Physiological Integrity: Physiological Adaptation
Physiological Adaptation tests the PN's ability to care for clients with acute and chronic illness, recognize system changes, and respond to emergencies.
Assessment priorities
Use ABCs: airway, breathing, circulation. For respiratory distress, position upright, apply oxygen per order, and monitor work of breathing. For chest pain, obtain vital signs, oxygen if indicated, and an ECG per protocol. For neurologic change, use a stroke screen and document the last known well time.
Worked example
A client suddenly develops right-sided weakness, facial droop, and slurred speech. The PN notes the last known well time was 1 hour ago, activates the stroke alert, keeps the client NPO, positions the head slightly elevated, starts IV access per protocol, and avoids giving aspirin until hemorrhage is ruled out. Reasoning: time is brain; thrombolysis may be an option only within a narrow window and only after imaging. Aspirin could worsen a hemorrhagic stroke. The PN's rapid recognition and accurate timeline directly affect treatment.
Chronic conditions
In heart failure, teach daily weights and report a gain of 2-3 lb in a day or 5 lb in a week. In COPD, target oxygen saturation is usually 88-92% per order. In diabetes, monitor for hypoglycemia such as sweating, tremor, and confusion, and treat per protocol. In renal failure, watch potassium, fluid balance, and access site.
Traps
Giving aspirin before a CT scan for stroke; giving oral fluids to a client with acute stroke; ignoring a change in mental status; applying high-flow oxygen to a COPD client without an order; treating a blood pressure of 80/50 with a wait-and-see approach.