This section for NCLEX review is called Potential
for Complications of Diagnostics Tests, Treatments,
and Procedures. Again this goes with risk
potential, and reducing that risk potential
that you are going to make sure that you know for
the NCLEX review. My name is Diana Shenefield,
let’s get started. So why is that we need to know
about complications? Well, you probably
are answering that for yourself, because as
nurses we need to make sure our patients are
safe. Risk reduction is a big part of what
we do as nurses, so it’s a big part of the
NCLEX exam, to make sure that you are competent
to take care of your patients, so no matter
what’s happening with them, whether they are
having testing or whether they are having
procedures that you know what to watch for,
what to monitor for, so that your patient
doesn’t become distressed, the patient doesn’t
have any complications, and if unfortunately
there's complications, that you know what
to do to help your patient through those.
And make sure you read through the learning
outcomes, make sure you understand what this
section is about, and make sure that you are
prepared to take this section of the NCLEX
exam. So let’s just go through a few things,
just to kind of refreshing your mind.
We are going to start with a question: Which
of the following nursing interventions is
appropriate for a patient who is suffering
from a fever? We get patients with fevers
all the time, so you may be asking yourself
“Well, how would I know?” Well you know
what a fever does to the body. So let’s read
through these answers and see which one
you picked. A, avoid giving the patient food.
B, provide oxygen, C, all of the above or
D, B and C. Now does that question
even make sense? Probably
not. Again this is just to point out that
sometimes when you're asked a question about
something as generic as a fever you may be
saying “Well, there's so many other variables”.
Don’t read into the question, make sure
that you just read for what is asking you,
and if that you have a patient that has a fever,
do you want to avoid giving the patient food?
Do you want to provide oxygen? You have to
really adjust your assessment to your patient.
With this one, there is not really a right
answer. I just kind of want to throw it in,
because a lot of times when you are talking
about procedures, and you are talking about
things that can happen to a patient, we don’t
know at all what can happen to a patient.
It depends on their age, and it depends on
their genetics and it depends on what’s
going on. So don’t let that scare you when
you start reading about just a fever. Make
sure you know about your patient and then
think back to what you know about fevers.
So next question. We have a comatose patient
that needs nasopharyngeal suctioning. So again,
in your mind, think about what you are going
to be doing. After the airway is inserted,
the patient gags and coughs, so what do you
need to do? So if you are confused at first
on what you need to do, think through your
head. What does a nasopharyngeal airway look
like, and how do you insert it? Run through
that procedure for yourself, then you’ll
be able to answer the question. So A, should
you remove the airway and insert a shorter
one? B, should I reposition the airway? C,
should I leave the airway in place until the
patient gets used to it? Or D should I remove
the airway and attempt suctioning without
it? So think through those things,
cause the patient to gag and cough? Hopefully
you picked A. Hopefully you knew that a longer
airway is going to cause gagging and coughing.
If you don’t, go back and review that procedure
again in your fundamentals book. So what do
I need to know generally about
this section of the NCLEX exam? One thing
I need to know is what complications am I
always watching for with patients? You always
need to be watching for their airway, you
always need to be watching breathing and circulation,
but what is happening with the patient that
I need to be monitoring? So I need to keep that in
mind. I need to keep in mind the position
of the patient, not only am I going to be
positioning them, but what could that position
do to them post-op? Next thing, is what does
a nurse need to know to perform the procedure
or the treatment correctly and safely? Again,
that is our top priority, to be competent
and safe in all of our care. We also want
to know how to evaluate the patient. How do
I know if the patient is getting into trouble? How do
I know if the test has been done successfully?
I do that by assessing and evaluating over,
and over with my patient, so that I can pick
up on any trends or any complications. So
one of the complications that comes to mind
when we talk about airway, breathing and circulation,
is bleeding. A lot of test and procedures,
we are using needles or we are causing damage
to tissues, which can cause bleeding. As a
nurse I need to know, is the possibility of
bleeding a real possibility and how would
I know that it happens. Sure if it happens on the
skin, that's easy to see, but how would
I know if there is internal bleeding, what
am I watching for? Things like vital signs,
things like change in behavior. So run all
that through your mind.
What about DVTs, and pulmonary embolus? If
I'm doing testing or the patient is on bed
rest as their treatment, is there a possibility
that they could get a DVT? How would I know
if they did or not? Run those assessments
through your mind, what would the patient
show, and how do I keep that from happening?
We know our post op patients are more prone
for DVT, so what do we do as nurses, to keep
that from happening? We get them up and we
get them walking around, we have them wear
ted hoes, we have SCDs on them, we teach them
how to pump their ankles. All of those things
that they don’t understand needs to be done,
but as nurses I know what I need to do to
keep my patient from developing that DVT,
and then ultimately, hopefully to keep from
having that pulmonary embolus. What about
respiratory distress? Anxiety can cause respiratory
distress. We know when patients are anxious
they can hyperventilate. What about if I have
obstructed an airway? What about if there
has been bleeding into their lungs? Again,
how would I know that as a nurse? What signs
and symptoms do I need to be alert for to
watch my patient to make sure they are not
getting into respiratory distress? Am I watching
their O2 sats? Am I listening to their breath
sounds? Am I monitoring their respiratory
rate? All of those are things that I need
to be doing on a constant basis when my patient
is getting treatments, post-op, pre-op, or
during, to make sure that I’m monitoring
that, to make sure I’m not missing anything.
What about cardiovascular compromise? Lot
of times we put patients in positions, especially
in the post-op, that can cause a compromise.
Maybe we have a leg bent, that needs to be
bent for the surgeon to do their job, but are we
watching for neurovascular and cardiovascular
compromise? Am I watching for good capillary
refill? Am I watching for good pulses?
Am I feeling the skin to make sure it’s warm,
and dry, and pink? So again, running all of
that through your mind, making sure that you
are prepared to catch any kind of complications.
We know cardiovascular wise if we don’t
catch it, you can end up losing a limp.
Again we don’t want that to happen, but if I don’t
understand the positioning or what’s going
on with the patient, I might miss something.
Neurovascular compromise, which we just talked
about, which goes a lot with cardiovascular
compromise, and positioning, so make sure
you are running those signs and symptoms
through your mind.
Pressure ulcers, huge things. We don’t think
a lot about treatments on pressure ulcers.
If you've ever been in the OR, a lot of
times patients are put on those tables, and
in the OR they don’t have time to watch
for skin breakdown and those kind of things,
they are on a mission, but when they get back,
out to the floor, we need to be making sure
we are watching those skins, especially of our
elderly patients or our malnourished patients,
that are already more prone to pressure ulcers
and breakdown. To make sure that while they
were in the OR, that maybe they weren't in a
position that was too long, looking at those
bony prominences. So again, I don’t always
understand what positions patients are in
the OR, but I have a pretty good idea, so
I need to take a close eye at my patient and
doing a good skin assessment. So what are
we going to do about interventions? And what does
the nurse need to be competent in when we
do nursing interventions? What about things
like putting in an NG? What kind of things
do I need to be watching for? Now if you need
to review your NG procedures, you need to make
sure you go back and look at your fundamentals
book. But we know there is a chance that you
could get into the lungs. What kind of signs
and symptoms would your patient show? What
happens if while you are giving a feeding
through the NG and the tube becomes dislodged,
and gets into the lungs, can you catch the
common complications, the coughing, maybe
the aspiration. Again, run all that through
your mind, be very familiar with the treatments
that you are going to be doing. Tracheostomy
suctioning. We don’t see as many trachs as we
used to, but that kind of makes it harder
because you are not going to be doing it all
the time. So run that procedure through your
mind. How would you know if somebody has a
tracheostomy plug? How would you know if they
need to have it replaced? What kinds of signs
and symptoms are you watching with your patient?
What happens if it becomes plugged and they
stop breathing? Do you know how to use the
bag valve mask on them? Again, if you haven’t
done trachs in a while or if it’s been a
long time since you've learned how to do it
in fundamentals class, you are going want
to go back and review. What about suctioning
of the trach? Do we instill normal saline or
do we not? You want to make sure you know
the best evidence practice with that as well.
What about defibrillation and cardioversion?
Make sure you know the difference between
the two. Make sure you know how to keep you
patient safe and yourself safe when you are
performing cardioversion or defibrillation.
Again if you are not familiar with that make
sure you go back and read that in your book.
ABG draws. A lot of nurses won’t get to
do ABG draws and all of the sudden one will
be ordered. Do you know how to do the Allen
test? Do you know what you are watching for
in the Allen test? Do you know the complications
that can happen with drawing an ABG? Are you
holding pressure? Again, all of those things
you need to review, because on the NCLEX they
want to make sure that you are safe, and that
you understand that what you do has complications,
pro and con effects to your patient, and so
before you can do those things you need to
understand what you are doing to your patient.
What about just putting in an IV? A lot of
times nurses just putting in an IV, they can
almost do it with their eyes closed, but what
happens with that one patient that you happen
to touch a nerve, and they start complaining
of tingling and burning in their fingers.
Do you catch the fact that you've touched
the nerve and you need to pull that IV out?
Again, don’t become very like “Oh, I’ve
done this a million times.” Make sure you
always know what the complications are. Foley
placement. Are you using sterile technique?
What happens when you are putting in a Foley
and you're sterile and the patient starts
to cough or moves? Do you know what to do? Do
you know how to know whether you are staying
sterile or not? Again, review that procedure.
What happens if you are putting a Foley catheter
in an older gentleman and you can’t get
the catheter to advance? Do you know tricks
on how to get it past the prostate? What happens
if blood comes out? So again, run all those
procedures through your mind, so that you
are ready for those complications.
Dressing changes. Pretty simple, but again
what happens when you take off that dressing
and there is lots of bleeding? How do you
assess that? How do you document wound care
to make sure that you are communicating to
the next nurse or the physician on what the
wound looks like, so they can tell, is the
wound getting better or is it getting
worse? Do you know how to measure wounds?
Make sure again you are reviewing all of that.
Making sure you are monitoring vital signs.
Don’t get lax on vital signs, make sure
that you understand what your baseline is.
Make sure that you understand that if your
patient runs 92% O2 sat and you do something
and now they are at 90, is that normal or not?
Only you as the nurse would know that because
your patient is individualized.
What about monitoring labs? We are responsible
for watching trending. And I go through with
my patients a lot about a normal isn't just
a normal, is it at the low end of normal,
or is it at the high end of normal. If a trend
is happening, just because the patient is
still in the normal range, I need to be watching
that, because I need to catch something before
it gets out of the normal range. So again, do you
understand trending, and do you understand
normal lab values which you do need to know.
What about monitoring Is & Os? It isn’t
just as easy as taking in how much did you
drink and how much did you urinate, but do
you understand that there is NG drainage,
or if there is bleeding, how to estimate that
and what that means to your patient if you
don’t catch how much output there is.
You know, is their kidney all of the sudden not functioning?
Is that something or is that something that
you got to watch for labs when you could
have caught maybe in your output. So again
what does that mean to the nurse, and what
complications are you watching for? What about
monitoring airways? That’s usually an easy
one. We are always focused on airways, but
again sometimes we get focused on another
body part and we forget that the patient has
to have an airway. So make sure you are watching
for that as well.
And any side effects? Again, we’ve talked
about side effects of medications, we've talked
about side effects of any kind of procedure
that we do for the patient. But again it’s
very important that you are watching for those
side effects, and that you are educating the
patient about those side effects. And then,
assess, assess, and reassess. And I know you've
heard in nursing school you gotta
assess, you gotta reassess, you gotta
go back and reassess, and that is so important.
Patients conditions can change so fast, and
it’s usually the patient that you think is
the most stable that will all of sudden change
on you, and if you don’t catch that, you
are going to miss it. So what does that mean
to reassess? Does that mean that you have
to do a total head to body? I don’t know,
maybe you do. But, only you would know as a
nurse on what’s going on with that procedure,
so make sure that you are watching, and you
are reassessing your patient. Proper positioning.
Are we watching for side lateral to allow
for drainage of secretions? Again, you have
a comatose patient, do you want them laying
on their back? Maybe you do, maybe you don’t.
But what’s going to happen if you put them
on their back? Are they going to be more prone
to aspiration? So just things like how you
position your patient is going to be good
for the patient, or it could be detrimental
and it's something you need to keep in mind.
What about head elevated. We know if somebody
is having difficulty breathing, having them
in High Fowler is going to help with lung
expansion. That’s an easy thing to do, that’s
a fast thing to do for your patient that is
having trouble breathing. What about elevating
the limbs to reduce swelling. Don’t forget
your RICE. Maybe they need to have their limb
elevated. What’s is that doing? What’s
the purpose of elevating a limb? Any time
that you have any kind of swelling, so run
that through your mind.
What about sideline? What position does the
patient need to be in for a lumbar puncture,
a spinal tap? Do you understand how to position
the patient? If it is an infant, do you understand
how to watch for airway obstruction? If it
is an adult, can you explain to them how to
position, and help them to understand why
they need to hold still. What about prone?
If they have hip joint problems. A lot of time
in our patients, we don’t let them lay prone,
but that allows for maximum extension of the
hip joint, so why don’t we allow them to
lay prone, maybe that’s the best
for the patient.
And then, trendelenburg. Used to always be
you put patients in trendelenburg when they
had a low blood pressure. But what about if
they have increased intracranial pressure?
Do you want to put them in trendelenburg?
No, that’s not a trick question, you do not.
You don’t want to increase that intracranial pressure.
So again be familiar with your positions,
when they are used for the best and when they are contraindicated.
So, we kind of talked about a lot of stuff here about complications.
Again, we do a lot of good
as nurses, and I know you have learned a lot
in nursing school, but one of the things we
need to keep in mind is to always keep in
mind that there always could be complications.
If you are prepared for them, you will be
able to catch them, and hopefully, prevent
them, and keep your patient safe. That is
what your patient wants, and that is what
NCLEX is looking for. So can go back and look
at your procedure books, and familiarize yourself,
and you will do fine on the NCLEX exam.
I am Diana Shenefield. Good luck.