Welcome to Potential for Alterations in Body Systems.
This section is part of the physiological
adaptation section of the NCLEX exam. And I’m Diana
Shenefield. Let’s get started. You want
to read through your overview of what we are
talking about, but basically we are talking
about the potential for alteration in body
systems. We all have that potential and all
of our patients have that potential. So we are
going to look at some of the details that
go along with that. We are also going to look
at our patients with acute, chronic or life
threatening physical health conditions, and
what those potential alterations could be.
You want to make sure you read through the
learning outcomes, as with all of these programs,
if we get done with a program and you haven’t
met or don’t feel like you’ve met the
learning outcomes, you want to go back and
review in your NCLEX review book or go back
and review in your nursing books and make
sure that you understand exactly what this
section of the NCLEX is referring to. So let’s
start with a question. Here we have a patient
being discharged to the ER after cast application.
So be thinking about these patients.
You’ve seen them over and over again, we've got a patient
that's had a cast, because of a tibial fracture.
Remember where your tibia is? Make sure you
know that. A serious complication of this,
be thinking about somebody that has a broken
bone, and what kind of complications, because
we are looking at potential complications.
So what kind of complications would fall under
impaired gas exchange for this patient? Now you
are going to read through these answers,
and you are going to think a lot of these
could be for this patient. But remember they
are asking you about impaired gas exchange.
So A, cough and deep-breathe every
2 to 3 hours, or every two hours. Is that going to help with this?
How about B, keep your leg elevated and apply
ice for the first 24 to 48 hours? Now these are
all things we are going to tell our patient
to do but again, is it falling under the nursing
diagnosis that the question is asking you
about? C, call the physician at once if you
experience apprehensiveness, shortness of
breath, fever, or palpitations. D, restrict
your fluid intake to 1 liter per day.
Now, you should be able to get rid of D right away.
We don’t want them to decrease their fluid
intake, but again we are looking at impaired
gas exchange, so which one of these answers
fits this question? Hopefully you picked C.
What we are looking for here is a pulmonary
embolus. Remember, somebody that's had a fracture,
that comes in with shortness of breath, be
thinking pulmonary embolus. Another
question. The nurse completes a skin
assessment. We do skin assessments all the
time. Which is most significant and needs
to be reported to the physician? Again, a
lot of these things are significant, but we
are looking for the most significant. So A,
you got a lower leg, skin color in a patient
with venous insufficiency. Be thinking about
what that patient looks like. Or B, you have
an asymmetrical black and brown 7 mm skin
lesion. Doesn’t really matter where it is,
but here it says it's on the neck. C, you've
got a port-wine stain on the patient’s forehead.
D, contact dermatitis on the hands appearing
after a patient weeded the garden. Now all
of these are patients that you’ve probably
seen, but think back to what of these four
patients should be reported to the physician,
and hopefully A, B, C, D came to mind.
You remember that? That they had to diagnose
skin cancer. A asymmetrical, B irregular borders,
C color changes, and D diameter greater than
6mm. So hopefully you picked B as your answer.
So what are we talking about here? So in general
it’s important for the nurse to know a patient’s
baseline, and be able to compare what’s
going on with them because of this disease
process. All of our patients come with different
baselines. Sometimes we know right away because
we've treated this patient over and over.
Sometimes we're seeing this patient for the
first time, and we've got to do a good health
history. We also need to know what are the
potential problems. Just like with that first
question with the patient that had a tibial
fracture. In our minds, we should know that
a PE is always a potential problem, so that
I'm are always watching and always assessing
for this complication.
Knowing your baseline compared to the current
status. Again, how do I know that? And I know
that by following the nursing process, and
the very first thing I do is an assessment.
Asking questions, knowing what their past
medical history is, what their past surgical
history is, knowing the medications that they
take on a regular basis. All of those things
the nurse puts together and critically thinks
about what the patient’s baseline is, and
then we start looking at what’s going on
with them now. What’s different? Is it a
disease process that’s just exacerbated or is
it something new? Is it an acute problem?
Is it a chronic problem? So we take the now
information and compare it to what we have
assessed as the patient’s baseline. So what
kind of alterations should we be looking for?
This on the screen is just an example. You
know as a nurse, your patient can have potential
because of any disease process going on. But
these are just some of the common ones, or
maybe ones just to get you thinking about
a patient and what kind of problems goes with
certain kinds of illnesses. So first one we
have aspiration in a patient with a stroke.
We know that if our patient had a stroke we
really need to watch for aspiration. We need
to make sure that they are sitting up. We
need to make sure they have a swallow study.
But any patient that has had a stroke is at
risk for aspiration. What about aspiration
in a patient with an NG tube? Again, we know
that we are supposed to check that NG tube
before every feeding, but I also know that
things happen, patients pull it out, it gets
caught on gowns, so am I watching for
possibility of aspiration?
What about skin breakdown in a patient that
is immobile? Even if it’s a 6-year-old who
happens to be in traction. That patient is
immobile and we really need to be watching
for skin breakdown. You have a paraplegic that’s
in a wheelchair. We are always assessing
for skin breakdown. What about a skin breakdown
in a patient that is incontinent?
Whether it’s incontinence that they suffer with
all the time, or whether it is an incontinence
that is just going on because of a disease
process. We know that incontinence can cause
skin breakdown so we need to keep up with
the assessment and looking at that skin, and
keeping it clean. What about insufficient
perfusion with a patient
with a cast? You know doing your CSN checks.
Are you making sure they can wiggle their
toes? Are you feeling a pulse? Is their skin
warm? What's the capillary refill? Even if
that cast has been on for 24 hours, 48 hours,
are we still watching to make sure that we
have good perfusion. What about insufficient
perfusion in a patient with diabetes? We know
as nurses that diabetes causes vessel problems.
We know it causes peripheral neuropathy.
So are we watching for this? Are we constantly
assessing skin and feeling for pulses, and
making sure the patient has sensation? It
can happen at any point in time, and if it’s
a patient that comes in over and over again,
you can't rely on what they were the time
before. We constantly need to be
assessing for this.
How about vision changes in a patient with
diabetes? Again we know patients with diabetes,
it affects their vision, and so every time
when we meet with them, or we are assessing
them, we need to ask them about the vision
changes, so that we catch it before it becomes
so bad that maybe it causes the patient to
fall. What about skin changes in a patient
with psoriasis? Psoriasis is one of those
problems that comes and goes, but again as
the person gets older and their skin gets more
frail, we want to make sure that we are
not having skin tears and breakdowns so are
we watching for that? What about skin tears
in our older population? If they have one
skin tear we go to move them, we have another
skin tear, then all of the sudden we have infection.
So all of these are just examples of potential
problems, problems that we are constantly
assessing for. Constantly keeping in the back
of our minds to know that this could happen
to our patients. How would I know? What am
I watching for? What signs and symptoms
would I see?
And then monitor for changes. Again, you may
have been in to see your patient, three, four
times already on this shift. But every time
you go in and you check on your patient, you
are required to monitor for changes. Things
can happen suddenly. And if we don’t keep
up on those, all of the sudden, we are behind the
eight ball. So making sure that we are monitoring
for changes. Things like decrease in output.
Do you remember what a normal output should
be? It should be at least 30ml per hour. So
again, all of the sudden now they are 25,
and then 20. As a nurse I need to make sure
that I am keeping up with that, and I’m
watching that before it gets too bad. What
about bright red blood in NG drainage?
You know it has been brown or green all day, all
of the sudden bright red blood shows up. Am
I assessing that? Am I monitoring for that?
Am I thinking what could be happening, and
expecting or not expecting that? What about
tea colored urine? Again, are we thinking
about bleeding? Do they have a foley catheter
in? All of those things are things that could
happen and we need to be monitoring for.
Decrease in blood pressure. You know is it
because of something going on, are they
dehydrated? Is it a medication that I just
gave them? What is causing a decreased blood
pressure? But maybe its decreasing slowly,
and as a nurse I’m required to make sure
I watch that trending. I don’t want to walk
in and have it be bottomed out, and I could
have caught it in between times. What about
open foot sores of a diabetic? We don’t
know that if we never take off their socks,
if we never off those non-skid socks, when
they are in the hospital that keep them safe.
If they've got ted hose on, you need to take
those off and look for those sores, because
we know those sores can happen, and we know
they can get infected and turn into gangrene
fast. So I need to be watching for those complications,
knowing that there is a possibility.
And then contractures in our patients that
have had head injuries, or patients that are
immobile, or patients that have had strokes. What are
we going to do to prevent those contractures
before they get to the point where we can’t
fix them, or physical therapy can’t get
that arm or leg straightened back out. So again,
as you're going back and you're reviewing
potential complications and monitoring for
changes, remember that every patient has a
potential for complication, and every patient
has potential for change in condition.
So making sure that you know what to watch for,
what signs and symptoms and then what is
the appropriate interventions. So in closing
for this section, make sure again that you
are doing your good assessments, and you're
following your nursing process, that you follow
it all the way through. Once you assess in
your mind you have a diagnosis, and you have
a goal, and then you do the intervention and
don’t forget evaluation, so that you can
go back and start the assessment process again.
This isn't something that you just do at the
beginning of your shift, this is something
that you do every time you see the patient.
So make sure you are watching for potential
complications. Make sure you are watching
for trending and labs, and vital signs. And make
sure that you are keeping your patient safe.
Good luck on NCLEX.