Nclex- Physiological Adaptation PDF

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Physiological Adaptation General Information Often, a patient will need some sort of physiological adaptation to preserve and maximize physiological integrity. These questions deal with providing appropriate care for patients with chronic, acute, or life-threatening health conditions and any adaptations required to improve their situations.

Body System Alterations A patient’s body undergoes numerous alterations in response to an illness, disease process, intervention, and/or surgery. Recognizing these alterations help to implement proper care to return the patient to a more “normal” state of health. Nurses must explain these adaptations and resultant changes in patient care to help patients understand the reason behind these interventions.

Patient Assessment Every patient’s care begins with your assessment of the health and psychological status of the patient. This includes not only alterations due to illness, disease, or interventions/treatments, but also the patient’s ability to cope with his or her health situation and adaptation to an altered (sometimes permanently) state of impairment. Patient assessment may also extend to the patient’s family and external support system as well.

Specific Situations The following are some of the more important clinical scenarios in which you will be required to perform these functions:

Drainage Tubes Any wound or tube drainage must be closely monitored. Pertinent characteristics of drainage assessment include monitoring for changes in color, consistency, and volume. Common drainage sites include surgical wound drains, respiratory secretions, chest tube drainage, and negative pressure wound therapy. Be familiar with the appropriate care involved in monitoring each. Nurses must be able to perform important interventions with drainage tubes including keeping dressings occlusive, monitoring for leaks or damage to the drainage systems, maintaining the drains (i.e., stripping,emptying, maintaining suction), and changing of equipment.

Radiation Therapy

Patients undergoing radiation therapy will need to be closely monitored for systemic and localized effects of treatment. Common adverse reactions can include: alopecia, damage to the skin and mucosa, fatigue, immunosuppression, etc. Also be familiar with appropriate lifestyle modifications to discuss with your patient such as proper dietary modifications and sunlight exposure precautions.

Prenatal Conditions Understand how to identify potential prenatal complications as well as give appropriate intervention during complications from pregnancy, labor, and/or delivery. Common prenatal complications include constant or excessive bleeding, chemical pregnancy, or molar pregnancy. Complications of later pregnancy, labor, and/or delivery include eclampsia, gestational diabetes, still-birth, birth positioning, and birth trauma. This may also include complications from previous surgical cesarean sections. Nurses should frequently monitor vital signs, especially heart rate and signs of fetal or maternal distress.

Infectious Diseases Be familiar with the signs and symptoms of infectious processes. This includes localized findings (pustule, erythema, swelling, etc.) as well as systemic signs (fever, chills, gastrointestinal changes, fatigue, etc.). Understand common incubation periods for various infections, and be able to link a patient’s history of exposure or contact with your clinical findings. Lastly, be familiar with various treatments for infectious processes (bacterial, fungal, viral) as well as specific interventions based on affected body systems (respiratory versus genitourinary versus gastrointestinal, etc.)

Invasive procedures Understand the role of the nurse during invasive procedures. Many of these are done at the bedside, so a general, working knowledge is critical. Understand how to identify the patient and verify the order, gather the supplies, and set up for the procedure (i.e., sterile field if necessary), assist and monitor the patient during the procedure, assess and monitor the patient post procedure, and how to properly document the procedure in the medical record. Examples of such procedures include a central line (know patient positioning, preparation, monitoring, etc.); thoracentesis (patient positioning, preparation, specimen care, post-procedural care, etc.); bronchoscopy (patient preparation, sedation/general anesthesia, post-procedure monitoring, etc.), and lumbar puncture (patient preparation, patient positioning, sedation if needed, vital signs, etc.).

Phototherapy Be familiar with the uses of phototherapy for both adults and newborns. Phototherapy is most commonly used for physiologic jaundice in neonates. Potential complications of phototherapy include eye damage (all clients should wear protective eye gear while under phototherapy), hyperthermia, and medication interaction (i.e., ibuprofen, diuretics,

specific antibiotics). Understand how to implement therapy per the practitioner’s order as well as monitor for therapeutic effectiveness.

Hypo and Hyperthermia Understand the risk factors for the development as well as the signs and symptoms of both hypo- and hyperthermia. Hypothermia is defined as a core body temperature less than 95 degrees. Hyperthermia is a core body temperature greater than 99.4 degrees. Nursing interventions to correct these conditions include correcting underlying disorders; hydration and cooling; wet packs for hyperthermia; and warming packs, warming blanket, and warm fluids for hypothermia.

Ventilator Use Understand the indications for the use of a ventilator as well as the many potential complications of their use (alveolar overdistension, cardiac complications, oxygen toxicity, hypo/hyperventilation, infection, etc.). While many facilities have specialized respiratory therapists who closely monitor these patients along with the nurse, it is important to have a working knowledge of the care of the patient on a ventilator.

Wound Care Be familiar with the signs and symptoms of wound infections including wound temperature changes, erythema, edema, and purulent drainage. Nurses should educate patients on smoking cessation, improved dietary changes, proper wound positioning, adequate hydration, dressing changes, wound care, and early signs of wound deterioration to improve wound healing and early detection of concerns. Understand how to monitor drainage devices in a postoperative patient.

Peritoneal Dialysis Be familiar with the indications for and frequency of peritoneal dialysis. Know how to monitor a patient before, during, and after this procedure, and be familiar with common complications and troubleshooting measures used during the treatment to ensure its safety and effectiveness. Nurses should especially monitor for fluid and electrolyte imbalances, consistency and volume of drainage, and patient vital signs.

Suctioning Know the proper procedures for performing suctioning of an endotracheal and/or tracheostomy tube, and oral and nasal passages. This also includes preoxygenation prior to and in between suctioning sessions when indicated/necessary. Always remember that when performing deep suction, the nurse should initiate suction while withdrawing the catheter, not during the insertion.

Alterations in Body Systems Patients may experience alterations in bodily systems. This includes patients at risk for aspiration, skin breakdown, insufficient vascular perfusion, complications from disease, and any changes from baseline status. Nurses not only monitor their patients for these risks, but also educate the patients and their caregivers how to manage these changes. It is critical for a patient’s recovery to adapt to these alterations whether it is thickening liquids to reduce aspiration after stroke or using a walker for stability after a hip surgery.

Ostomy Care Be familiar with the care of patient and patient education for all ostomies including bowel diversion ostomies, tracheal ostomies (tracheostomy), and enteral ostomies (gastrostomy tubes or buttons). Specifically, understand the techniques used to maintain patency of each, prevent complications of each, monitor intake and output (as appropriate) for each and to ensure proper placement and functioning. Stomas of these diversions should be pinkish-red in color without skin excoriation or breakdown.

Seizures Understand the difference between primary and secondary seizure disorder as well as the signs and symptoms of the many different types of seizures (absence, tonic, clonic, grand mal, etc.). Be familiar with your responsibilities for patient care during a seizure (patient safety, etc.) and proper postictal care, including proper documentation of the seizure.

Pulmonary Care Be familiar with all aspects of pulmonary hygiene care from simple techniques like coughing and deep breathing to more complicated procedures like vibration, percussion, and postural drainage for the removal of respiratory secretions. Understand how to use and teach incentive spirometry. Specifically, understand proper patient positioning during postural drainage, as well as proper technique and location for percussion and vibration.

Increased Intracranial Pressure Be familiar with the etiology, signs and symptoms, diagnosis, monitoring and care of patients with increased intracranial pressure. This includes all invasive and non-invasive monitoring (CT, ventriculostomy, etc.). Monitor for changes in consciousness, mental awareness, and physical signs such as pupil size changes and changes in motor skill. Also be familiar with treatments for increased intracranial pressure depending on the underlying cause and severity (pharmacologic management, procedures/interventions, etc.).

Post-Operative Care Be familiar with the principles of postoperative care for patients who have received conscious sedation and/or general anesthesia. Understand common postoperative complications (bleeding, pain, infection, etc.) and how to effectively monitor for them and intervene when appropriate to prevent them. Review the procedures for removing sutures and/or staples. Educate patients and their caregivers on any post-operative instructions such as signs of infection, wound disruption, medications, and dressing changes as indicated.

Evaluation Nursing care will always include an evaluation of the patient’s response to many of the therapeutic interventions discussed above (surgery, radiation therapy, medications, etc.). Evaluate the patient’s progress toward achieving his or her individual treatment goals. This process typically has five steps: collection of data on the current health status; analysis of the data; comparison of the analyzed data to the patient’s expected outcome; determining the success/failure of specific interventions using critical thinking and professional judgement; and deciding to continue.modify, or discontinue a specific plan of care based on its effectiveness or lack thereof.

Patient Education Also incorporate education into patient care to promote the patient’s progress toward his or her health goals. Be mindful of all intrinsic and extrinsic factors that can help or hinder the patient’s progress. For example, the presence of a complicating intrinsic factor, such as diabetes, will require special education and attention to improve the patient’s self-care and implementation of healthy lifestyle choices . Likewise, an extrinsic factor, like a strong family support system, should be maximized to help patients fully return to their optimal state of health. Educating patients on how to maximize their strengths and minimize weaknesses is critical to improving their overall outcome and health.

Fluids and Electrolytes Proper nursing care is essential with regard to a patient’s balance of fluid and/or electrolytes.

Signs and Symptoms of Imbalance Recognize the signs and symptoms associated with both excess and deficient fluid volume (hypovolemia and hypervolemia) and important electrolytes (sodium, potassium, calcium, magnesium, phosphate, and chloride). Understand the most likely cause of these imbalances given the current health state of the patient as well as the proper management of these conditions.

Fluid Hypervolemia is an excess of body fluids (plasma). Underlying causes can vary. Common causative factors include an increased sodium level ( hypernatremia), the inability to clear excessive fluids/supplementation effectively, and organ failure (heart, renal, and/or hepatic). Hypervolemic patients may demonstrate hypertension, dyspnea/shortness of breath, abdominal ascites, peripheral edema, distended jugular veins, and tachycardia. Monitor for bounding pulses and adventitious breath sounds (rales, crackles) throughout the exam. Hypovolemia is the deficit of body fluids and may occur in response to loss via hemorrhage, dehydration, vomiting, and diarrhea. Clinical signs of hypovolemia may include hypovolemic shock, decreased cardiac output, metabolic acidosis, multisystem organ failure, coma and death, if uncorrected. Weak, thready pulses, shallow breath sounds, sunken facial features, and poor skin turgor may be assessed during episodes of hypovolemia.

Electrolytes 

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Sodium: 135–145 mEq/L. Understand the most likely causes and manifestations of excess sodium (hypernatremia) and sodium deficits (hyponatremia). Understand the direct inverse relationship to fluid. Know the likely endocrine disorders that primarily manifest with sodium imbalances (diabetes insipidus, syndrome of inappropriate antidiuretic hormone/SIADH). Symptoms of hypernatremia include thirst, confusion, neuromuscular excitability, seizures, and coma. Symptoms of hyponatremia include nausea/vomiting, headache, confusion, fatigue, restlessness/irritability, muscle weakness, seizures, and coma. Potassium: 3.7–5.2 mEq/L. Understand the most likely causes and manifestations of excess potassium (hyperkalemia) and deficits (hypokalemia). Hypokalemia may occur in the event of diuretics, laxatives, corticosteroids, vomiting/diarrhea, hypomagnesemia, dialysis, insulin overdose, alkalosis, refeeding syndrome, and anorexia. Hyperkalemia may occur in the event of acute/chronic kidney disease, heparin, lithium, congestive heart failure, cirrhosis, sickle cell disease, insulin deficiency, acidosis, digoxin toxicity, and potassium supplementation. Peaked T-waves are often noted with hyperkalemia, whereas decreased T-wave amplitude is characteristic of hypokalemia. Neuromuscular changes are also common in the event of either hypo or hyperkalemia. Calcium: 8.5–10.6 mg/dL. Understand the endocrine feedback system responsible for calcium regulation. Know the most common pathophysiologic causes of calcium excess ( hypercalcemia) and deficits (hypocalcemia) as well as common medications that can trigger calcium imbalance (thiazides, lithium, phenobarbital, corticosteroids, etc.). Symptoms of hypercalcemia include fatigue, depression, confusion, anorexia, nausea, constipation, renal tubular defects, polyuria, short QT interval, and arrhythmias.

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Symptoms of hypocalcemia include fatigue, cramping, weakness, paresthesias, altered mental status, hypotension, prolonged QT interval, and arrhythmias. Magnesium: 1.7–2.2 mg/dL. Understand the underlying endocrine and disease processes that commonly affect magnesium levels along with medications that can potentially trigger hypermagnesemia (antacids and laxatives ) as well as hypomagnesemia (diuretics, antibiotics, cisplatin, PPIs , etc.). Symptoms of hypermagnesemia include neuromuscular symptoms, muscle weakness, nausea/vomiting, shortness of breath, cutaneous flushing, hypotension, bradycardia, and hypocalcemia. Symptoms of hypomagnesemia include muscle cramps, hyperreflexia, depression, generalized weakness, anorexia, vomiting, convulsions, apathy, hypertension, ventricular arrhythmia, and death. Phosphate: 0.81–1.45 mmol/L. Be able to identify the disease processes, medications, and endocrine dysfunctions that produce phosphate imbalances. Be able to identify the clinical manifestations of both hypo and hyperphosphatemia. Symptoms of hyperphosphatemia include muscle cramps, numbness around the mouth, bone and joint pain, weak bones, rash, and itchy skin. Symptoms of hypophosphatemia include weakness, trouble breathing, bone fractures, anorexia, tooth decay, and irritability. Chloride: 97–107 mEq/L. Understand the main metabolic causes for low chloride levels or hypochloremia (metabolic alkalosis, respiratory acidosis, hyponatremia, etc.), as well as disease processes that can produce it (cystic fibrosis, etc.). Be able to recognize the clinical signs and symptoms of hypochloremia including fluid loss, dehydration, weakness, fatigue, increased work of breathing, and diarrhea or vomiting. Increased chloride levels, or hyperchloremia, can be the result of numerous disease processes (renal disease, diabetes, hyperparathyroidism, etc.) and through fluid losses (diarrhea, dehydration, diuresis). Be familiar with the common clinical manifestations of hyperchloremia such as fatigue, muscle weakness, excessive thirst, dry mucous membranes, and hypertension l.

Pathophysiology Application Caring for a patient with either fluid or electrolyte imbalances or both requires you to carefully consider and anticipate both the pathophysiologic responses to the condition and its treatment. In addition to recognizing the signs and symptoms of these disorders, you must also be aware of the risk factors for their development. This should be an important part of your overall assessment and evaluation.

Patient Care Management Care of hypervolemia generally includes fluid/sodium restriction and diuretic medications to clear excess fluid. In hypovolemia, treatment is directed at correction of the underlying cause and is dictated by the patient’s severity. This may range from intravenous fluid supplementation to proper patient positioning (Trendelenburg), plasma expanders, and the administration of blood and blood products.

Management of a patient with electrolyte imbalance(s) will rely heavily on correcting the underlying cause (when applicable) along with replacement of depleted electrolytes when indicated and interventions to deplete excesses when applicable. Some of these management scenarios can include emergent interventions, so be familiar with these (cardiac manifestations, seizures, etc.).

Evaluation of Patient Response to Treatment As with any treatment given, ongoing patient evaluation will be necessary to ensure patient safety and effectiveness. This will include monitoring for clinical signs and symptoms of normalization of fluids and electrolytes as well as over or undercorrection. Serial lab draws and values will be utilized as well. Certain lifestyle modifications (diet, fluid restriction, medications, etc.) may be necessary for long-term maintenance.

Hemodynamics The care of patients who require hemodynamic monitoring is complex. Understand the unique pathophysiologic changes of each patient, as well as the basic aspects of care for patients that require routine and advanced hemodynamic monitoring and intervention.

Patient Assessment for Decreased Cardiac Output Understand the physiological principle of: cardiac output (CO) = stroke volume (SV) x heart rate (HR). Normal cardiac output of 4 to 8 L/min is necessary to meet the body’s physiological demands. When this falls short, impairment (mild to severe) will occur. Be familiar with the clinical signs of diminished cardiac output such as diminished peripheral pulses, hypotension, hypoxia, and reduced organ/tissue perfusion (and its sequelae).

Cardiac Rhythm Strip Abnormalities Being able to read a cardiac rhythm strip and identify abnormalities is essential for prompt identification and intervention of potentially fatal arrhythmias. Know the proper steps for reading a rhythm strip and the proper timing for all of the waveforms, intervals, and complexes. U...