Potential for Alterations in Body Systems (Nursing)

00:01 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.

00:35 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.

01:06 You’ve seen them over and over again, we've got a patient that's had a cast, because of a tibial fracture.

01:12 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.

02:18 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.

03:26 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.

03:45 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.

04:02 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.

04:45 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.

04:57 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.

05:59 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.

06:08 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.

07:39 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.

07:58 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.

10:42 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.

10:59 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.

11:31 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.

12:07 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.

12:17 Good luck on NCLEX.