In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of potential for alterations in body systems in order to:

  • Identify client potential for aspiration (e.g., feeding tube, sedation, swallowing difficulties)
  • Identify client potential for skin breakdown (e.g., immobility, nutritional status, incontinence)
  • Identify client with increased risk for insufficient vascular perfusion (e.g., immobilized limb, post-surgery, diabetes)
  • Educate client on methods to prevent complications associated with activity level/diagnosed illness/disease (e.g., contractures, foot care for client with diabetes mellitus)
  • Compare current client data to baseline client data (e.g., symptoms of illness/disease)
  • Monitor client output for changes from baseline (e.g., nasogastric [NG] tube, emesis, stools, urine)

Identifying the Client's Potential for Aspiration

The risk for aspiration, as defined by the North American Nursing Diagnosis Association (NANDA), is "At risk for the entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into the tracheobronchial passages".

The risk factors associated with the risk for aspiration include:

  • An impaired cough and/or gag reflex
  • Gastrointestinal feeding tubes particularly when there is residual
  • An impaired esophageal sphincter
  • Impaired gastrointestinal tract emptying and motility
  • Dysphagia
  • Decreased level of consciousness
  • Oral or facial surgery or trauma
  • An endotracheal tube or a tracheostomy tube
  • An inability to clear airway secretions
  • Sedation

Identifying the Client's Potential for Skin Breakdown

The risk factors associated with skin breakdown include both internal, intrinsic patient related risks and external, extrinsic risk factors.

Some of the internal, intrinsic patient related risk factors include:

  • Poor nutritional status
  • Immobility
  • A decreased level of consciousness including that which occurs with sedating medications
  • Fecal and/or urinary incontinence
  • Impaired circulation and tissue perfusion
  • Alterations in terms of the fluid balance
  • Altered neurological sensory functioning
  • Changes in terms of skin turgor
  • Boney prominences

Some of the external, extrinsic risk factors associated with impaired skin integrity include:

  • Mechanical forces like pressure, friction and shearing
  • Moisture including environmental humidity and bodily fluids including urine and diaphoresis
  • Radiation
  • Hypothermia
  • Hyperthermia

The Norton Scale and the Braden Scale are two standardized scales that are used to identify clients at risk for skin breakdown.

Identifying the Client with Increased Risk for Insufficient Vascular Perfusion

Ineffective tissue perfusion, as defined by the North American Nursing Diagnosis Association (NANDA), is "a decrease in oxygen resulting in a failure to nourish tissues at the capillary level." Ineffective tissue perfusion can occur in terms of the renal system, the brain, the heart, the gastrointestinal tract and the peripheral vascular system.

Some of the risk factors associated with impaired vascular perfusion include:

  • Hypervolemia
  • Hypovolemia
  • Low hemoglobin
  • An immobilized limb
  • Hypotension
  • Hypoxia
  • Decreased cardiac output
  • Diabetes
  • Impaired oxygen transportation
  • Hypoventilation

Identifying the Client with Increased Risk for Cancer

The following are the most common risk factors for cancer:

  • Tobacco Use and Second Hand Smoke Including Smokeless Tobacco: Cancers of the lung, bladder, mouth, esophagus, pancreas and larynx.
  • Age: Clients over 65 years of age are at greatest risk.
  • Family History: Genetics and Familial Tendency: Cancers of the colon, breast, ovaries, and uterus.
  • Chemicals and Other Substances: Asbestos, benzene, benzidine, cadmium, nickel, and vinyl chloride may cause cancer.
  • Ionizing Radiation and Radon Gas: Radioactive fallout, radon gas, which is an odor less gas found in many buildings, x-rays, therapeutic radiation for cancer, and other sources.
  • Sunlight and Ultraviolet Radiation (UV): Skin cancer.
  • Viruses and Bacteria: Human papillomaviruses (HPV) (Cancer of the cervix, vagina, penis, anus and mouth), Hepatitis B and C (Liver cancer), Helicobacter pylori ((Cancer of the stomach) and the Epstein-Barr virus (Burkitt's lymphoma).
  • Hormones: Cancer of the prostate, breast, and uterine cancer.
  • Alcohol: Cancer of the liver
  • Poor Diet, Lack of Physical Activity, Being Overweight: Cancer of the colon, rectum, pancreas, kidney, prostate, gall bladder, ovary, uterus, breast, esophagus

Educating the Client on Methods to Prevent Complications Associated with Activity Level/Diagnosed Illness/Disease

Client and family education should address all "At risk" potential nursing diagnoses. For example, clients at risk for impaired skin integrity should be instructed to move and turn in bed, clients at risk for contractures secondary to immobility should be instructed and coached on full range of motion exercises, and diabetic clients must be educated about the needs for daily foot care and foot inspections to prevent peripheral skin breakdown and infections.

Comparing Current Client Data to Baseline Client Data

Nurses compare current client data to baseline client data in order to monitor and evaluate the client's therapeutic plan of care and also to determine and identify any new health care problems including those that can occur as the result of a complication associated with their risk factors.

Monitoring the Client's Output for Changes from the Baseline

Changes in the client's output in relationship to nasogastric tube drainage, emesis, stools and urinary output can also indicate the presence of a disease, illness or disorder. For example, increases in terms of emesis can indicate the presence of a side effect of a medication or an impairment of the gastrointestinal tract functioning; decreased urinary output can indicate dehydration or renal disease; and excessive fecal waste can indicate diarrhea or a gastrointestinal tract infection.

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