Page 2 - Reduction of Risk Potential Study Guide for the NCLEX-PN Exam

Monitoring the Client

Alterations in Body Systems

While monitoring the client, the LPN will be looking for alterations in body systems. These may be expected due to the client’s condition or disease process or may be unexpected and require intervention.

Prenatal

For a pregnant client, the LPN should be able to identify signs or symptoms of potential prenatal complications. Some of the common complications are gestational diabetes and hypertension, ranging from mild hypertension to mild preeclampsia to severe preeclampsia to HELLP syndrome.

Circulation

The client’s circulatory status should be frequently assessed, and for some clients, there may be an increased risk of insufficient blood circulation, which may be related to comorbid health conditions such as diabetes or an immobilized limb.

circulatory checks— When assessing the client’s circulatory status, the LPN should be able to perform circulatory checks. This will include checking for a pulse in the area (manually or by doppler), assessing the temperature and color of the area, and checking for capillary refill.

compression devices— For clients at risk for insufficient blood flow, compression devices may be ordered. These include compression stockings (TED hose) and sequential compression devices (SCDs). The LPN should apply these and check for proper use when they are ordered.

Neurological

The LPN will also check the client’s neurological status. Changes to the neurological status may be more subtle or subjective as opposed to objective lab results, and thus special attention should be paid to minor changes. The assessments will include the client’s level of consciousness, orientation, and muscle strength.

recognize change— It is critical to recognize any change in the client’s neurological status, as it may indicate a more serious underlying issue. As with vital signs, it is important to compare the findings to the client’s baseline. For example, a client who is confused is less alarming if the client has a disease process where he or she is regularly confused.

neurological checks— The LPN may be responsible for performing neurological checks on clients. This may include assessing the client’s level of consciousness or orientation (orientation to place, person, and time). Additionally, muscle strength or cranial nerves may be physically assessed.

Elimination

Monitoring a client’s elimination habits is also important. Just as inadequate intake can have an impact on the client’s condition, inadequate output can also have an effect.

Urinary Retention

Urinary retention is an accumulation of urine in the bladder that is unable to be naturally emptied by the client. There are a number of reasons why the client may not be able to empty the bladder. When urinary retention is suspected, the nurse can check for the volume of urine being retained using palpitation, a bladder scan, or ultrasound.

Output

In addition to urine output, the LPN should monitor other sources of client output and compare it to the client’s baseline. Other common sources of output may be nasogastric emesis and stool. If clients have tubes or drainage devices, the output from these devices should be monitored as well.

Activity Level

The LPN should monitor the client’s activity level and be on alert for complications that may be associated with the activity level coupled with the client’s illness or disease. The LPN should reinforce teaching on the ideal activity level for the client’s condition. For example, a client with diabetes mellitus and insufficient blood flow to the lower extremities may be advised to take caution with excessive physical activity and perform appropriate foot care.

Potential for Complications

At all times, the LPN should be on alert for potential complications. It is important to identify these potential complications along with the appropriate actions to take.

Diagnostic Tests, Treatments, and Procedures

When the client is at risk for potential complications, there are a number of diagnostic tests that may be performed, treatments that may be administered, and procedures that may be completed.

General

The client’s risk for complications should be evaluated with respect to the disease processes and client’s condition.

Identify client risk— Clients should be evaluated for their risk of potential complications. Most hospitalized clients are at increased risk of infection related to the prevalence of nosocomial infections. This is particularly relevant to clients with a compromised immune system.

Prevent— When possible, the LPN should implement measures to prevent a complication of the current condition or complications during a procedure. It is also important to reinforce teaching to prevent complications after tests, treatments, or procedures. These may include circulatory complications, seizure, aspiration, or a potential neurological disorder.

Identify client response— In the event of a diagnostic test, treatment, or procedure, the LPN should monitor the client’s response. The LPN should be able to identify whether the response is expected or unexpected.

Notify— When the client exhibits a sign of a potential complication, such as fever, hypotension, limb pain, or thrombus formation, the primary healthcare provider should be notified as soon as it is safe to do so.

Suggest— ** Based on the client’s response to the diagnostic test, treatment, or procedure, the LPN should feel comfortable suggesting a **change in the intervention based on the client’s response. This may include ceasing treatment or switching medication.

Specific

There are a number of common, specific situations and conditions that may warrant additional steps, and the LPN should be knowledgeable of the appropriate next steps.

Tube patency— For a client with any type of tube, such as a chest tube or tracheostomy tube, the LPN should monitor for tube patency. A blocked tracheostomy tube is an emergency situation that will require suctioning or tube replacement.

Care for ECT— When the LPN is caring for a client who is undergoing electroconvulsive therapy (ECT), the LPN may be responsible for preparing the client for the treatment, monitoring the client, and reinforcing teaching related to the treatment.

Incident management— There are a number of situations that require appropriate follow-up according to the facility’s policies and procedures. These include, but are not limited to, a fall, client elopement, or medication error.

Suction— For a client with a nasogastric (NG) tube, the LPN may be required to monitor continuous or intermittent suction. The LPN should monitor for patency and appropriate placement during and after suctioning.

Oxygen saturation— The client’s oxygen saturation will be monitored routinely, and during certain procedures, it should be monitored closely. For example, when an endotracheal or tracheostomy tube is suctioned, the client’s oxygen saturation may decrease, and the suctioning may need to be paused or discontinued.

Surgical Procedures and Health Alterations

When clients are undergoing surgical procedures, there are a number of health alterations and potential complications that the LPN may be required to monitor for or reinforce teaching. This includes ensuring the client is appropriately prepared for surgery and assisting in the client’s response to the procedure and subsequent recovery.

Prior Care

Prior to the surgical procedure, the LPN may be required to provide care to assist the client in preparing for surgery. This may include medication administration, maintaining an NPO status, and/or removing hair using clippers in the operative area.

Intraoperative Care

In the intraoperative phase, the LPN may provide care by maintaining the sterile field, positioning the client for surgery and/or providing operative observation. Special attention should be paid to client positioning, as the client will be unable to voice discomfort while under anesthesia.

Identify Client Response

After surgery, the LPN should monitor the client’s response to the procedure along with response to any resulting health alterations. The LPN should be able to identify if the client’s response is expected or unexpected. If unexpected, the primary healthcare provider may need to be notified.

Education

The LPN should reinforce any teaching related to the procedure to decrease anxiety. Additionally, the LPN should reinforce teaching that may prevent surgical complications. For example, cough and deep breathing exercises should be encouraged to promote respiratory health, and elastic stockings are beneficial in preventing DVTs.

Suggest Change

When the client does not seem to be responding appropriately to a procedure, the LPN should be prepared to suggest a change in intervention. The primary healthcare provider should be contacted to discuss any changes suggested to ordered medications or treatments.

Therapeutic Procedures

The client may be undergoing a number of therapeutic procedures while in the LPN’s care. These procedures can include increased risks for varying client responses and/or complications that the LPN should be knowledgeable about and prepared for.

Before and During

Before and during the procedure, the LPN may be called on to prepare the client for the procedure, assist physically with the procedure, and/or reinforce client teaching as it relates to the procedure.

Client education— When the client is undergoing a treatment or procedure, there may be an increased level of anxiety. The LPN can reinforce client teaching to aid in decreasing this anxiety.

Assisting— During the procedure, the LPN may be asked to assist with the performance of a diagnostic or invasive procedure. The LPN should follow the facility’s policies and procedures to determine what actions are appropriate and within the scope of his/her care.

Specific Procedures

In addition to generally reinforcing education or assisting with procedures, there are specific procedures the LPN may be asked to perform. These may range from inserting an intravenous line to removing an indwelling urinary catheter.

Urinary catheter— For clients with urinary retention, the LPN may be asked to insert a urinary catheter. This should be performed as a sterile procedure to decrease the risk of a urinary tract infection.

Central venous catheter— Clients who do not have suitable peripheral veins for the ordered treatments may have a central venous catheter. The LPN may be asked to maintain this and should ensure sterile technique is observed when necessary. Note that LPNs are not allowed to administer medications through a central venous catheter.

NG tube— For clients at risk for aspiration, the LPN may be required to insert and/or maintain a nasogastric tube. When the risk is resolved, the LPN may be asked to remove this tube.

IV catheter— For IV fluid or medication administration, the LPN will be required to maintain a patent peripheral intravenous (IV) catheter. The LPN may assess the IV site and may flush a peripheral IV line in preparation for a RN to administer medication. However, the LPN may not administer medication through an IV line. Prior to discharge, the LPN can remove this catheter.

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