 132
Nursing Process 133
Assessment/Data Collection 133
Nursing Diagnosis, Planning, and Implementation 134
Patient Education 138
Evaluation 139
Review Questions 140
Chapter 10 Nursing Care of Patients with Cancer 143
Lucy L. Colo and Janice L. Bradford
Review of Normal Anatomy and Physiology of Cells
144
Cell Structure 144
Cytosol and Cell Organelles 144
Nucleus 144
Genetic Code and Protein Synthesis 145
Mitosis 145
Cell Cycle 146

Intraoperative Phase 184
Health-Care Team Member Roles 186
Patient Arrival in Surgery 186
Anesthesia 187
Transfer from Surgery 189
Postoperative Phase 189
Admission to the Postanesthesia Care Unit 190
Nursing Process for Postoperative Patients
in PACU 190
Family Visitation 192
Discharge from the Postanesthesia Care Unit 192
Transfer to Nursing Unit 192
Nursing Process for Postoperative Patients 193
Postoperative Patient Discharge 201
Home Health Care 202
Review Questions 203
Contents xxiii
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Copyright © 2007 by F. A. Davis.
Chapter 12 Nursing Care of Patients with Emergent
Conditions and Disaster/Bioterrorism Response 206
Susan Smith
Primary Survey 207
A — Airway 207
B — Breathing 207
C — Circulation 208
D — Disability/Central Nervous System 208
Secondary Survey 208
Shock 208
Anaphylaxis 208

Nursing Process for the Patient with a Psychiatric
Emergency 221
Disaster Response 222
Bioterrorism 222
Recognition of Potential Bioterrorism Agents 222
Smallpox/Variola Major 222
Anthrax 223
Plague 224
Botulism 224
Review Questions 225
UNIT THREE
Understanding Life Span Influences on Health
and Illness 227
Chapter 13 Developmental Considerations in the
Nursing Care of Adults 228
Ruth Remington
Health, Wellness, and Illness 229
The Nurse’s Role in Supporting and Promoting
Wellness 229
Developmental Stages 229
The Young Adult 229
The Middle-Aged Adult 230
The Older Adult 231
Chronic Illness 232
Incidence of Chronic Illness 233
Types of Chronic Illnesses 233
Gerontological Influence 233
Effects of Chronic Illness 234
Health Promotion 238
Nursing Care 238

The Social Worker 262
Assisted Living Facilities 263
Transition from Hospital-Based Nursing to Home
Health Care 262
xxiv Contents
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Copyright © 2007 by F. A. Davis.
The Role of the LPN/LVN in Home Health 264
Steps in the Home Health Visit 264
Preparing for the Visit 264
Safety Consideratiosn 265
Infection Control 265
Documentation 266
Patient Education 266
Nursing Process: The Home Health Patient 267
Assessment/Data Collection 267
Nursing Diagnosis, Planning, and Implementation 267
Evaluation 267
Other Types of Home Health Nursing 267
Private Duty Nursing 267
Hospice Nursing 267
Home Health Nursing 268
Review Questions 268
Chapter 16 Nursing Care of Patients at the End
of Life 270
Betsy Murphy
Case Study 271
A Good Death 271
Identifying Impending Death 271
Advance Directives, Living Wills, and Durable Medical

Normal Immune Anatomy and Physiology 289
Antigens 290
Lymphocytes 290
Antibodies 290
Mechanisms of Immunity 290
Antibody Responses 291
Types of Immunity 292
Aging and the Immune System 292
Immune System Assessment 292
Nursing Assessment 292
Diagnostic Tests 296
Gene Testing 196
Therapeutic Interventions 296
Immunotherapy 299
Medications 299
Surgical Management 299
New Therapies 299
Review Questions 300
Chapter 18 Nursing Care of Patients with Immune
Disorders 301
Sharon M. Nowak
Hypersensitivity Reactions 302
Type I 302
Type II 306
Type III 309
Type IV 310
Autoimmune Disorders 312
Pernicious Anemia 312
Idiopathic Autoimmune Hemolytic Anemia 313
Hashimoto’s Thyroiditis 313

Viral Loading Testing 330
Genotyping 330
General Tests 330
Therapeutic Interventions 330
Highly Active Antiretroviral Therapy (HAART) 333
Nursing Management 344
Nursing Process: The Adult Patient with
HIV/AIDS 334
Evaluation 340
Review Questions 341
UNIT FIVE
Understanding the Cardiovascular System 345
Chapter 20 Cardiovascular System Function,
Assessment, and Therapeutic Measures 346
Linda S.Williams and Janice L. Bradford
Review of Normal Anatomy and Physiology 347
Heart 347
Blood Vessels 350
Blood Pressure 350
Pathways of Circulation 352
Aging and the Cardiovascular System 352
Cardiovascular Disease 352
Nursing Assessment of the Cardiovascular System 353
Subjective Data 353
Objective Data 354
Therapeutic Measures for the Cardiovascular
System 368
Exercise 368
Smoking Cessation 368
Diet 368

and Infectious Cardiovascular Disorders 387
Linda S.Williams
Inflammatory and Infectious Cardiac Disorders 388
Rheumatic Carditis 388
Infective Endocarditis 389
Pericarditis 391
Myocarditis 394
Cardiac Trauma 395
Cardiomyopathy 395
Venous Disorders 397
Thrombophlebitis 397
Review Questions 402
Chapter 23 Nursing Care of Patients with Occlusive
Cardiovascular Disorders 404
Maureen McDonald
Arteriosclerosis 405
Atherosclerosis 405
Pathophysiology 405
Causes 405
Signs and Symptoms 405
Diagnostic Tests 405
Therapeutic Intervention 405
Coronary Artery Disease and Acute Coronary
Syndrome 407
Pathophysiology and Etiology 407
Prevention 407
Therapeutic Interventions 408
Nursing Process: The Patient with Athersclerosis and
Coronary Artery Disease 411
Acute Coronary Syndromes 412