Page 2 - Physiological Adaptation Study Guide for the NCLEX-PN Exam

Other Situations

Unexpected Response to Therapies

While it is important to know the expected responses to therapies, the LPN should also be aware of unexpected responses to certain therapies. Some may be more common than others.

General Procedures

Generally, the LPN should look for signs of an unexpected response to therapy. This may be a known potential side effect or reaction, or it may be an abnormal response. Depending on the reaction, there may be an appropriate intervention to counter the unexpected response. Also, the therapy may or may not be continued based on the client’s response.

Recognize and Report

When the client is undergoing a type of therapy, which may include drug administration or a procedure, the LPN should observe the client’s condition. If there is a change in his or her condition that is not an expected response to the therapy, the primary healthcare provider should be notified.

Intervene

When there is an unexpected negative response to therapy, the LPN should intervene if necessary. For example, if there is unexpected bleeding during a routine dressing change, there may be a medication or type of dressing prescribed for the client to combat this.

Document

In the event of an unexpected response to therapy, this should be thoroughly documented. In most cases, the client is likely to exhibit the same unexpected response if the therapy is repeated, so it is imperative that the documentation makes the care team aware of this.

Promote Recovery

The LPN should promote recovery even when the client has an unexpected negative response to therapy. This may include an additional therapy to counter the negative response or a replacement therapy. For example, if the client develops a urinary tract infection from a catheter placement, he or she may receive antibiotics to combat the infection.

Intravenous (IV) Line Infiltration

When the client has an IV line inserted or has an existing IV line, the LPN should be able to identify and treat an IV line infiltration. This can be caused by improper placement of the line or dislodgement of the catheter. The client may complain of swelling, burning, or pain at the IV site. In the event of infiltration, the IV catheter should be removed and the limb elevated, in most cases. Note that administering IV medications is not part of the LPN’s scope of practice; however, LPNs can be responsible for performing saline flushes to maintain patency of an IV line and regular assessments of the line site.

Medical Emergencies

The LPN will likely encounter medical emergencies both inside and outside of the healthcare setting. He or she should be aware of the most appropriate actions to take along with the facility’s policies and procedures for emergencies.

Emergency Care

In the event of an emergency, the LPN should refer to his or her knowledge of the appropriate interventions along with the policies and procedures of the facility. The emergencies that the LPN may encounter include an unconscious client who may or may not be breathing, wound disruption after a procedure, or abnormal bleeding.

Cardiopulmonary Emergency

The LPN should be prepared to respond and intervene in a life-threatening situation. If the client is unconscious and not breathing, cardiopulmonary resuscitation will likely be required. The LPN should prioritize the safety of the client and be sure to activate the facility’s emergency response system.

Wound Disruption

Following a surgical procedure, particularly after an open abdominal procedure, the LPN should be on alert for a wound disruption that may require emergency care. The likely disruptions are a dehiscence, where the incision has separated, and/or evisceration, where, in addition to dehiscence, an internal organ protrudes externally.

Procedures

Most facilities will have policies and procedures in place for emergency situations. The LPN should ensure they are familiar with these so that in the stressful event of an emergency, they are comfortable with interventions necessary.

Notify

In the event of an emergency, the primary healthcare provider should be notified. There may be an emergency response system at the facility that, when activated, will notify the primary healthcare provider.

Recommend

When emergency treatment is provided, the LPN should monitor the client’s response to these interventions. If the client does not seem to be responding well to these interventions, there may be recommended changes to the treatment that the care team should consider.

Review and Document

Following an emergency intervention, when the client has stabilized, it will be helpful for the team to review the situation and client’s response. Additionally, the interventions and responses should be fully documented so that the care team is aware of when vital signs like respirations and pulse were restored and what intervention was most effective.

Teach

It is important to make the client aware of what is happening if they are conscious during an emergency in order to decrease the client’s stress and anxiety. When the client has stabilized, the LPN should reinforce the teaching of these interventions to the client and the client’s family or caregiver.

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