The topic we are going to cover this time
is on reduction of risk potential category
and underneath that is system specific assessments.
So we are going to talk a little bit about
that and before we get started I just want
to introduce myself. I am Diana Shenefield
and let’s get started. So overview of the
content. What are we going to talk about in
this section and what we are talking about
is system specific assessments. In a lot of
time, you'll hear it called focused assessments and we
know when we have our patients on the floor
that every time we go in to see them we
don’t always do it head to toe. But we focused
on certain body systems and this is what this
lecture is a little bit about. Just to
get you thinking about that topic and what
NCLEX would be looking for. So as before make
sure you read through the learning outcomes.
Make sure that you are comfortable with assessment
and re-assessment. Make sure that you are
looking as specific risk assessments. So we
get focusing on a body system and risks and
complications that could happen in that body
system and being able to recognize changes
in your patient.
So let’s start with a question. We have
a child with a diagnosis of meningococcal
meningitis and they develop signs of sepsis
and purpuric rash over both legs. So as you
are taking NCLEX questions a lot of times
it helps if you can read the question and
picture that patient in front of you. Make
that patient real to you so that it will be
easier for you to think through the question
and the answers. The physicians should be
notified immediately because of the following
signs. So which of the four answers should
the physician be notified immediately if the
patient presents with these signs and symptoms.
A, a severe allergic reaction to the antibiotic
with impending anaphylaxis. Now a lot of times
students will see anaphylaxis and think that’s
the one has to be. Because anaphylaxis is
life threatening. But again make sure that
your answer is fitting the question and in
this question we have a patient with meningococcal
meningitis. B, has onset of syndromes of inappropriate
antidiuretic hormone, SIADH. We also know
that a patient with meningitis could develop
SIADH. But is that what the symptoms on that
question is telling us. How about C, meningococcemia or
D, adhesive arachnoiditis? Again sometimes
you know you are looking at answers and you
are like “I don’t even know what that
is?” Use your medical terminology and make
sure you breakdown the word. But again sometimes
they'll throw things on that just a kind of
throw yet just to see if they can riddle you.
Why? Because as nurses we need to be able to
keep our heads in critical situations.
So looking at these four answers, you got
the patient with sepsis and they've got the purple
rash. So which one of this answers are you
going to pick? Hopefully you pick C, meningococcemia.
Again hard word to say but you know what I
am talking about. Make sure that you are watching
that purple rash. It is so important to watch
for. They are going into a sepsis caused
by meningococcal. So again don’t get stuck
on keywords like anaphylaxis. Make sure your
answers fits the question that is being asked.
There is another question. You have a nurse
assessing a patient who just sustained blunt
force trauma to the chest from a steering
wheel. We know we have patients that come in
all the time. They hit the steering wheel.
So run through your mind what is blunt force trauma
from a steering wheel looks like. Which of
these signs would indicate the presence of
the pneumothorax? So we have a blunt force
trauma and we have pneumothorax. Is it A-,
a low respiratory rates? B, diminished breath
sounds? C, the presence of a barrel chest or
D, a sucking sound at the site of injury?
Now again remember a blunt chest wound is
not going to have sucking sounds because it's
all contained. So you can eliminate that one
right away. A low respiratory rate. Think
through all your patients that have had trauma
to the chest. Their respiratory rate probably
is not going to go down. They are going to
start breathing faster. And what about the presence
of the barrel chest? We know from learning
in nursing school, a barrel chest happens
over time from chronic respiratory problems.
So that leaves B diminished breath sounds.
So right there in your mind a pneumothorax,
what is that? That is one of the lungs has
been decompressed. We are going to have the
diminished breath sounds.
So again make sure you look at the questions.
Make sure you know exactly what it’s asking
you and then pick the answer that fits with
the question is asking. So now let’s get
back to our system specific assessment. Again
most of the time you are going to hear nurses
call a focused assessment. You are focusing
on the body part that has the illness. But
remember, if I have a patient that comes in
with COPD, we know that the major area the
COPD affects is the lungs. But that patient
can also have diabetes. So as I am treating
the patient, I can’t just forget about the
diabetes. I can’t just do a focus assessment
on the lungs. Because I have to treat the
whole body. But what we are talking about
here is being able to pick up what is system
specific assessment is and looking for risk
factors for that assessment. You need to do
an initial head to toe assessment and then
be able to focus on the patient’s primary
problem. So when we are looking at a risk
assessment, the nurse must be able to clarify
what’s going on with her patient. To be
able to watch for specific complications in
specific areas of the body. So some of the
examples again. These are just examples there
are lots and lots of patients out there
with lots of different examples that you could
plug in here. But these examples are just
kind of give you an idea on how you should
be thinking. We know patients with diabetes
have a probability of poor wound healing.
So again I have my patient with diabetes.
They come and they have surgery. I may have
nothing to do with their diabetes but as a
nurse I know the diabetics have a poor wound
healing. So I am really watching my wounds
on those patient. What about risks of
hyperglycemia in a patient that receiving
steroids? May be they are getting steroids
because they have COPD or they have asthma
and they are on long term steroids. I know
that long term steroids can cause hyperglycemia.
So again am I watching for that in my patient?
Am I focused on watching blood sugars? What
about respiratory distress in a patient with
asthma? Just because they are on their inhalers,
just because they are taking their medicines
and they come into the hospital with maybe
appendectomy. I don’t want to get so focused
on that appendectomy that I forget that they
are at risk for respiratory failure.
What about risk of pulmonary emboli in your
patient with a fractured bone? Again remember
any patient that has a fractured bone, it
can happened immediately and it can happen
days afterwards. So again being able to understand
that it’s not just the bone but I also need
to focus on lungs and watching for those complications.
Risk of diminished peripheral circulation
in a patient with afib. Remember with afib,
the atrium aren't beating the way they should and
so what happens is that the blood kind of
just sits in the atrium. So how would I catch
that if that’s happening in my patient,
that’s not on telemetry? You start looking
at peripheral pulses and when you can’t
feel a radial or popliteal pulse, you will know
that something is going on in the central
body. Again if I just get focused on just
the afib and I am watching a monitor I can miss
out on the fact that they are not perfusing.
So you want to watch for that risk. How about
the risk of over hydration in your patient
with congestive heart failure that also has
anemia and needs a blood transfusion? Again
all your patients are getting blood transfusion.
You want to make sure that you are listening
to the lungs and making sure that we are not
over hydrating them and pushing them into
a congestive heart failure or an exacerbation
of congestive heart failure. How about the risk
of dehydration with your patient with hyperemesis?
Lot of times women that are pregnant will
have a lot of vomiting. Some women have more
than others. Some women have other processes
going on that cause them to dehydrate a lot
faster. So again it’s not so much you know
we are watching them and their vomiting. But
we are watching for dehydration, we are watching
their kidneys, and their perfusion to make
sure that we're focused on that part of
assessment as well.
And then risk of falls in our patients with
narcotics. That can be any patient. I think
sometimes we get focused on our older patients
and that we do need to focus on them. But
any patient that were getting narcotics too,
any patient’s blood pressure medicines
too, we know that there is a risk of falls.
And so being able to watch for that and assess
for that and to keep our patient safe, knowing
what kind of side effects happen with those
kind of medications. Then responding to changes.
As you look at lawsuits and negligent cases
that are brought against nurses. Many of them
are brought because of failure to act, failure
to catch a complication happening, failure
to catch the trending as it is going on and
not seeing other results until after the patient
crashes. So you need to make sure that you
understand about trending. About looking at
lab results and even though the lab results
maybe within the normal parameter is it leading
more towards to too high or too low and being
able to monitor that before gets out of luck.
Watching for patients vital signs and catching
a dropping blood pressure or an increasing
heart rate before it gets to the point where
the patient starts to code. So again failure
to act and failure to act in a timely manner.
So how do I know what is going on? Is I have
to understand my patient and I have to do
good assessments. I have to be able to look
at labs and understand are they getting better?
Are they getting worse? Are they really staying
in a normal range? Trending is a big part
of nursing. And again you have to look at labs,
you have to look at vital signs, but you also
have to look at your patient. And doing thorough
assessment and then focusing on potential
complications. Again is there a complication
with the lungs? Could there be a complication
with the blood clot? And am I focusing on that
or am I just focusing on what’s happening
with the patient at the time? So again as
nurses we understand that we are looking at
the whole body. It doesn’t necessarily mean
I am doing a head to toe assessment. It means
that I understand a disease processes and
what kind of risk potentials that there are.
So make sure you are getting a PRN medicine.
Make sure that you are following up. Make
sure that the medicines that you are giving
are doing their intended therapeutic effect.
Don’t just assume that when you give somebody
a medication, that it is going to go by what
the book says. Are you reassessing? Are you
looking for potential risk factors? And are
you catching potential risk factors and eliminating
them before they happen? Make sure that you
are looking at your whole patient. Make sure
that you understand their disease processes,
make sure you understand diagnostic tests,
and medications. So that you can preemptively watch
for these complications before they happen.
So get to studying your NCLEX review, take a
lot of questions and make sure that you are
able to answer. And again as you are answering
those questions, make sure you understand what
the question is asking you. So that you can
make the right choice. Good Luck.