Page 1 - Physiological Adaptation Study Guide for the NCLEX-RN® Exam
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.
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.
The following are some of the more important clinical scenarios in which you will be required to perform these functions:
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.
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.
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.
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.)
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.).
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.
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.
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.
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.
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.
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.
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.
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.).
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.
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.
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.