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Study guide · Physiological Integrity

Physiological Adaptation

6 to 12% of the exam · 19 activity statements

Physiological Adaptation is the care of clients whose bodies are coping with an acute or chronic illness: understanding what the disease does, spotting complications early, caring for wounds, drains, ostomies, airways and pacemakers, managing fluid, electrolyte, oxygen and temperature problems, helping with invasive procedures and responding in an emergency. REx-PN items test whether the practical nurse links a finding to its cause, acts first when a life is at risk (CPR, the AED, opening the airway), does the PN's procedures safely and reports to the RN or primary health care provider when the client is unstable or needs a new order.

A study feature written by ExamDragon, not part of the real exam. Each heading is one of the Related Activity Statements the Test Plan lists for this category (19 of them), in our words; the official wording is in the Test Plan.

At a glance

Physiological Integrity
6 to 12%

of the exam (the Test Plan's range)

Activity statements
19
Key terms
10

What this guide covers, statement by statement

  1. Understand the disease process behind acute and chronic conditions
  2. Spot signs of complications and act on them
  3. Explain a short or long term illness to the client
  4. Care for wounds and change dressings
  5. Watch and look after drainage devices, such as wound drains, chest tubes or wound vacs
  6. Carry out emergency care, such as CPR, breathing support or defibrillation
  7. Care for a client whose breathing or oxygen levels are impaired
  8. Care for a client with fluid or electrolyte imbalance
  9. Keep the client's body temperature in a healthy range
  10. Care for ostomies and teach about them
  11. Suction the mouth, airway or nasopharynx
  12. Care for someone who has a permanent pacemaker
  13. Help with invasive procedures, such as central line insertion
  14. Care for a client after surgery
  15. Care for a client with problems in blood flow, perfusion or clotting
  16. Judge whether the treatment plan is working for a short or long term illness
  17. Remove wound drains
  18. Take out sutures or staples
  19. Recognize basic abnormal heart rhythms on a strip

1Understand the disease process behind acute and chronic conditions

  • Link each sign to its cause: crackles and edema in heart failure come from fluid backing up behind a weak ventricle; ascites in cirrhosis from portal hypertension and low albumin.
  • Type 1 diabetes is a lack of insulin; type 2 is resistance with a relative lack. Both raise glucose; only a total lack produces ketones quickly.
  • Chronic obstructive pulmonary disease traps air and carbon dioxide; asthma narrows the airways in reversible attacks.
  • Chronic kidney disease keeps potassium, phosphate, fluid and waste in the body and lowers erythropoietin, so anemia follows.
  • Knowing why a sign appears tells you which finding to watch and which change to report.
  1. In practiceA client with chronic kidney disease has a hemoglobin of 92 g/L (120 to 160) and is tired. The practical nurse understands that the kidneys make less erythropoietin, so the anemia is expected, and watches for fatigue, shortness of breath and falls.
  2. Where questions turnExplaining a sign by the wrong mechanism and so watching the wrong thing.
Practise this activity

2Spot signs of complications and act on them

  • Know the complication each condition carries: deep vein thrombosis and pulmonary embolism after surgery or immobility, hypoglycemia with insulin, bleeding with anticoagulants, increased intracranial pressure after head injury.
  • Sudden chest pain and shortness of breath with a fast heart rate after surgery suggests pulmonary embolism: raise the head of the bed, apply oxygen, stay with the client and call for help.
  • A new change in level of consciousness is often the first sign of a complication in any system.
  • Act within your role at once (position, oxygen, stop an infusion, treat hypoglycemia) and report to the RN or primary health care provider.
  • Do not massage a calf that may hold a clot.
  1. In practiceOn the second day after a hip replacement, a client suddenly becomes short of breath with chest pain and a heart rate of 124. The practical nurse raises the head of the bed, applies oxygen as protocol allows, stays with the client and calls the rapid response team.
  2. Where questions turnLeaving an unstable client to look up an order or call from the desk.
Practise this activity

3Explain a short or long term illness to the client

  • Reinforce the teaching the RN or primary health care provider began about the condition: what it is, the medications, the diet and activity, and the warning signs.
  • Heart failure: weigh every morning at the same time and report a gain of about 1 to 2 kg in a day or 2 to 2.5 kg in a week, or as the provider directs.
  • Diabetes: check glucose as directed, know the signs of high and low glucose, and treat a low with 15 g of fast-acting carbohydrate.
  • Chronic obstructive pulmonary disease: pursed-lip breathing, energy conservation, stopping smoking and the action plan for a flare.
  • Check understanding with teach-back, and match teaching to the client's language, literacy and culture.
  1. In practiceA client with heart failure asks why daily weights matter. The practical nurse explains that a quick gain means fluid is building up before swelling is visible, and asks the client to repeat when and how to weigh and what gain to report.
  2. Where questions turnReinforcing a fact without checking the client can use it, such as handing over a diet sheet without teach-back.
Practise this activity

4Care for wounds and change dressings

  • Clean from the cleanest area to the least clean, using a new swab each stroke, with the solution ordered (usually normal saline).
  • Keep a healthy wound bed moist and the surrounding skin dry; choose the dressing the care plan names.
  • Measure and describe the wound: length, width, depth, tunnelling, tissue type, drainage amount, colour and odour.
  • Signs of infection: more redness, warmth, swelling, pain, purulent drainage or odour, and fever; report them.
  • Evisceration: cover the wound with sterile saline-moistened dressings, keep the client in low Fowler's with knees bent, stay with them and call for help.
  1. In practiceDuring a dressing change the practical nurse sees a small amount of yellow-green drainage with a foul odour and new redness 3 cm around the incision. The practical nurse measures and documents the findings, takes a swab if ordered and reports to the primary health care provider.
  2. Where questions turnCleaning a wound from the outside edge inward, which carries bacteria into the wound.
Practise this activity

5Watch and look after drainage devices, such as wound drains, chest tubes or wound vacs

  • Closed-suction drains (bulb drains) work only when compressed; empty, record and recompress them as ordered.
  • Chest tubes: keep the drainage system below the chest, tubing free of loops and kinks; gentle fluctuation (tidaling) in the water seal is expected.
  • Continuous bubbling in the water seal chamber suggests an air leak; check the connections from the client outward and report.
  • If a chest tube comes out of the chest, cover the site with a sterile dressing taped on three sides and call for help; if it disconnects from the system, put the end in sterile water.
  • Negative pressure wound therapy: the dressing should stay collapsed and sealed; an alarm or a loose dressing is fixed or reported promptly, and the device is not left off for long.
  1. In practiceA client's chest drainage system shows continuous bubbling in the water seal chamber that was not there an hour ago. The practical nurse checks the tubing connections and the dressing from the chest outward, and reports the new air leak to the RN.
  2. Where questions turnClamping a chest tube to stop bubbling, which can cause a tension pneumothorax.
Practise this activity

6Carry out emergency care, such as CPR, breathing support or defibrillation

  • An unresponsive client who is not breathing normally (gasping counts as not breathing): call for help and an AED and start compressions at once.
  • Adult compressions: centre of the chest, 5 to 6 cm deep, 100 to 120 a minute, full recoil, as few pauses as possible, 30 compressions to 2 breaths without an advanced airway.
  • Apply the AED as soon as it arrives and follow its prompts; resume compressions right after the shock.
  • Choking in a conscious adult who cannot speak or cough: alternate 5 back blows and 5 abdominal thrusts (chest thrusts in late pregnancy or obesity); if they become unresponsive, start CPR.
  • Check for a DNR order or advance directive, but never delay CPR to search when none is known.
  1. In practiceThe practical nurse finds a client unresponsive with gasping breaths. The practical nurse shouts for help, has a colleague bring the AED and call the code, and starts chest compressions immediately.
  2. Where questions turnLeaving the client to call for help, or checking for a pulse for longer than 10 seconds before starting compressions.
Practise this activity

7Care for a client whose breathing or oxygen levels are impaired

  • Early signs of hypoxia are restlessness, anxiety and a fast heart rate and breathing; cyanosis is late.
  • Position upright (high Fowler's or leaning forward) to help the lungs expand.
  • Give oxygen as ordered; clients with chronic carbon dioxide retention often have a target saturation of 88 to 92%, others usually 92 to 96%, as ordered.
  • Encourage deep breathing, coughing, the incentive spirometer and early walking to prevent atelectasis and pneumonia.
  • Increasing work of breathing, a falling level of consciousness or a saturation that will not rise is reported at once.
  1. In practiceA client with chronic obstructive pulmonary disease is ordered oxygen to keep saturation 88 to 92%. The saturation is 95% and the client is drowsier than before. The practical nurse lowers the oxygen to the ordered range and reports the drowsiness, which may mean carbon dioxide is rising.
  2. Where questions turnTurning the oxygen up for a client with carbon dioxide retention whose saturation is already above the target.
Practise this activity

8Care for a client with fluid or electrolyte imbalance

  • Fluid volume deficit: thirst, dry mucous membranes, low urine output, fast weak pulse, orthostatic drop. Excess: edema, crackles, weight gain, bounding pulse.
  • Weight is the best measure of fluid change: 1 kg is about 1 L.
  • Potassium (3.5 to 5.0 mmol/L): both high and low cause dangerous heart rhythms; low causes weakness and cramps.
  • Sodium (135 to 145 mmol/L): low or high sodium changes the level of consciousness and can cause seizures; correct it only as ordered and slowly.
  • Calcium (2.10 to 2.60 mmol/L total): low calcium causes tingling, muscle cramps and tetany; high calcium causes weakness and constipation.
  1. In practiceA client with vomiting for two days has a potassium of 3.1 mmol/L (3.5 to 5.0), leg cramps and weakness. The practical nurse reports the result, starts intake and output and fall precautions, and gives the replacement ordered, never as an IV push.
  2. Where questions turnTreating a weight gain of 2 kg overnight as fat rather than fluid.
Practise this activity

9Keep the client's body temperature in a healthy range

  • Fever: give the antipyretic ordered, offer fluids, use light covers and a cool room; avoid shivering, which raises heat.
  • Hypothermia: remove wet clothing, warm gradually with warm blankets or a forced-air warmer, and handle gently.
  • Older adults and clients on immunosuppressants may have serious infection with little or no fever.
  • Heat stroke (high temperature with confusion and hot, often dry skin) is an emergency: cool quickly and call for help.
  • Measure temperature by the same route each time so readings can be compared.
  1. In practiceAn older client found on the floor of a cold room has a temperature of 34.6 °C. The practical nurse removes damp clothing, covers the client with warm blankets, handles the client gently and reports the findings.
  2. Where questions turnApplying ice packs to bring down a fever in a client who is already shivering.
Practise this activity

10Care for ostomies and teach about them

  • A healthy stoma is moist and pink to red; a pale, dusky, purple or black stoma is reported at once.
  • Measure the stoma and cut the skin barrier to fit about 2 to 3 mm larger than it; empty the pouch when it is one third to one half full.
  • Ileostomy output is liquid and rich in enzymes, so the skin is at higher risk and fluid and electrolyte loss is greater than with a colostomy.
  • Tracheostomy care: clean the inner cannula and stoma with the technique ordered, change ties with a second person holding the tube, and keep an obturator and spare tube at the bedside.
  • Reinforce the client's own care, diet and signs to report, and acknowledge feelings about body image.
  1. In practiceA client with a new ileostomy has red, weeping skin around the stoma. The practical nurse remeasures the stoma, finds the barrier opening is cut too large, refits the barrier and reports the skin damage.
  2. Where questions turnCutting the barrier opening much larger than the stoma, which leaves skin exposed to output.
Practise this activity

11Suction the mouth, airway or nasopharynx

  • Suction only when needed (audible secretions, noisy breathing, falling saturation), not on a fixed schedule.
  • Preoxygenate, use sterile technique for tracheal suctioning and apply suction only while withdrawing.
  • Limit each pass to 10 to 15 seconds and allow recovery between passes.
  • Use the pressure the policy sets (about 100 to 150 mmHg for adults) and a catheter no more than half the width of the airway.
  • Stop if the heart rate drops or the client becomes cyanotic, and give oxygen.
  1. In practiceDuring tracheal suctioning a client's heart rate falls from 88 to 52. The practical nurse stops suctioning, removes the catheter, gives oxygen and watches for the heart rate to recover before reporting.
  2. Where questions turnApplying suction while inserting the catheter, or suctioning for longer than 15 seconds.
Practise this activity

12Care for someone who has a permanent pacemaker

  • Check the pulse for a full minute; a rate below the pacemaker's set rate may mean the device is failing.
  • After a new pacemaker, keep the arm on that side below shoulder level and avoid vigorous arm movement for the time ordered so the leads stay in place.
  • Watch for dizziness, fainting, hiccups (lead stimulating the diaphragm), swelling or bleeding at the site.
  • Reinforce carrying the device card, telling health care providers, and keeping phones and strong magnets away from the device.
  • Report symptoms of a slow heart rate or a rate below the set rate.
  1. In practiceA client with a pacemaker set at 60 has a pulse of 44 and feels dizzy. The practical nurse has the client lie down, checks the blood pressure and reports the findings at once.
  2. Where questions turnEncouraging full range of motion of the arm on the pacemaker side the day after insertion.
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13Help with invasive procedures, such as central line insertion

  • Before an invasive procedure, confirm the consent, allergies and identification, gather the supplies and position the client as the primary health care provider directs.
  • Thoracentesis: the client sits upright leaning forward over a table; tell them not to cough or move during the needle insertion.
  • During a central line insertion, the client may be placed flat or head down; keep the sterile field and report any break in it.
  • Afterward, watch vital signs, oxygen saturation, the site and the client's breathing; sudden shortness of breath may mean a pneumothorax.
  • The provider performs the procedure; the practical nurse assists, supports the client and monitors.
  1. In practiceBefore a thoracentesis, the practical nurse helps the client sit on the edge of the bed leaning over a padded over-bed table, explains the need to stay still and not cough during the puncture, and stays to monitor.
  2. Where questions turnPositioning the client flat on the back, which makes the fluid hard to reach.
Practise this activity

14Care for a client after surgery

  • Priorities after surgery follow airway, breathing and circulation: saturation, respiratory rate, blood pressure, heart rate and bleeding at the dressing.
  • Encourage deep breathing, coughing with splinting and the incentive spirometer, and get the client moving as soon as ordered.
  • Watch urine output (at least about 0.5 mL/kg an hour) and report a client who has not voided within the time policy sets.
  • Manage pain so the client can breathe and move; assess and reassess after each dose.
  • Watch for complications: hemorrhage, atelectasis, ileus, wound infection, deep vein thrombosis and delirium.
  1. In practiceFour hours after surgery a client's blood pressure is 92/58 from 126/80, heart rate 116, and the dressing is soaked. The practical nurse reinforces the dressing, keeps the client flat or as ordered, checks the vital signs again and reports to the RN at once.
  2. Where questions turnRemoving a soaked surgical dressing to look, instead of reinforcing it and reporting.
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15Care for a client with problems in blood flow, perfusion or clotting

  • Hypovolemic shock: fast weak pulse, falling blood pressure, cool clammy skin, restlessness and low urine output.
  • Peripheral arterial disease: legs dependent eases pain; venous disease: legs elevated eases swelling.
  • Deep vein thrombosis: one calf swollen, warm and tender; do not massage it, and report.
  • Bleeding risk: watch for bruising, nosebleeds, blood in urine or stool and changes in level of consciousness in clients on anticoagulants or with low platelets.
  • Act first (pressure on bleeding, position, oxygen) and report an unstable client to the RN or primary health care provider.
  1. In practiceA client on warfarin with an INR of 4.8 (therapeutic 2.0 to 3.0) has gums that bleed when brushing and new bruises. The practical nurse holds the next warfarin dose pending the prescriber, reports the result and findings, and uses bleeding precautions.
  2. Where questions turnElevating the legs of a client with arterial insufficiency, which reduces blood flow to the feet.
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16Judge whether the treatment plan is working for a short or long term illness

  • Evaluate against the expected outcome in the plan: the measure that shows the treatment works (weight, lung sounds, glucose, pain score, wound size).
  • Compare with the baseline and the trend, not with a single reading.
  • When a treatment is working, continue it and record the result; when it is not, report so the plan can change.
  • Ask the client how they feel and what they are able to do; function is an outcome too.
  • Document evaluations with measurements and the time.
  1. In practiceA client with heart failure on furosemide has lost 2.4 kg over three days, has fewer crackles and sleeps on one pillow instead of three. The practical nurse records these as signs the treatment is working.
  2. Where questions turnJudging the plan by one reading, such as one glucose value, instead of the trend.
Practise this activity

17Remove wound drains

  • Remove a drain only with an order, and explain that the client may feel a pulling sensation.
  • Release suction on a closed drain and remove the suture holding it before withdrawing.
  • Withdraw steadily and gently; stop and report if there is strong resistance.
  • Check that the tip is intact, apply a dry sterile dressing, and record the drainage and the condition of the site.
  • Watch for drainage at the site, swelling or fluid collecting under the skin afterward.
  1. In practiceWith an order to remove a bulb drain, the practical nurse empties and records the drainage, releases the suction, cuts and removes the securing suture, asks the client to breathe out and withdraws the drain steadily, then checks the tip and covers the site.
  2. Where questions turnPulling a drain out while the bulb still holds suction.
Practise this activity

18Take out sutures or staples

  • Remove sutures or staples only with an order, and look at the wound first: a wound that is not well joined is reported before removal.
  • Often every second suture or staple is removed first, with strips applied, and the rest removed if the edges hold.
  • Lift the knot, cut the suture close to the skin on the side opposite the knot, then pull the knot gently toward the cut side so the outer part does not go through the tissue.
  • Use a staple remover under the middle of the staple and squeeze so the ends lift out.
  • Apply wound closure strips as ordered and reinforce that they fall off on their own.
  1. In practiceWith an order to remove abdominal staples, the practical nurse removes every second staple and sees the edges begin to separate. The practical nurse stops, applies wound closure strips and reports to the primary health care provider.
  2. Where questions turnRemoving all staples first and only then checking whether the wound holds.
Practise this activity

19Recognize basic abnormal heart rhythms on a strip

  • Normal sinus rhythm: regular, 60 to 100 a minute, a P wave before every QRS.
  • Sinus bradycardia is regular below 60 and sinus tachycardia regular above 100; check the client for symptoms.
  • Atrial fibrillation: irregularly irregular, no clear P waves; risk of stroke.
  • Ventricular tachycardia: wide, fast, regular complexes; ventricular fibrillation: chaotic waves with no QRS. Check the client: a client without a pulse needs CPR and the AED.
  • Count the rate on a 6-second strip by multiplying the number of QRS complexes by 10.
  1. In practiceThe monitor of a client on telemetry shows chaotic waves with no QRS complexes. The practical nurse checks the client, finds them unresponsive and pulseless, calls the code and starts compressions until the AED or defibrillator arrives.
  2. Where questions turnTreating a monitor pattern without checking the client first; a loose lead can look like ventricular fibrillation.
Practise this activity

Key terms

Pathophysiology
How a disease changes normal body function, which explains its signs.
Evisceration
Organs pushing out through an opened surgical wound; an emergency.
Tidaling
Fluctuation of the water in a chest drainage water seal chamber with breathing; expected.
Hypoxia
Too little oxygen in the tissues; early signs are restlessness and a fast heart rate.
Fluid volume deficit
Too little fluid in the body: thirst, low urine output, fast weak pulse, weight loss.
Stoma
An opening on the body surface from a bowel, urinary or airway diversion.
Pacemaker set rate
The lowest heart rate the device allows; a pulse below it may mean failure.
AED
Automated external defibrillator: it reads the rhythm and tells the rescuer when to shock.
Ventricular fibrillation
A chaotic rhythm with no effective heartbeat; the client has no pulse.
Hypovolemic shock
Organs underperfused because of blood or fluid loss.

After this guide: After this guide you should be able to link a client's findings to the condition, act first in an emergency, carry out the PN's wound, drain, ostomy, airway and device care safely, and report what needs the RN or primary health care provider.

Practise Physiological Adaptation