Potential for Complications of Diagnostic Tests/Treatments/Procedures (Nursing)

00:01 This section for NCLEX review is called Potential for Complications of Diagnostics Tests, Treatments, and Procedures. Again this goes with risk potential, and reducing that risk potential that you are going to make sure that you know for the NCLEX review. My name is Diana Shenefield, let’s get started. So why is that we need to know about complications? Well, you probably are answering that for yourself, because as nurses we need to make sure our patients are safe. Risk reduction is a big part of what we do as nurses, so it’s a big part of the NCLEX exam, to make sure that you are competent to take care of your patients, so no matter what’s happening with them, whether they are having testing or whether they are having procedures that you know what to watch for, what to monitor for, so that your patient doesn’t become distressed, the patient doesn’t have any complications, and if unfortunately there's complications, that you know what to do to help your patient through those.

01:00 And make sure you read through the learning outcomes, make sure you understand what this section is about, and make sure that you are prepared to take this section of the NCLEX exam. So let’s just go through a few things, just to kind of refreshing your mind.

01:13 We are going to start with a question: Which of the following nursing interventions is appropriate for a patient who is suffering from a fever? We get patients with fevers all the time, so you may be asking yourself “Well, how would I know?” Well you know what a fever does to the body. So let’s read through these answers and see which one you picked. A, avoid giving the patient food. B, provide oxygen, C, all of the above or D, B and C. Now does that question even make sense? Probably not. Again this is just to point out that sometimes when you're asked a question about something as generic as a fever you may be saying “Well, there's so many other variables”.

01:57 Don’t read into the question, make sure that you just read for what is asking you, and if that you have a patient that has a fever, do you want to avoid giving the patient food? Do you want to provide oxygen? You have to really adjust your assessment to your patient.

02:14 With this one, there is not really a right answer. I just kind of want to throw it in, because a lot of times when you are talking about procedures, and you are talking about things that can happen to a patient, we don’t know at all what can happen to a patient.

02:27 It depends on their age, and it depends on their genetics and it depends on what’s going on. So don’t let that scare you when you start reading about just a fever. Make sure you know about your patient and then think back to what you know about fevers.

02:41 So next question. We have a comatose patient that needs nasopharyngeal suctioning. So again, in your mind, think about what you are going to be doing. After the airway is inserted, the patient gags and coughs, so what do you need to do? So if you are confused at first on what you need to do, think through your head. What does a nasopharyngeal airway look like, and how do you insert it? Run through that procedure for yourself, then you’ll be able to answer the question. So A, should you remove the airway and insert a shorter one? B, should I reposition the airway? C, should I leave the airway in place until the patient gets used to it? Or D should I remove the airway and attempt suctioning without it? So think through those things, what could cause the patient to gag and cough? Hopefully you picked A. Hopefully you knew that a longer airway is going to cause gagging and coughing. If you don’t, go back and review that procedure again in your fundamentals book. So what do I need to know generally about this section of the NCLEX exam? One thing I need to know is what complications am I always watching for with patients? You always need to be watching for their airway, you always need to be watching breathing and circulation, but what is happening with the patient that I need to be monitoring? So I need to keep that in mind. I need to keep in mind the position of the patient, not only am I going to be positioning them, but what could that position do to them post-op? Next thing, is what does a nurse need to know to perform the procedure or the treatment correctly and safely? Again, that is our top priority, to be competent and safe in all of our care. We also want to know how to evaluate the patient. How do I know if the patient is getting into trouble? How do I know if the test has been done successfully? I do that by assessing and evaluating over, and over with my patient, so that I can pick up on any trends or any complications. So one of the complications that comes to mind when we talk about airway, breathing and circulation, is bleeding. A lot of test and procedures, we are using needles or we are causing damage to tissues, which can cause bleeding. As a nurse I need to know, is the possibility of bleeding a real possibility and how would I know that it happens. Sure if it happens on the skin, that's easy to see, but how would I know if there is internal bleeding, what am I watching for? Things like vital signs, things like change in behavior. So run all that through your mind.

05:26 What about DVTs, and pulmonary embolus? If I'm doing testing or the patient is on bed rest as their treatment, is there a possibility that they could get a DVT? How would I know if they did or not? Run those assessments through your mind, what would the patient show, and how do I keep that from happening? We know our post op patients are more prone for DVT, so what do we do as nurses, to keep that from happening? We get them up and we get them walking around, we have them wear ted hoes, we have SCDs on them, we teach them how to pump their ankles. All of those things that they don’t understand needs to be done, but as nurses I know what I need to do to keep my patient from developing that DVT, and then ultimately, hopefully to keep from having that pulmonary embolus. What about respiratory distress? Anxiety can cause respiratory distress. We know when patients are anxious they can hyperventilate. What about if I have obstructed an airway? What about if there has been bleeding into their lungs? Again, how would I know that as a nurse? What signs and symptoms do I need to be alert for to watch my patient to make sure they are not getting into respiratory distress? Am I watching their O2 sats? Am I listening to their breath sounds? Am I monitoring their respiratory rate? All of those are things that I need to be doing on a constant basis when my patient is getting treatments, post-op, pre-op, or during, to make sure that I’m monitoring that, to make sure I’m not missing anything.

06:58 What about cardiovascular compromise? Lot of times we put patients in positions, especially in the post-op, that can cause a compromise. Maybe we have a leg bent, that needs to be bent for the surgeon to do their job, but are we watching for neurovascular and cardiovascular compromise? Am I watching for good capillary refill? Am I watching for good pulses? Am I feeling the skin to make sure it’s warm, and dry, and pink? So again, running all of that through your mind, making sure that you are prepared to catch any kind of complications.

07:32 We know cardiovascular wise if we don’t catch it, you can end up losing a limp.

07:38 Again we don’t want that to happen, but if I don’t understand the positioning or what’s going on with the patient, I might miss something. Neurovascular compromise, which we just talked about, which goes a lot with cardiovascular compromise, and positioning, so make sure you are running those signs and symptoms through your mind.

07:57 Pressure ulcers, huge things. We don’t think a lot about treatments on pressure ulcers.

08:01 If you've ever been in the OR, a lot of times patients are put on those tables, and in the OR they don’t have time to watch for skin breakdown and those kind of things, they are on a mission, but when they get back, out to the floor, we need to be making sure we are watching those skins, especially of our elderly patients or our malnourished patients, that are already more prone to pressure ulcers and breakdown. To make sure that while they were in the OR, that maybe they weren't in a position that was too long, looking at those bony prominences. So again, I don’t always understand what positions patients are in the OR, but I have a pretty good idea, so I need to take a close eye at my patient and doing a good skin assessment. So what are we going to do about interventions? And what does the nurse need to be competent in when we do nursing interventions? What about things like putting in an NG? What kind of things do I need to be watching for? Now if you need to review your NG procedures, you need to make sure you go back and look at your fundamentals book. But we know there is a chance that you could get into the lungs. What kind of signs and symptoms would your patient show? What happens if while you are giving a feeding through the NG and the tube becomes dislodged, and gets into the lungs, can you catch the common complications, the coughing, maybe the aspiration. Again, run all that through your mind, be very familiar with the treatments that you are going to be doing. Tracheostomy suctioning. We don’t see as many trachs as we used to, but that kind of makes it harder because you are not going to be doing it all the time. So run that procedure through your mind. How would you know if somebody has a tracheostomy plug? How would you know if they need to have it replaced? What kinds of signs and symptoms are you watching with your patient? What happens if it becomes plugged and they stop breathing? Do you know how to use the bag valve mask on them? Again, if you haven’t done trachs in a while or if it’s been a long time since you've learned how to do it in fundamentals class, you are going want to go back and review. What about suctioning of the trach? Do we instill normal saline or do we not? You want to make sure you know the best evidence practice with that as well.

10:13 What about defibrillation and cardioversion? Make sure you know the difference between the two. Make sure you know how to keep you patient safe and yourself safe when you are performing cardioversion or defibrillation. Again if you are not familiar with that make sure you go back and read that in your book. ABG draws. A lot of nurses won’t get to do ABG draws and all of the sudden one will be ordered. Do you know how to do the Allen test? Do you know what you are watching for in the Allen test? Do you know the complications that can happen with drawing an ABG? Are you holding pressure? Again, all of those things you need to review, because on the NCLEX they want to make sure that you are safe, and that you understand that what you do has complications, pro and con effects to your patient, and so before you can do those things you need to understand what you are doing to your patient.

11:03 What about just putting in an IV? A lot of times nurses just putting in an IV, they can almost do it with their eyes closed, but what happens with that one patient that you happen to touch a nerve, and they start complaining of tingling and burning in their fingers.

11:16 Do you catch the fact that you've touched the nerve and you need to pull that IV out? Again, don’t become very like “Oh, I’ve done this a million times.” Make sure you always know what the complications are. Foley placement. Are you using sterile technique? What happens when you are putting in a Foley and you're sterile and the patient starts to cough or moves? Do you know what to do? Do you know how to know whether you are staying sterile or not? Again, review that procedure. What happens if you are putting a Foley catheter in an older gentleman and you can’t get the catheter to advance? Do you know tricks on how to get it past the prostate? What happens if blood comes out? So again, run all those procedures through your mind, so that you are ready for those complications.

12:01 Dressing changes. Pretty simple, but again what happens when you take off that dressing and there is lots of bleeding? How do you assess that? How do you document wound care to make sure that you are communicating to the next nurse or the physician on what the wound looks like, so they can tell, is the wound getting better or is it getting worse? Do you know how to measure wounds? Make sure again you are reviewing all of that.

12:25 Making sure you are monitoring vital signs. Don’t get lax on vital signs, make sure that you understand what your baseline is. Make sure that you understand that if your patient runs 92% O2 sat and you do something and now they are at 90, is that normal or not? Only you as the nurse would know that because your patient is individualized.

12:46 What about monitoring labs? We are responsible for watching trending. And I go through with my patients a lot about a normal isn't just a normal, is it at the low end of normal, or is it at the high end of normal. If a trend is happening, just because the patient is still in the normal range, I need to be watching that, because I need to catch something before it gets out of the normal range. So again, do you understand trending, and do you understand normal lab values which you do need to know. What about monitoring Is & Os? It isn’t just as easy as taking in how much did you drink and how much did you urinate, but do you understand that there is NG drainage, or if there is bleeding, how to estimate that and what that means to your patient if you don’t catch how much output there is.

13:34 You know, is their kidney all of the sudden not functioning? Is that something or is that something that you got to watch for labs when you could have caught maybe in your output. So again what does that mean to the nurse, and what complications are you watching for? What about monitoring airways? That’s usually an easy one. We are always focused on airways, but again sometimes we get focused on another body part and we forget that the patient has to have an airway. So make sure you are watching for that as well.

14:00 And any side effects? Again, we’ve talked about side effects of medications, we've talked about side effects of any kind of procedure that we do for the patient. But again it’s very important that you are watching for those side effects, and that you are educating the patient about those side effects. And then, assess, assess, and reassess. And I know you've heard in nursing school you gotta assess, you gotta reassess, you gotta go back and reassess, and that is so important. Patients conditions can change so fast, and it’s usually the patient that you think is the most stable that will all of sudden change on you, and if you don’t catch that, you are going to miss it. So what does that mean to reassess? Does that mean that you have to do a total head to body? I don’t know, maybe you do. But, only you would know as a nurse on what’s going on with that procedure, so make sure that you are watching, and you are reassessing your patient. Proper positioning.

14:54 Are we watching for side lateral to allow for drainage of secretions? Again, you have a comatose patient, do you want them laying on their back? Maybe you do, maybe you don’t.

15:06 But what’s going to happen if you put them on their back? Are they going to be more prone to aspiration? So just things like how you position your patient is going to be good for the patient, or it could be detrimental and it's something you need to keep in mind.

15:19 What about head elevated. We know if somebody is having difficulty breathing, having them in High Fowler is going to help with lung expansion. That’s an easy thing to do, that’s a fast thing to do for your patient that is having trouble breathing. What about elevating the limbs to reduce swelling. Don’t forget your RICE. Maybe they need to have their limb elevated. What’s is that doing? What’s the purpose of elevating a limb? Any time that you have any kind of swelling, so run that through your mind.

15:46 What about sideline? What position does the patient need to be in for a lumbar puncture, a spinal tap? Do you understand how to position the patient? If it is an infant, do you understand how to watch for airway obstruction? If it is an adult, can you explain to them how to position, and help them to understand why they need to hold still. What about prone? If they have hip joint problems. A lot of time in our patients, we don’t let them lay prone, but that allows for maximum extension of the hip joint, so why don’t we allow them to lay prone, maybe that’s the best for the patient.

16:23 And then, trendelenburg. Used to always be you put patients in trendelenburg when they had a low blood pressure. But what about if they have increased intracranial pressure? Do you want to put them in trendelenburg? No, that’s not a trick question, you do not.

16:36 You don’t want to increase that intracranial pressure. So again be familiar with your positions, when they are used for the best and when they are contraindicated. So, we kind of talked about a lot of stuff here about complications.

16:52 Again, we do a lot of good as nurses, and I know you have learned a lot in nursing school, but one of the things we need to keep in mind is to always keep in mind that there always could be complications. If you are prepared for them, you will be able to catch them, and hopefully, prevent them, and keep your patient safe. That is what your patient wants, and that is what NCLEX is looking for. So can go back and look at your procedure books, and familiarize yourself, and you will do fine on the NCLEX exam.

17:20 I am Diana Shenefield. Good luck.