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

Body System Alterations

Identify patients at risk for potentially dangerous and life-threatening alterations to various body systems. Good nursing care in this area plays a key role in the reduction of risk potential.

Patient Potential

Numerous conditions may place a patient at increased risk of morbidity and mortality. Identify patients at risk for aspiration such as patients on tube feedings, sedated patients, and those with swallowing difficulties (i.e., developmental delay, stroke). Be aware that several conditions can predispose a patient to skin breakdown and decubitus ulcers such as immobility, fecal and/or urinary incontinence, poor neurologic sensory function, and poor nutritional status. Be aware of the conditions that place patients at increased risk for insufficient vascular perfusion such as diabetes, hypotension, postoperative recovery, and decreased mobility.

This list of conditions is not exhaustive. Developing a nursing assessment that is comprehensive and detailed will help to identify potential areas that may require intervention. Be aware of specific treatments and care that nurses may be able to provide for patients at risk.

Patient Education

An important part of nursing care plan for these patients will be to provide the proper patient education and self-care strategies. Patient activity and ability to participate impact nursing care plans. For example, an immobile patient should be educated on the importance of passive range of motion exercises and frequent position changes to prevent contractures.

The nurse should also be able to educate patients on specific methods to prevent complications due to a particular disease process and or diagnosed illness. For example, discussing the importance of proper foot care and how to perform it daily to a patient with diabetes.

Patient Data Use

Remember that the nurse will not only need to compare current patient data with baseline data to determine if therapeutic goals are being met, but will also need to monitor data to assess for potential complications and side effects of therapy. The ability to closely monitor data may also aid in the diagnosis of new conditions or illness that may arise during the course of care. This applies to vital signs, laboratory testing, imaging, other diagnostic testing and patient output measurements (nasogastric tube, emesis, stool, and urine).

Complications

Patients are at risk for complications with almost any diagnostic test, treatment and/or procedure. Generally speaking, the more invasive any of these are, the greater the risk. Use nursing knowledge and develop a set of skills for caring for these patients.

Assessment of Patient

Always assess patients for abnormal responses to tests, treatments, or interventions. This will require knowledge of the most common potential complications and vigilant monitoring for more subtle signs of abnormalities or rare complications.

Complication Prevention

Many complications of therapy can be prevented by nursing intervention. For example, if a patient is undergoing a tube feeding, the nurse should keep the head of the bed elevated to the proper angle (>30 degrees) to reduce the risk of aspiration. Another example, if a patient has an immobile extremity that is casted, the nurse should perform schedule assessments of the limb for appropriate circulation and neurologic function to monitor for changes such as compartment syndrome. Nurses are responsible for educating patients on signs and symptoms of potential complications and when to report them.

Patient Care

Another important piece of complication prevention includes understanding the basic principles of nursing care for those at risk for complications. For example, using proper aseptic technique when caring for peripheral and central venous access lines or raising the side rails of the bed for a patient who may be at an increased risk of falls, etc. In most cases, the nurse will need to apply knowledge of nursing procedures to take the proper precautions.

Monitoring

The nurse will need to focus the assessment on the potential complications following diagnostic testing, procedures, or treatments. If the patient has had an invasive test or surgery, the nurse should frequently monitor for signs of bleeding (hemodynamics, urinary output, shock) and wound site changes (drainage, infection, closure). If the patient has tubing, such as nasogastric tube, chest tube, or artificial airway, know the proper schedule of assessment to maintain patency and proper placement. In the case of endotracheal tubing, this may include performing suctioning.

Procedures

Often, the nurse is responsible for performing procedures that help reduce the risk of complications. This may include placement and removal of nasogastric tubes, urinary catheters, and peripheral venous access line.

In some cases, maintenance of external tubing may include additional nursing intervention. Nasogastric tubes, urinary catheters, and peripheral venous access may need routine or interventional flushing with appropriate solutions (normal saline, sterile water, etc.) to maintain patency. Chest tubes may need to be stripped to maneuver drainage and avoid blockage.

Special Circumstances

Some procedures, such as electroconvulsive therapy (ECT), require special nursing precautions to protect a patient from dangerous complications. In ECT, the nurse will need to be prepared to teach the patient about these special considerations and implement them while monitoring the patient for potential complications that may occur during and after the procedure. The nurse should assess the patient’s airway (ensure patency) and understand side effects such as confusion, memory loss, nausea, headache, jaw pain, and muscle aches.

Intervention

In many cases, the nurse will need to provide direct intervention in order to prevent and treat potential medical complications. Common complications a nurse may see include issues within the circulatory system (thrombosis, hemorrhage, all forms of shock, etc.), concerns for aspiration (bottle feeding, foreign bodies, swallowing disorders, tube feedings, etc.), and neurologic complications due to tight dressings/casts or foot drop due to immobility.

Evaluation

Lastly, the nurse will need to evaluate and document a patient’s response to any procedure and/or treatment. This includes the intended effect as well as unintended side effects or complications. Objective data, such as laboratory results and imaging, along with the patient’s subjective reports are both required in a thorough assessment.

Surgical Procedures and Health Alterations

Patients undergoing a surgical procedure will require special consideration and nursing care to minimize, prevent, and respond to common complications.

Monitoring

Apply knowledge of pathophysiology when caring for the post-surgical patient. Know the signs of thrombocytopenia, infection, inadvertent puncture of a major blood vessel, pneumothorax, and hemorrhage. This will require the nurse to understand the etiology of potential complications and the specific risk factors for development.

Evaluation

Post-operative nursing care begins prior to surgery. Patients will require special education and instruction on proper postoperative care and interventions to prevent complications. Nursing interventions, such as preventing aspiration (elevated head of bed, monitoring diet orders), preventing venous stasis (Ted hose and sequential devices), and increasing mobility and activity to prevent immobility, should be addressed in all patients. Always document the nursing interventions provided and their effectiveness.

System-Specific Assessments

Be familiar with several system-specific assessments for patients that have undergone procedures. Understand the importance of how abnormalities may affect healing or patient outcomes, so that appropriate care plans and interventions can be implemented.

Types of Assessments

System-specific assessments are crucial to understanding expectations, changes, and management of patients health needs. Here is a list of some of the more important assessments:

Abnormal Peripheral Pulses— Assess the major peripheral pulses and note their strength, fullness, and regularity. Be familiar with the appropriate rating scale for documentation. Also know when and how to use a Doppler system to aid in pulse assessment.

Abnormal Neurological Status— Assess the level of consciousness, mobility, muscle strength, deep tendon reflexes, and cranial nerve function. Be familiar with the proper documentation for each.

Peripheral Edema— Understand the physiologic settings in which peripheral edema occurs as well as how to properly assess it and document the findings.

Hypoglycemia or Hyperglycemia— Be able to recognize and understand the clinical signs and symptoms of hypo and hyperglycemia, including ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome (HHNS).

Factors of Delayed Wound Healing— Be able to identify potential factors that may impact or delay wound healing including: age, nutrition, cigarette/alcohol use, medications, and chronic health conditions.

Trends and Changes in Condition— Use ongoing assessments to monitor for trends or changes in the patient’s condition. Be able to identify appropriate times to intervene and with which specific intervention. An example of this includes deciding between notifying the attending practitioner versus performing a more focused assessment for more information versus applying an appropriate nursing intervention.

Risk Assessment— Performing assessments and making nursing diagnoses are an essential part of the risk assessment process. For example, patient findings of reduced muscle strength and mobility with impaired sensory function alert the nurse to a potentially increased risk of falls. Likewise, a patient with limited mobility will be at an increased risk of skin breakdown. Nursing assessment will directly shape the plan of care and guide interventions to prevent further illness or morbidity.

Focused Assessment— Be able to perform, interpret, and act upon a more focused assessment. An example would be a patient with a cardiac condition who requires a more extensive exam of heart sounds,as well as evaluation of EKG findings and pertinent laboratory findings (cardiac enzymes, etc.).

Always remember to perform careful reassessment of patient conditions/status when indicated.

Therapeutic Procedures

Apply nursing knowledge to the care of patients undergoing various therapeutic procedures in order to reduce the risk of potential negative outcomes.

Anesthesia Recovery Assessment

Know how to assess patients recovering from local, regional, and/or general anesthesia. This also includes conscious sedation. Understand how these various types of anesthesia are employed (intravenously, inhaled, IM, etc.) and when they are used. Be familiar with the unique risks that each presents and what tools are used to continuously monitor a patient undergoing each type. Collect vital signs and perform assessments to determine the level of consciousness, cognition, and orientation. Nurses should monitor for common effects of anesthesia including nausea and vomiting, sore throat, postoperative delirium, muscle aches, itching, hypothermia, difficulty urinating, hematoma. More severe complications of anesthesia include postoperative delirium/cognitive dysfunction and malignant hyperthermia (general anesthesia) and pneumothorax and nerve damage (intravenous, local, or regional anesthesia). Be able to recognize these potential complications and identify when urgent intervention is required.

Patient Education

Patient education consists of informing patients of all planned procedures and treatments; ensuring that informed consent is obtained for appropriate therapies; identifying healthcare proxies; and providing instructions for pre/post procedure care, care after discharge, and coordination of home care.

Before, During, and After Procedure

Nursing care before the procedure ensures that a patient is both physicallyand psychologically prepared to undergo the planned treatment. The nursing assessment helps to determine the appropriateness of the treatment for the patient’s condition. During a procedure or treatment, continuous monitoring of a patient’s physiologic status(vitals, blood pressure, pulse oximetry, etc.) is important. These physical assessments will continue after the conclusion of the procedure along with more focal assessments involving the treated organ system.

About Aftercare at Home

Specific instructions and education should be given to all patients upon discharge after a procedure and/or treatment. This should begin as soon as the patient is admitted to the facility. Verbal discussions, visual learning aids, written materials and step-by-step instructions are just a few of the methods nurses should be familiar with to accomplish this teaching. Examples include teaching/showing a patient how to care for a tracheostomy (suctioning, hygiene, etc.) or properly care for an ostomy (bag emptying/changes, skin care, etc.). Tailoring the educational approach based on each patient’s cognitive needs and abilities is required in every patient encounter.

Patient Monitoring

In addition to the topics in the discussion above, the nurse will need to perform a variety of patient monitoring assessments specific to the patient’s needs. For example, a patient with a fracture will need evaluation of alignment, intact circulatory and neurologic function prior to, during, and after the application of a cast.

For a patient undergoing conscious sedation, a registered nurse who is specially trained (a nurse anesthetist) will be responsible for the administration, monitoring, and recovery phases of patient care as is specified by the institution’s policies and governing bodies that oversee this specialized form of nursing (JCAHO, AAMSN, etc.).

Monitoring patients during and after procedures requiring moderate sedation may involve a little more attention from the nurse. Patients should have frequent monitoring of vital signs, side effects (described earlier in this document), as well as level of cognition to assess when the patient can return to normal activities. Patients with continued effects from sedation, including delirium and muscle weakness, should be monitored closely for injury, such as falling. Assess the patient closely to monitor for subtle changes in vital signs or mental status that may indicate more serious complications (delirium, hyperthermia, hypotension, etc.).

Precautions

Be familiar with special nursing care and interventions that involve precautions against further injury or illness. This is especially important when caring for patients with musculoskeletal injuries. Often, special techniques or assistive devices are used, such as the log-rolling technique to maintain spinal alignment or an abduction pillow to prevent further injury in a patient with a hip fracture.

Device Monitoring

The nurse will need to know how to continuously monitor various therapeutic devices for effective functioning. These may include chest tubes, drainage tubes, various wound drainage devices, and continuous bladder irrigation. Be familiar with common problems associated with each, and understand how to troubleshoot to determine the underlying cause of a malfunction. Know when it is appropriate to remove and replace a device all together.