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Study guide · Physiological Integrity

Physiological Adaptation

11 to 17% of the exam · 24 activity statements

Physiological Adaptation is care of clients with acute, chronic or life-threatening physical health conditions: drains and devices, emergencies, ventilation and oxygenation, dialysis, telemetry, fluid and electrolyte balance, perfusion and the complications that follow. The NCLEX tests it by asking you to read a device, a rhythm or a trend, decide which finding is dangerous, and choose the first safe action an entry-level nurse can take before calling for help.

A study feature written by ExamDragon, not part of the real exam. Each heading is one of the Related Activity Statements NCSBN lists for this category (24 of them), in our words; NCSBN's wording is in its Test Plan.

At a glance

Physiological Integrity
11 to 17%

of the exam (NCSBN's range)

Activity statements
24
Key terms
14

What this guide covers, statement by statement

  1. Monitor and look after drainage devices, such as chest tubes or wound drains
  2. Carry out emergency care procedures
  3. Monitor and care for clients on mechanical ventilation
  4. Do wound care and change dressings
  5. Assist with invasive procedures, such as a thoracentesis
  6. Give care and teaching for ostomies, such as a tracheostomy
  7. Give care after surgery
  8. Carry out and manage peritoneal dialysis
  9. Suction the client's airway
  10. Help clear the lungs, for example with incentive spirometry
  11. Manage care for a client on cardiac telemetry
  12. Manage care for a client with poor breathing or oxygenation
  13. Keep the client's body temperature in the right range
  14. Start and monitor phototherapy
  15. Manage care for a client with a pacemaker or similar device
  16. Monitor and look after arterial lines
  17. Manage care for a client with fluid or electrolyte imbalance
  18. Manage care for a client with changes in hemodynamics, perfusion or clotting
  19. Judge whether treatment is working for an acute or chronic condition
  20. Identify the disease process behind an acute or chronic condition
  21. Manage care for a client on hemodialysis or continuous renal replacement
  22. Spot signs of complications and act on them
  23. Teach the client about an acute or chronic condition
  24. Monitor and look after internal monitoring devices, such as an intracranial pressure monitor

1Monitor and look after drainage devices, such as chest tubes or wound drains

  • Chest tube: keep the drainage system upright and below the level of the chest, with tubing free of kinks and dependent loops; never clamp it routinely or for transport.
  • Tidaling (water rising with inspiration and falling with expiration in a spontaneously breathing client) in the water seal chamber is expected; it stops when the lung has re-expanded or the tubing is blocked.
  • Continuous bubbling in the water seal chamber means an air leak: check the dressing and every connection from the client toward the unit; gentle continuous bubbling in a wet suction control chamber is expected.
  • If the tube disconnects from the system, submerge its end 1 to 2 inches (2 to 3 cm) in sterile water; if it falls out of the chest, cover the site with a sterile occlusive dressing taped on three sides, then notify the provider.
  • Surgical drains (closed bulb or spring evacuators): empty when half full, compress to restore suction, measure and record amount and color; report a sudden rise in bright red output.
  • Negative pressure wound therapy: keep the seal airtight at the prescribed pressure; if therapy stops and cannot be restored within about 2 hours (per protocol), remove the foam and apply a moist dressing, and watch for bleeding, especially in clients on anticoagulants.
  1. In practiceA client with a right chest tube after a lobectomy has continuous vigorous bubbling in the water seal chamber that was not present an hour ago. The nurse checks the insertion site dressing and tightens a loose connector near the client, then reassesses the chamber, because an air leak in the system must be found before assuming a leak from the lung.
  2. Where questions turnClamping the chest tube when bubbling appears or when the client walks, which can cause a tension pneumothorax.
Practise this activity

2Carry out emergency care procedures

  • Check responsiveness and breathing while checking a carotid pulse for no more than 10 seconds; if no pulse, call for help and an AED and start compressions.
  • Adult compressions: at least 2 inches (5 cm) but not more than 2.4 inches (6 cm) deep, 100 to 120 per minute, full chest recoil, interruptions under 10 seconds; 30 compressions to 2 breaths without an advanced airway.
  • Child depth is about 2 inches (5 cm) and infant about 1.5 inches (4 cm); with two rescuers the ratio for a child or infant is 15 to 2.
  • Defibrillate as early as possible for ventricular fibrillation or pulseless ventricular tachycardia, then resume compressions immediately for 2 minutes before the next rhythm check; asystole is not shocked.
  • Conscious adult with a complete airway obstruction: 5 back blows alternated with 5 abdominal thrusts (chest thrusts in late pregnancy or when the abdomen cannot be encircled) until the object is expelled or the client becomes unresponsive, then start CPR; for an infant, 5 back blows alternated with 5 chest thrusts, never abdominal thrusts.
  • Anaphylaxis: epinephrine intramuscularly in the mid-outer thigh is the first drug, with airway support, oxygen and the client lying flat with legs raised unless breathing is easier sitting.
  1. In practiceA nurse finds a client on a rehabilitation unit unresponsive and not breathing, with no carotid pulse after 8 seconds. The nurse calls for help and the AED, starts compressions at 100 to 120 per minute, and attaches the AED as soon as it arrives, because early compressions and early defibrillation decide survival.
  2. Where questions turnDelaying compressions to obtain vital signs, start an IV or wait for the provider instead of beginning CPR and getting the AED.
Practise this activity

3Monitor and care for clients on mechanical ventilation

  • High pressure alarm: something resists airflow (secretions, coughing, biting the tube, kinked tubing, bronchospasm, pneumothorax); assess the client, suction if needed, and straighten tubing.
  • Low pressure or low volume alarm: air is escaping (disconnection, cuff leak, dislodged tube); check connections from the client to the ventilator first.
  • If you cannot find the cause of an alarm or the client is in distress, disconnect and ventilate with a bag-valve device on 100% oxygen and call the respiratory therapist; never silence an alarm without assessing.
  • Ventilator-associated pneumonia prevention: head of bed 30 to 45 degrees, oral care with toothbrushing, daily sedation interruption and readiness-to-wean assessment as prescribed, and hand hygiene.
  • Check tube position (the centimeter mark at the lip or teeth), bilateral breath sounds and cuff pressure (commonly kept about 20 to 30 cm H2O); positive end-expiratory pressure can lower blood pressure.
  • A client on a ventilator cannot speak: give a means to communicate, and keep a bag-valve device and suction at the bedside.
  1. In practiceA client on mechanical ventilation has a high pressure alarm, is coughing and has coarse crackles over the trachea. The nurse suctions the endotracheal tube using sterile technique and the alarm clears, because secretions are the most common cause of rising airway pressure.
  2. Where questions turnSilencing the alarm or calling the provider first instead of assessing the client and, if the cause is not found, ventilating manually.
Practise this activity

4Do wound care and change dressings

  • Assess before and after: size, depth, wound bed color, drainage amount and type, odor, the surrounding skin and pain; premedicate for pain before a painful dressing change.
  • Clean from the least contaminated area to the most contaminated, using a new swab for each stroke; for an incision, clean along the line and then outward.
  • Keep the wound bed moist and the surrounding skin dry; do not pack tightly, and count any packing removed and inserted.
  • Signs of infection: increasing redness, warmth, swelling, purulent drainage, odor and fever; report them.
  • Dehiscence (the edges separate) and evisceration (organs protrude): stay with the client, cover with sterile dressings moistened with sterile normal saline, place in low Fowler's with knees bent, keep NPO and notify the surgeon immediately.
  • Pressure injury prevention: reposition at least every 2 hours in bed, use pressure-redistributing surfaces, manage moisture and support nutrition and protein intake.
  1. In practiceOn postoperative day 5, a client with obesity coughs and says something gave way; the nurse sees loops of bowel through the abdominal incision. The nurse stays with the client, covers the wound with sterile saline-moistened dressings, lowers the head of the bed with knees flexed and has a colleague call the surgeon, because the exposed organs must stay moist and tension on the wound must fall.
  2. Where questions turnTrying to push eviscerated organs back in or covering them with a dry dressing.
Practise this activity

5Assist with invasive procedures, such as a thoracentesis

  • The provider explains the procedure and obtains informed consent; the nurse may witness the signature, confirms the client understands and reports doubts before sedation is given.
  • Take part in the time-out (right client, procedure and site), gather equipment, keep the sterile field and monitor vital signs, oxygen saturation and comfort throughout.
  • Central line insertion or removal in the neck or chest: position supine or in Trendelenburg as prescribed and have the client perform the Valsalva maneuver to prevent air embolism; tip placement is confirmed (for example by chest x-ray) before first use.
  • Thoracentesis: the client sits upright leaning forward over a bedside table; watch for dyspnea, falling saturation, coughing or chest pain that may signal pneumothorax, and expect a chest x-ray afterward.
  • Bronchoscopy: NPO before; afterward keep NPO until the gag reflex returns, and watch for stridor, bleeding and breathing difficulty.
  • Suspected air embolism (sudden dyspnea, chest pain, hypotension): clamp the line, place the client on the left side with the head down, give oxygen and call for help.
  1. In practiceAfter a bronchoscopy with moderate sedation, a client asks for a drink of water. The nurse checks the gag reflex first and keeps the client NPO until it returns, because the throat was anesthetized and the client could aspirate.
  2. Where questions turnPositioning a client for central line insertion or removal with the head up, which raises the risk of air embolism.
Practise this activity

6Give care and teaching for ostomies, such as a tracheostomy

  • Stoma assessment: a healthy stoma is moist and red to pink; a pale, dusky, purple or black stoma means poor blood flow and is reported at once.
  • Empty the pouch when one third to one half full; size the skin barrier opening to fit about 1/16 to 1/8 inch (2 to 3 mm) larger than the stoma to protect the skin.
  • An ileostomy drains liquid output continuously, so teach fluid intake and watch for dehydration and electrolyte loss; a descending or sigmoid colostomy forms formed stool and may be irrigated.
  • Tracheostomy: keep a spare tube of the same size and one size smaller and the obturator at the bedside; clean the inner cannula with sterile technique, and change ties with a second person holding the tube, leaving room for one finger under them.
  • If a new tracheostomy (tract not yet mature) is dislodged, call for emergency help and ventilate; a mature tract can be reintubated with a new tube and obturator per protocol.
  • Enteral tubes: confirm initial placement by x-ray, then check the external length mark and aspirate pH before each use; keep the head of bed at least 30 degrees during feeding and flush with water before and after each medication.
  1. In practiceA client with a new ileostomy reports dizziness and has dark urine and 1,800 mL of liquid stoma output since yesterday. The nurse assesses for fluid volume deficit, reports the output and encourages fluid intake as prescribed, because high ileostomy output quickly causes dehydration and electrolyte loss.
  2. Where questions turnTreating a dark purple or black stoma as normal postoperative bruising instead of reporting it immediately.
Practise this activity

7Give care after surgery

  • On arrival from the post-anesthesia unit, assess airway and breathing first, then circulation (vital signs, dressing, drains), level of consciousness and pain.
  • Watch for hemorrhage and hypovolemic shock: rising heart rate, falling blood pressure, restlessness, cool pale skin and a saturated dressing; check under the client, where blood can pool.
  • Expect urine output of at least 30 mL per hour (0.5 mL/kg/h) in an adult; less is reported.
  • Prevent complications: incentive spirometry and early ambulation for the lungs, venous thromboembolism prophylaxis as prescribed, and turning to protect the skin.
  • Bowel sounds and passing flatus show returning peristalsis; abdominal distention, nausea and absent flatus suggest paralytic ileus.
  • Malignant hyperthermia (rising end-tidal carbon dioxide, muscle rigidity, tachycardia, then high fever) is an emergency treated with dantrolene; stop the triggering agent and call for help.
  1. In practiceTwo hours after a hip replacement, a client's heart rate rises from 84 to 118, blood pressure falls from 128/76 to 94/58 mm Hg, and the client is restless. The nurse checks the dressing and the bed beneath the client, raises the legs if not contraindicated and notifies the surgeon, because these are signs of hemorrhage.
  2. Where questions turnAttributing restlessness and a rising heart rate to pain and giving an opioid before ruling out bleeding or hypoxia.
Practise this activity

8Carry out and manage peritoneal dialysis

  • Warm the dialysate to body temperature with dry heat (a warmer, never a microwave) to prevent cramping and discomfort.
  • Use strict aseptic technique (mask, hand hygiene) when connecting; cloudy effluent, abdominal pain and fever suggest peritonitis and are reported, with a sample sent as prescribed.
  • If outflow is less than inflow or slows, check the tubing for kinks and clamps, keep the drainage bag below the abdomen, turn the client side to side and assess for constipation.
  • Shortness of breath during the dwell: raise the head of the bed and slow or reduce the fill as prescribed, because the fluid presses on the diaphragm.
  • The dialysate contains dextrose: monitor blood glucose, weight, blood pressure and intake and output daily.
  • Blood-tinged effluent is common in the first exchanges after catheter placement; bright red or persistent bleeding is reported.
  1. In practiceA client on home peritoneal dialysis calls to say the drained fluid looks cloudy and the abdomen is tender. The nurse tells the client to save the bag and come in for assessment the same day, because cloudy effluent is the earliest sign of peritonitis.
  2. Where questions turnTreating cloudy effluent as a harmless change from diet instead of a sign of peritonitis.
Practise this activity

9Suction the client's airway

  • Suction when assessment shows a need (coarse crackles or gurgling, visible secretions, falling saturation, a high pressure alarm), not on a fixed schedule.
  • Hyperoxygenate with 100% oxygen before and after suctioning an artificial airway.
  • Use sterile technique for endotracheal and tracheostomy suctioning; insert the catheter without suction and apply suction only while withdrawing.
  • Limit each pass to 10 to 15 seconds, allow recovery between passes and limit the number of passes; use the wall pressure range in policy (commonly about 100 to 150 mm Hg for an adult).
  • Stop and reoxygenate if the client becomes bradycardic, develops a dysrhythmia or desaturates; routine saline instillation is not recommended.
  • Clients with increased intracranial pressure are especially vulnerable: keep passes brief and few.
  1. In practiceA client with a tracheostomy has gurgling respirations and an oxygen saturation of 89%. The nurse hyperoxygenates, suctions with sterile technique for no more than 10 seconds per pass, and stops when the heart rate drops from 92 to 54, then reoxygenates, because suctioning can cause hypoxia and vagal bradycardia.
  2. Where questions turnApplying suction while inserting the catheter or suctioning longer than 15 seconds.
Practise this activity

10Help clear the lungs, for example with incentive spirometry

  • Incentive spirometer: sit upright, exhale normally, seal the lips around the mouthpiece, inhale slowly and deeply, hold the breath at least 3 seconds, then exhale; about 10 times an hour while awake.
  • Teach coughing and deep breathing with a pillow splinting a chest or abdominal incision; give analgesia first so the client can take deep breaths.
  • Chest physiotherapy (percussion, vibration and postural drainage) loosens secretions; schedule it before meals or at least 1 to 2 hours after eating, and follow it with coughing or suctioning.
  • Chest physiotherapy is avoided or modified with increased intracranial pressure, unstable spine or rib fractures, bleeding risk or hemodynamic instability.
  • Hydration thins secretions; early ambulation and position changes open the lung bases.
  • Oscillating positive expiratory pressure devices and huff coughing help clients with chronic secretions, such as those with cystic fibrosis or bronchiectasis.
  1. In practiceOn the first day after abdominal surgery, a client takes rapid shallow breaths through the incentive spirometer. The nurse coaches slow deep inhalation with a 3-second hold while splinting the incision with a pillow, because slow sustained breaths open the alveoli and prevent atelectasis.
  2. Where questions turnTeaching the client to blow out forcefully into an incentive spirometer, which is an inspiratory device.
Practise this activity

11Manage care for a client on cardiac telemetry

  • When the monitor shows an alarming rhythm, look at the client first: an alert client talking normally with a flat line on the screen has a lead off, not asystole.
  • Normal sinus rhythm: rate 60 to 100, a P wave before every QRS, PR interval 0.12 to 0.20 seconds, QRS under 0.12 seconds.
  • Atrial fibrillation: irregularly irregular rhythm without clear P waves; the risk is stroke from atrial clots, so expect rate control and anticoagulation; atrial flutter shows sawtooth flutter waves.
  • Ventricular tachycardia: wide fast regular complexes; check for a pulse, because pulseless ventricular tachycardia is treated like ventricular fibrillation with CPR and defibrillation.
  • Ventricular fibrillation (chaotic waves, no pulse) needs immediate defibrillation; asystole needs CPR and epinephrine, never a shock.
  • Report new or frequent premature ventricular contractions, a prolonged QT interval and symptomatic bradycardia; check potassium and magnesium levels as possible causes.
  1. In practiceThe telemetry alarm shows a chaotic wavy line for a client in room 12; the nurse finds the client unresponsive and pulseless. The nurse calls a code, starts compressions and applies the defibrillator pads, because ventricular fibrillation is a shockable rhythm and every minute without defibrillation lowers survival.
  2. Where questions turnActing on the monitor (calling a code, giving a drug) before looking at the client to rule out artifact or a loose lead.
Practise this activity

12Manage care for a client with poor breathing or oxygenation

  • Early hypoxia shows as restlessness, anxiety, confusion, tachycardia and tachypnea; cyanosis and bradycardia are late signs.
  • Position upright (high Fowler's or leaning forward) to ease breathing, and never withhold oxygen from a hypoxic client.
  • Titrate oxygen to the prescribed saturation target (commonly 92% to 96%; often 88% to 92% for clients with COPD who retain carbon dioxide).
  • Delivery: a nasal cannula gives 1 to 6 L/min; a nonrebreather mask gives the highest concentration without an airway device, with the reservoir bag kept inflated.
  • Arterial blood gases: pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, HCO3 22 to 26 mEq/L, PaO2 80 to 100 mm Hg; a rising PaCO2 with falling pH means respiratory acidosis and failing ventilation.
  • Teach pursed-lip breathing for COPD; pulse oximetry can mislead with poor perfusion, cold fingers or carbon monoxide poisoning.
  1. In practiceA client with pneumonia becomes newly restless and confused, with a respiratory rate of 30 and oxygen saturation of 86% on 2 L/min by cannula. The nurse raises the head of the bed, increases oxygen as prescribed or per protocol and calls the rapid response team, because new confusion is an early sign of hypoxia.
  2. Where questions turnGiving a sedative to a newly restless client instead of assessing for hypoxia.
Practise this activity

13Keep the client's body temperature in the right range

  • Normal adult oral temperature is about 98.6 F (37 C); older adults may have little or no fever despite serious infection.
  • Fever: give antipyretics as prescribed, remove extra covers and offer fluids; cool without causing shivering, which raises oxygen demand and heat production.
  • Heat stroke (hot dry or sweaty skin, confusion, core temperature above about 104 F (40 C)) needs rapid cooling; antipyretics do not work for it.
  • Hypothermia: remove wet clothing, rewarm with warmed blankets, forced-air warming and warmed IV fluids, and handle the client gently because a cold heart is prone to ventricular fibrillation.
  • After resuscitation from cardiac arrest, the team uses deliberate temperature control to prevent fever, as prescribed; monitor core temperature, shivering and skin.
  • Newborns lose heat fast: dry immediately, give skin-to-skin contact with a cap, and keep axillary temperature about 97.7 to 99.5 F (36.5 to 37.5 C).
  1. In practiceA client brought in from the cold has a core temperature of 89.6 F (32 C) and slow speech. The nurse removes wet clothing, applies a forced-air warming blanket and prepares warmed IV fluids while moving the client gently, because rough handling can trigger ventricular fibrillation.
  2. Where questions turnGiving an antipyretic for heat stroke, or cooling a febrile client so fast that shivering raises the temperature.
Practise this activity

14Start and monitor phototherapy

  • Phototherapy treats newborn hyperbilirubinemia; treatment thresholds come from the bilirubin level for the infant's age in hours and risk factors.
  • Undress the newborn except for a diaper to expose as much skin as possible, and cover the eyes with opaque shields while under the lights.
  • Remove eye shields during feeding and holding to check the eyes and support bonding; turn the newborn regularly.
  • Monitor temperature, hydration (wet diapers, weight) and stools; feed often, because the lights increase insensible water loss and loose green stools are expected.
  • Do not apply lotions or oils to the skin under the lights; turn the lights off while drawing blood for bilirubin.
  • Jaundice in the first 24 hours of life is pathologic and is reported immediately.
  1. In practiceA 3-day-old newborn under phototherapy has fewer wet diapers than yesterday and a temperature of 99.9 F (37.7 C). The nurse reports the findings and supports more frequent feeding as prescribed, because phototherapy increases fluid loss and dehydration slows bilirubin excretion.
  2. Where questions turnLeaving the eye shields on during feeding or applying lotion to dry skin under the lights.
Practise this activity

15Manage care for a client with a pacemaker or similar device

  • On a paced rhythm, a pacing spike appears before the P wave (atrial) or the QRS (ventricular), or both.
  • Failure to capture: a spike with no complex after it; failure to sense: spikes fall where they should not; failure to pace: no spike when the rate falls below the set rate. Report each and assess the client.
  • After insertion, watch the site for bleeding and hematoma, limit raising the arm on the device side above the shoulder for the period prescribed, and keep the incision dry.
  • Persistent hiccups or muscle twitching can mean the lead is stimulating the diaphragm or chest wall and is reported.
  • Teach: carry the device card, keep cell phones about 6 inches (15 cm) from the generator, tell security screeners about the device, and have MRI only if the device is approved for it.
  • Implanted defibrillator: after a shock, the client sits or lies down and follows the care plan; repeated shocks or feeling unwell after a shock means calling emergency services.
  1. In practiceA client with a new ventricular pacemaker set at 70 has a heart rate of 48, and the monitor shows pacing spikes without QRS complexes after them. The nurse assesses blood pressure and level of consciousness and notifies the provider, because this is failure to capture.
  2. Where questions turnEncouraging full overhead arm exercises on the device side soon after insertion, which can dislodge the lead.
Practise this activity

16Monitor and look after arterial lines

  • Level the transducer at the phlebostatic axis (fourth intercostal space, midaxillary line) and zero it to atmosphere; re-level after the client changes position.
  • Keep a pressure bag inflated to about 300 mm Hg on the flush solution so the line stays open.
  • Before radial insertion, the circulation to the hand is checked (for example a modified Allen test); monitor color, warmth, movement and capillary refill distal to the site.
  • A dampened waveform suggests air bubbles, a clot, kinked tubing or a wrist position problem; check the system and the client.
  • Never give medications through an arterial line; keep connections tight, because a disconnection causes rapid blood loss.
  • After removal, hold firm direct pressure for at least 5 minutes (longer for clients on anticoagulants) and check the site and distal pulse.
  1. In practiceA client's arterial line reads 168/94 mm Hg, while a cuff pressure is 132/78, and the transducer is found hanging at the level of the client's hip. The nurse re-levels and zeroes the transducer at the phlebostatic axis, because a transducer below the heart reads falsely high.
  2. Where questions turnPushing a medication through the arterial line flush port.
Practise this activity

17Manage care for a client with fluid or electrolyte imbalance

  • Reference ranges vary by laboratory; typical adult values: sodium 135 to 145 mEq/L, potassium 3.5 to 5.0 mEq/L, total calcium 8.5 to 10.5 mg/dL, magnesium 1.3 to 2.1 mEq/L.
  • Daily weight at the same time on the same scale is the best measure of fluid balance: a 1 kg (2.2 lb) change is about 1 L of fluid.
  • Fluid volume excess: weight gain, edema, crackles, bounding pulse, jugular vein distention; deficit: tachycardia, low blood pressure, low concentrated urine and dry mucosa.
  • Hyperkalemia (peaked T waves, muscle weakness) risks fatal dysrhythmias: place on a cardiac monitor and expect calcium gluconate, insulin with dextrose and potassium removal; hypokalemia (flat T waves, U waves) raises digoxin toxicity risk.
  • Never give potassium by IV push; give diluted IV potassium by infusion pump at the rate in policy.
  • Hyponatremia causes confusion and seizures and is corrected slowly; hypocalcemia (after thyroid surgery) shows Chvostek and Trousseau signs and tetany; hypermagnesemia depresses reflexes and breathing.
  1. In practiceA client with kidney disease has a potassium of 6.8 mEq/L (3.5 to 5.0) and peaked T waves. The nurse places the client on a cardiac monitor, notifies the provider and prepares calcium gluconate as prescribed, because calcium protects the heart while other treatments lower the potassium.
  2. Where questions turnGiving potassium IV push, or treating a hyperkalemic client by restricting fluids instead of protecting the heart first.
Practise this activity

18Manage care for a client with changes in hemodynamics, perfusion or clotting

  • Mean arterial pressure (systolic plus twice the diastolic, divided by 3) of at least 65 mm Hg is generally needed to perfuse the organs.
  • Shock types: hypovolemic (blood or fluid loss), cardiogenic (pump failure), distributive (septic, anaphylactic, neurogenic) and obstructive (tension pneumothorax, tamponade, massive pulmonary embolism); early signs are tachycardia, restlessness and narrowing pulse pressure.
  • Peripheral arterial disease: pain with walking, cool pale legs, weak pulses, legs kept dependent; venous disease: edema, brown skin, legs elevated.
  • Anticoagulants: heparin is monitored by aPTT or anti-Xa (reversal protamine), warfarin by INR (usual target 2 to 3; reversal vitamin K); typical aPTT 25 to 35 seconds and INR about 0.8 to 1.1 without therapy.
  • Bleeding precautions with platelets under 150,000/mm3 (150 to 400 x 10^9/L normal): soft toothbrush, electric razor, no IM injections when avoidable, watch for blood in urine, stool and gums.
  • A platelet drop of about 50% during heparin therapy suggests heparin-induced thrombocytopenia: report it and expect heparin to be stopped.
  1. In practiceA client receiving a heparin infusion has a platelet count that fell from 240,000 to 110,000/mm3 (150,000 to 400,000) over 5 days and a new cool, painful leg. The nurse stops the infusion per protocol and notifies the provider, because heparin-induced thrombocytopenia causes clotting, not only bleeding.
  2. Where questions turnElevating the legs of a client with peripheral arterial disease, which further reduces arterial flow.
Practise this activity

19Judge whether treatment is working for an acute or chronic condition

  • Evaluation compares the client's current findings with the expected outcomes set in the plan: improved, unchanged or worse.
  • Use measurable data: weight, intake and output, vital signs, laboratory trends, pain scores, the client's ability to perform a task.
  • Reassess after an intervention at the right time (for example pain 15 to 30 minutes after an IV analgesic, 30 to 60 minutes after an oral one).
  • If outcomes are not met, reassess and revise the plan, and report findings that show worsening to the provider.
  • Typical outcome markers: heart failure (weight down, crackles cleared, less dyspnea), diabetes (glucose in target, A1C commonly below 7%), asthma (peak flow in the green zone, 80% to 100% of personal best).
  1. In practiceA client with heart failure on IV furosemide has lost 2 kg (4.4 lb) in 2 days, crackles are now only at the bases and the client can lie at 30 degrees without dyspnea. The nurse records that diuresis is effective and continues the plan, because weight loss and clearing lungs show fluid removal.
  2. Where questions turnJudging a treatment effective from the client's report alone when the measured data (weight, labs, vital signs) show no change or worsening.
Practise this activity

20Identify the disease process behind an acute or chronic condition

  • Left-sided heart failure backs fluid into the lungs (dyspnea, crackles, pink frothy sputum); right-sided backs it into the body (jugular vein distention, edema, liver enlargement).
  • Acute kidney injury is prerenal (low flow, such as dehydration or shock), intrarenal (damage to kidney tissue, such as nephrotoxic drugs) or postrenal (obstruction, such as an enlarged prostate).
  • Diabetic ketoacidosis results from a lack of insulin: fat breakdown produces ketones and metabolic acidosis; hyperosmolar hyperglycemic state has extreme glucose and dehydration with little ketosis.
  • Syndrome of inappropriate antidiuretic hormone retains water (low sodium, concentrated urine); diabetes insipidus loses water (high sodium, large volumes of dilute urine).
  • COPD traps air and retains carbon dioxide; the kidneys compensate by keeping bicarbonate, so the pH may be near normal in chronic disease.
  • Cirrhosis causes portal hypertension (varices, ascites) and reduced clotting factors and ammonia clearance (bleeding, confusion).
  1. In practiceAfter a head injury, a client's urine output rises to 400 mL per hour of very dilute urine and serum sodium is 151 mEq/L (135 to 145). The nurse recognizes the pattern of diabetes insipidus, reports it and monitors intake, output and neurological status, because lack of antidiuretic hormone causes rapid water loss.
  2. Where questions turnConfusing syndrome of inappropriate antidiuretic hormone with diabetes insipidus by mixing up which one lowers sodium.
Practise this activity

21Manage care for a client on hemodialysis or continuous renal replacement

  • Arteriovenous fistula or graft: palpate the thrill and auscultate the bruit each shift; their absence suggests clotting and is reported.
  • No blood pressure, venipuncture or IV in the access arm; teach the client to avoid tight sleeves, carrying heavy loads or sleeping on that arm.
  • Before dialysis, weigh the client and check whether to hold medications that are dialyzed or that lower blood pressure, as prescribed; after dialysis, weigh again and watch for hypotension and bleeding from the access.
  • Dialysis disequilibrium syndrome (headache, nausea, restlessness, confusion, seizures) comes from rapid shifts during early treatments; report it.
  • If the access site bleeds after needle removal, apply firm direct pressure; heparin given during dialysis increases bleeding risk for a few hours.
  • Continuous renal replacement therapy is used for hemodynamically unstable clients: it removes fluid slowly over 24 hours; monitor fluid balance, electrolytes, filter clotting, the catheter site and temperature (the circuit can cool the client).
  1. In practiceA client with an arteriovenous fistula in the left forearm returns from dialysis, and the nurse cannot feel a thrill or hear a bruit. The nurse notifies the provider promptly, because the fistula has likely clotted and early treatment can save the access.
  2. Where questions turnTaking a blood pressure or starting an IV in the arm with the fistula.
Practise this activity

22Spot signs of complications and act on them

  • Sepsis: infection with fever or low temperature, tachycardia, tachypnea, altered mental status, hypotension and lactate above about 2 mmol/L; obtain blood cultures before antibiotics, then start antibiotics, IV crystalloid and vasopressors as prescribed, without delay.
  • Diabetic ketoacidosis (glucose usually above 250 mg/dL, pH below 7.30, ketones, Kussmaul breathing): IV fluids first, then an IV regular insulin infusion once potassium is at least 3.3 mEq/L, with hourly glucose and frequent potassium checks.
  • Increased intracranial pressure: a change in level of consciousness is the earliest sign; Cushing's triad (rising systolic pressure with widening pulse pressure, bradycardia, irregular breathing) is late. Keep the head of bed 30 degrees, head midline, avoid hip flexion and straining, and report at once.
  • Pulmonary embolism: sudden dyspnea, pleuritic chest pain, tachycardia, anxiety and low saturation; stay with the client, raise the head of the bed, give oxygen and call the rapid response team.
  • Hypoglycemia (glucose below 70 mg/dL) in a conscious client: 15 g of fast-acting carbohydrate, recheck in 15 minutes; if unconscious, glucagon or IV dextrose as prescribed.
  • Autonomic dysreflexia in spinal cord injury at T6 or above: sit the client up, find and remove the trigger (often a full bladder or bowel) and check blood pressure often.
  1. In practiceA client 2 days after a knee replacement suddenly reports sharp chest pain on breathing in, a heart rate of 124 and oxygen saturation of 87%. The nurse stays with the client, raises the head of the bed, applies oxygen and calls the rapid response team, because these are signs of pulmonary embolism.
  2. Where questions turnStarting insulin in diabetic ketoacidosis before fluids and before checking potassium, which can cause life-threatening hypokalemia.
Practise this activity

23Teach the client about an acute or chronic condition

  • Assess what the client knows, wants to know, reading level and language first; use a qualified interpreter when needed, not a family member.
  • Use plain words, a few key points per session and teach-back (the client explains or shows in their own words) to confirm understanding.
  • Heart failure: weigh daily and report a gain of about 2 to 3 lb (1 kg) in a day or 5 lb (2 kg) in a week, limit sodium, and take medications as prescribed.
  • Diabetes sick days: keep taking insulin unless told otherwise, check glucose and ketones more often (about every 3 to 4 hours), keep drinking fluids and call the provider for vomiting or ketones.
  • COPD and asthma: teach inhaler technique, pursed-lip breathing, the rescue inhaler for symptoms and when to seek emergency care.
  • Chronic kidney disease: limit sodium, potassium and phosphorus as prescribed, avoid nonsteroidal anti-inflammatory drugs unless the provider approves, and keep dialysis appointments.
  1. In practiceA client newly diagnosed with heart failure is going home. The nurse teaches daily morning weights after voiding and asks the client to say back when to call, and the client says to call after a gain of 3 lb in a day, because teach-back confirms the client can act on the teaching.
  2. Where questions turnTelling a client with type 1 diabetes to skip insulin when not eating during an illness.
Practise this activity

24Monitor and look after internal monitoring devices, such as an intracranial pressure monitor

  • Normal intracranial pressure in an adult is about 5 to 15 mm Hg; a sustained value above 20 mm Hg needs treatment and is reported.
  • Cerebral perfusion pressure equals mean arterial pressure minus intracranial pressure; an adult target is commonly at least 60 mm Hg.
  • External ventricular drain: level the transducer and drip chamber at the reference point prescribed (usually the tragus of the ear), keep the system closed and sterile, and clamp only as the protocol directs when moving the client; drainage set too low can overdrain.
  • Report cloudy cerebrospinal fluid, fever, a sudden increase or stop in drainage, and any change in neurological status.
  • Intrauterine pressure catheter: needs ruptured membranes; it measures the strength of contractions and resting tone in mm Hg, and can be used for amnioinfusion.
  • Report tachysystole (more than 5 contractions in 10 minutes, averaged over 30 minutes) or an elevated resting tone, especially in a client receiving oxytocin.
  1. In practiceA client with a traumatic brain injury has an intracranial pressure of 24 mm Hg and a mean arterial pressure of 78 mm Hg. The nurse calculates a cerebral perfusion pressure of 54 mm Hg, checks head position and drain level, and notifies the provider, because the brain is not being perfused adequately.
  2. Where questions turnRaising or lowering the head of the bed with an open ventricular drain without re-leveling it, which causes overdrainage or false readings.
Practise this activity

Key terms

Tidaling
The rise and fall of water in a chest tube's water seal chamber with breathing; expected until the lung re-expands.
Water seal
The chest drainage chamber that lets air leave the pleural space but not return.
Negative pressure wound therapy
A sealed foam dressing attached to controlled suction that removes exudate and promotes healing.
Evisceration
Protrusion of organs through a separated surgical wound; an emergency.
Phlebostatic axis
Fourth intercostal space at the midaxillary line, the level of the right atrium, where hemodynamic transducers are leveled.
Failure to capture
A pacemaker spike that is not followed by depolarization of the chamber it paces.
Mean arterial pressure
The average pressure perfusing the organs; usually kept at 65 mm Hg or more.
Cerebral perfusion pressure
Mean arterial pressure minus intracranial pressure; the pressure driving blood to the brain.
Cushing's triad
Rising systolic pressure with widening pulse pressure, bradycardia and irregular respirations; a late sign of increased intracranial pressure.
Thrill and bruit
The vibration felt and the whooshing sound heard over a working arteriovenous fistula or graft.
Dialysis disequilibrium syndrome
Headache, confusion or seizures from rapid fluid and solute shifts during early dialysis.
Peritonitis
Infection of the peritoneum; in peritoneal dialysis, first seen as cloudy effluent.
Hyperoxygenation
Giving 100% oxygen before and after suctioning an artificial airway to prevent hypoxia.
Teach-back
Asking the client to explain or show what was taught, to confirm understanding.

After this guide: You should be able to read a drain, device, rhythm or laboratory trend, tell the expected finding from the dangerous one, and choose the first safe nursing action for a client whose physiology is changing.

Practise Physiological Adaptation