Welcome! Today’s NCLEX review subject is
Alterations in Body Systems, and we are going
to get started right now. You want to read
through the overview of what we are going to talk
about today, and some of the things we are
going to talk about are under the physiological
part of NCLEX exam. Each part of the exam
has different sections, and so today we are
going to talk about, we are going to start
here, we are going to talk about patients
with chronic or with life threatening physical
conditions. And we are going to just review a
little bit on what you’ve probably already
learnt in nursing school, but we are going
to bring it down to just a real fine topic.
So you want to make sure you read through
the learning objectives. If after we are all
done, if there's are topics that you aren’t
clear about, you want to make sure you go
back and review those topics, you want to
make sure you go back and look at your nursing
text books on areas that you might not be
as familiar with, or maybe you have forgotten.
So let’s start off with a question, to kind
of get us in the mode of what we are talking
about today. So we have a nurse that needs
to assess for a patient with hyperkalemia, which
if you remember is an increase in potassium.
Which of these patients which she'd be watching
for? A, a patient with renal failure. B, a
patient with nausea and vomiting. C, a patient
that has excessive laxative use or D, a patient
with loop diuretic use. So, think
back to potassium, and which of
these patients would she need to be watching
for? Hopefully you picked A, renal failure,
because we know the other, B, C, and D will be
hypokalemia. So again, if you can’t remember
your lab values, you are going to want to
go back and review those.
Here is another question, so you have a nurse
caring for which of the following patients.
Again read through what question
is asking you, and this one specifically
asking you about a nursing diagnosis, and
this nursing diagnosis is going to relate
to one of the following answers. Is it a newly
admitted 32 year old with myasthenia gravis?
Again myasthenia gravis is not a real common disease,
but it is an important disease that has a
lot of life threatening effects, so you want to
make sure you review that. Or is it a post-op
patient, who had just have a Fem-Pop bypass
surgery. Again, if that isn’t familiar to
you, you are going to want to go back and
review that. A 56-year-old patient admitted
with an appendectomy or D, an 83-year-old
patient that has had prostate cancer.
So again, you are looking at the nursing diagnosis.
Now, a lot of these patients are patients
you are going to take care of, but you want
to make sure you are addressing the nursing
diagnosis that the question is asking about,
and this question is asking about breathing
difficulties, so we are going to pick question,
or answer A, with a patient with
myasthenia gravis. Patients with myasthenia
gravis a lot of times have problems with the
respiratory system. So again,
as we are going through some of
these topics, make sure that you understand
or have an understanding of what part of the
body we are dealing with, so that you can use
your critical thinking to be able to narrow
down your answers. So, we are
going to start out with the general.
Patients can experience alterations in body
systems whenever they are suffering from any
kind of illness. And again, sometimes we get
focused on what they came to the hospital
for, or what they came the physician’s office
for, but remember a lot of our patients have
co-morbidities, and so how one patient reacts
to an illness might be different than the
way another patient react to their illness.
So, we need to look at how is this disease
process affecting your patient. The nurse
should be able to monitor and assess for changes.
One of the biggest things as for nurses,
is we kind of know how the pathway should go,
but our patients surprise us at times. And so we need
to be watching for those changes so that
we can prevent complications. The nurse
should be able to implement appropriate
interventions. Not waiting necessarily for physician
orders, but should be able to critically
think through about what’s happening with
the patient, and be able to intervene in a
timely manner. The nurse is
assessing proper patient education.
We know as nurses that what we tell the patients
is very important. They don’t get a lot
of education from physicians, because the
physicians know that nurses are with the patients
longer. We need to make sure that we are thoroughly
educating our patients. We need to make sure
that they understand what’s happening before,
during, and once they go home, giving them
a little written paper, and sending them out
the door does not do it. We need to make sure
that they totally understand what could happen
to them, and what their disease process is
going to entail, what medicine. So we really
need to focus a lot on patient education.
And then, the nurse should be educated in
pathophysiology. When you are going through
nursing school, I’m sure you had a huge
pathophysiology book, and you are thinking
to yourself "There is no way I can know about
every disease," and that’s true. But you
do need to know about the major diseases,
and then you are responsible that when you have
the patient that comes in with a disease process
that you are not familiar with, to go back
and educate yourself so that you can have the
best care of your patient. Just not knowing
is not an excuse. So again, as
you are going through and you're looking
at NCLEX questions, if there's disease processes
that maybe you are not as familiar with, you
should at least be able to pick out what body
system, and go from there. When you are out
on the floor, you need to know, you need to
look those things up for the safety of your
patient. So, what are some
of the common therapeutic
procedures we do as nurses. Think back to
nursing school, all the things that you've learned.
We did things like assessing tube drainage,
not just saying we 'assessed' it, but looking
at what’s the color? What’s the drainage
coming from? How much is there? Documenting
all of that. Being able to understand what
does it mean, if it's just sanguineous? What
does it mean if it's serosanguineous? What
does it mean if it's yellow? And being able
to critically think through on whether it’s
an expected outcome, or whether something
else is going on. What about monitoring
a patient on a ventilator.
We don’t just leave ventilators just to
respiratory therapy but we have to watch those
ventilators, and make sure that the respiratory
rate is correct, to make sure that our patient
isn’t getting too much oxygen. So what would
you need to be watching for, for your patient
on a ventilator? How about using temperatures?
We take temperatures all the time, but what
does that mean for your patient? And, are you
able to watch trending? Even if they are
in a normal parameter? Are they trending too high
or too low? Sometimes we take temperature
and heart rate kind of for granted because
we do that all the time. But sometimes that is
the fastest way to figure out what’s going
on with your patient before things get too
bad. So don’t forget about that. What about
monitoring phototherapy on an infant.
If it has been a long time since you have been in
an OB or in pediatrics, review phototherapy.
We know that phototherapy can cause damage
to the retinas. So do you understand that?
And then what about the blood draw? What
are they looking for in the blood draw? And what
is a normal bilirubin level? So you want to
make sure that you are reviewing that.
Ostomy care. Nobody gets thrilled about doing
ostomy care, but what are we looking for?
Not only the stoma, and what it looks like,
but the skin around it, and what are kinds
of complications that can happen with that
skin, from yeast infection to breakdown, and
are we monitoring that, and are we
And then, postictal care. You know you have
a patient that has had a seizure, what are you
watching for afterwards? Do they have a good
respiratory rate? What is their neurological
status? And are they safe in the environment
that they are in? Those are all things that
you need to run through your mind and again
if there's topics that maybe you don’t
feel strong at, you want to go back
and review those.
What about suctioning, orally or from a trach.
If you haven’t done that for a while, you
are going to want to review that procedure,
and look at how would you know if you are
suctioning too hard? How would you know if you
are going down too far? Is bleeding normal?
Are you watching the heart rate? Are you causing
the patient to vagal down? Again, what are
the complications that can happen? How often
should you be doing these procedures and then
what are you documenting? Monitoring ICP,
Intracranial Pressure. What
are you looking for? What patients are going
to be more prone to have increased intracranial
pressure? What kind of symptoms are going
to tell you that the pressure is going up?
What do you need to watch for before maybe
the patient is getting ready to herniate,
things that you should have been watching for.
So, you want to review the sign and symptoms
of increased intracranial pressure.
Monitoring cardiopulmonary systems. Again,
it’s more than just heart rate. It’s blood
pressure. It’s perfusion. It’s capillary
refill. So again, making sure you that understand
how to keep your patient safe, and how to
watch for complications before they happen.
Assisting a physician with invasive procedures.
Do they need a consent? Making sure that consent
is signed. Making sure the physician has the
equipment that they need. Making sure that
you have the safety equipment that you need,
or safety medications that you need. And then
what are you monitoring for? Are you making
sure that they are breathing. Are you making
sure that they are not compromised? Are you
watching the positioning that they are in,
especially if it is an elderly person.
So make sure you review all that.
And then wound care, making sure that you
know how to document a wound. Do you know
how to measure it? How you assess depth?
How you assess pressure ulcers? Pressure ulcers
are a big problem, again with our patients
that are immobile or our diabetic patients.
So it’s important that you understand how
to prevent, and then how to treat, and how
to assess, and how to document. So you are
going to want to make sure you go back
and review that.
Complications. How do we know what complications?
We use our critical thinking, but we start
with assessment, you have to assess and reassess,
assess and reassess, and when you go in and
you do an assessment, and you might be really
good at assessment, but if you are not going
back and reassessing, things happen in the
meantime, things that maybe we thought could
happen, or maybe things that just kind of
surprised us. So don’t forget about assess,
reassess, and how important that is that you
are doing that constantly through your shift.
Nursing process, NCLEX will drill you, and
drill you on the nursing process, and it is
so important that you understand that assessment
is the first thing that you do. And a lot
of times in nursing school we get focused
on interventions and what do I need to do,
but don’t forget you can’t do anything
with a patient, until you’ve assessed.
Then you are going to plan a nursing diagnosis,
and that doesn’t mean that you are always
writing it down, or going to the computer, but
in your mind you should be thinking through
a nursing diagnosis that fits the assessment
that you just did.
And then planning. What’s the plan? How
are you going to know that what you do is
making the patient any better? There has to
be goals, so that you can mark the goals off
when they’ve met them, or reevaluate if
they are not meeting them.
Then we get to intervention, then we get to
the fun part when we get to do something.
But again, we can’t do until we’ve met
the other criteria.
And then don’t forget the fifth step, evaluation,
that’s our reassessment. We go through this
whole process. We cannot know how we
are affecting our patient. We can’t know
if the patient is getting any better if we
don’t go back and evaluate, and start back
at the top and make sure that they are meeting
the goals that we've set for them.
So, in closing on this section, assessing,
assessing, assessing is so important, and
reassessing. Looking for alterations in body
systems. Remembering that our patients come
as individuals. And even though we have a
general idea of what a disease process does
to the body, don’t forget that everybody
comes with something else, either genetics,
culture, age, that adds to that, so make sure
that you are reading those questions but making
sure that you are taking care of your patients.
Being able to assess, diagnose, plan, intervene,
and evaluate. Knowing that nursing process
forward and backwards. And then remembering
that you have the responsibility to identify
changes in your patients, to catch when a
heart rate is going too high or too low, and
not waiting until a complication is full blown,
but making sure that you are catching that
beforehand, and intervening, assessing, and
doing your nursing process. So that’s all for this topic.
Go and study for NCLEX, and good luck.