Physiological Integrity

Master physiological integrity concepts with free flashcards and spaced repetition practice to reinforce your NCLEX-RN preparation. This lesson covers basic care and comfort (nutrition, elimination, mobility, rest), pharmacology (dosage calculations, medication administration, adverse effects, drug interactions), reduction of risk potential (lab values, diagnostic tests, potential complications), and physiological adaptation (alterations in body systems, fluid/electrolyte imbalances, hemodynamics, illness management, medical emergencies, pathophysiology)—essential concepts for passing your nursing licensure exam.

Welcome to Physiological Integrity 🏥

Welcome to the most heavily weighted category on the NCLEX-RN exam! Physiological Integrity accounts for approximately 38-62% of the test questions, making it the largest content area you'll encounter. This lesson will equip you with the critical knowledge needed to assess, monitor, and intervene when patients experience alterations in body systems.

As a registered nurse, you'll be responsible for recognizing early warning signs of complications, interpreting diagnostic data, calculating medication dosages accurately, and responding appropriately to medical emergencies. The content in this lesson builds directly on the foundational concepts from your earlier lessons on safety, infection control, and psychosocial integrity—now we're diving deep into the physiological processes that underpin patient care.

Core Concepts: Basic Care and Comfort 🛏️

Basic care and comfort encompasses the fundamental nursing interventions that promote patient well-being and address activities of daily living (ADLs).

Nutrition and Hydration 🥗

Enteral nutrition refers to feeding through the gastrointestinal tract, whether orally or via feeding tubes (nasogastric, gastrostomy, jejunostomy). Parenteral nutrition (TPN) bypasses the GI tract entirely, delivering nutrients directly into the bloodstream through central venous access.

💡 Tip: Remember the mnemonic "ABCDEF" for assessing nutrition status:

• Albumin levels (normal: 3.5-5.0 g/dL)
• Body mass index (BMI)
• Cholesterol levels
• Dietary intake assessment
• Elimination patterns
• Fluid balance

Aspiration precautions are critical for patients receiving enteral nutrition:

• Elevate head of bed 30-45 degrees during feeding and for 1 hour after
• Check gastric residual volumes before intermittent feedings (hold feeding if >500 mL)
• Verify tube placement before each feeding (pH testing, X-ray confirmation)
• Monitor for signs of aspiration: coughing, dyspnea, decreased oxygen saturation

Elimination Patterns 🚽

Urinary elimination alterations include:

• Anuria: No urine output (<100 mL/24 hours) - medical emergency!
• Oliguria: Decreased output (<400 mL/24 hours) - indicates renal dysfunction or hypovolemia
• Polyuria: Excessive output (>2500 mL/24 hours) - seen in diabetes insipidus, diabetes mellitus
• Dysuria: Painful urination - suggests UTI or urethral irritation

Indwelling catheter care requires strict aseptic technique:

• Keep drainage bag below bladder level at all times
• Secure catheter to thigh to prevent urethral traction
• Empty drainage bag when 2/3 full or every 8 hours
• Perform perineal care twice daily
• Monitor for catheter-associated UTI (CAUTI): fever, cloudy urine, hematuria, suprapubic pain

Bowel elimination assessment includes frequency, consistency, color, and presence of blood or mucus. The Bristol Stool Chart classifies stool types 1-7, with type 4 (smooth, snake-like) being ideal.

Mobility and Immobility 🏃‍♀️

Immobility complications develop rapidly and affect multiple body systems:

COMPLICATIONS OF IMMOBILITY BY SYSTEM

🫀 CARDIOVASCULAR
├─ Orthostatic hypotension
├─ Venous thromboembolism (DVT/PE)
└─ Decreased cardiac output

🫁 RESPIRATORY
├─ Atelectasis
├─ Pneumonia
└─ Decreased lung expansion

💪 MUSCULOSKELETAL
├─ Muscle atrophy
├─ Contractures
├─ Osteoporosis
└─ Pressure injuries

🧠 NEUROLOGICAL
├─ Confusion/disorientation
└─ Sensory deprivation

🍽️ GASTROINTESTINAL
├─ Constipation
└─ Fecal impaction

🚽 GENITOURINARY
├─ Urinary stasis
└─ Renal calculi

Pressure injury prevention follows the Braden Scale assessment (scores 6-23, with ≤18 indicating risk):

• Sensory perception
• Moisture exposure
• Activity level
• Mobility
• Nutritional status
• Friction and shear

Interventions: Reposition every 2 hours, use pressure-relieving devices, maintain skin integrity, optimize nutrition, keep skin clean and dry.

Rest and Sleep 😴

Sleep architecture includes:

• NREM (Non-REM) sleep: Stages 1-3, with stage 3 being deep restorative sleep
• REM (Rapid Eye Movement) sleep: Dream stage, essential for memory consolidation

A complete sleep cycle lasts approximately 90 minutes. Adults need 7-9 hours of sleep nightly.

Promoting sleep in hospitalized patients:

• Cluster care activities to minimize interruptions
• Reduce noise and dim lights after 9 PM
• Maintain comfortable room temperature (68-72°F)
• Limit caffeine intake after 2 PM
• Address pain before bedtime
• Encourage relaxation techniques

Core Concepts: Pharmacology 💊

Pharmacology is a critical nursing competency that requires mathematical precision and clinical judgment.

Medication Dosage Calculations 🧮

The dimensional analysis method is the most reliable calculation approach:

Formula: Desired dose × Volume available ÷ Dose available = Amount to administer

Example: Order: Amoxicillin 500 mg PO. Available: 250 mg/5 mL. How many mL to give?

Step	Calculation	Result
1	Identify desired dose	500 mg
2	Identify available concentration	250 mg/5 mL
3	Set up equation: (500 mg × 5 mL) ÷ 250 mg
4	2500 ÷ 250	10 mL

IV drip rate calculations use the formula:

mL/hour = Total volume (mL) ÷ Time (hours)

For drop factor calculations:

Drops/minute = (Volume in mL × Drop factor) ÷ Time in minutes

💡 Tip: Remember common drop factors:

• Macrodrip: 10, 15, or 20 gtt/mL
• Microdrip: 60 gtt/mL (microdrip drop factor always equals mL/hour!)

Weight-based dosing is essential for pediatrics and critical medications:

Dose = Weight (kg) × Ordered dose (mg/kg)

⚠️ CRITICAL: Always convert pounds to kilograms (divide by 2.2) before calculating weight-based doses!

Medication Administration Routes 💉

Route	Onset	Considerations
IV (Intravenous)	Immediate	Most rapid; no absorption phase; risk of fluid overload
IM (Intramuscular)	10-30 min	Deltoid max 1 mL; ventrogluteal max 3 mL; use Z-track for irritating meds
SubQ (Subcutaneous)	15-30 min	Abdomen, thigh, upper arm; max 1.5 mL; rotate insulin sites
PO (Oral)	30-60 min	Most convenient; affected by first-pass metabolism
SL (Sublingual)	3-5 min	Bypasses first-pass; nitroglycerin for angina
Topical	Variable	Local or systemic effects; rotate patch sites

Six Rights of Medication Administration:

1. Right patient (2 identifiers: name + DOB/MRN)
2. Right medication (check label 3 times)
3. Right dose (calculate and verify)
4. Right route (confirm appropriate for patient condition)
5. Right time (within 30-60 minutes of scheduled time)
6. Right documentation (never document before administering!)

Modern practice adds additional rights: right reason, right to refuse, right assessment, right evaluation, right patient education.

Adverse Effects and Drug Interactions ⚠️

Adverse drug reactions (ADRs) range from mild to life-threatening:

Type A reactions (Augmented): Predictable, dose-dependent

• Example: Hypotension from antihypertensives, bleeding from anticoagulants

Type B reactions (Bizarre): Unpredictable, not dose-dependent

• Example: Anaphylaxis, Stevens-Johnson syndrome

Anaphylaxis recognition - know the signs:

• Respiratory: Dyspnea, wheezing, stridor, throat tightness
• Cardiovascular: Hypotension, tachycardia, cardiac arrest
• Skin: Urticaria (hives), flushing, angioedema
• GI: Nausea, vomiting, diarrhea, cramping

Emergency intervention: Stop medication immediately → Call for help → Administer epinephrine 0.3-0.5 mg IM (anterolateral thigh) → High-flow oxygen → IV fluids → Antihistamines and corticosteroids

High-alert medications require extra vigilance:

• Anticoagulants (heparin, warfarin): Monitor PT/INR or aPTT; have reversal agents available (vitamin K for warfarin, protamine for heparin)
• Insulin: Always use insulin syringe; double-check sliding scale orders; monitor blood glucose
• Opioids: Monitor respiratory rate (hold if <12/min); have naloxone readily available
• Chemotherapy: Verify dose with second RN; use appropriate PPE; extravasation precautions

Nephrotoxic medications to monitor:

• Aminoglycosides (gentamicin, tobramycin)
• NSAIDs (ibuprofen, naproxen)
• ACE inhibitors
• Contrast dye
• Amphotericin B

Ototoxic medications can cause hearing loss:

• Aminoglycosides
• Loop diuretics (furosemide)
• Aspirin (high doses)
• Cisplatin

Drug-food interactions:

• Warfarin + Vitamin K foods (leafy greens): Decreases anticoagulant effect
• MAOIs + Tyramine foods (aged cheese, wine): Hypertensive crisis
• Grapefruit juice + Statins: Increases drug levels and toxicity risk
• Dairy products + Tetracycline: Decreases absorption

Core Concepts: Reduction of Risk Potential 🔬

Reduction of risk potential involves recognizing early warning signs of complications and intervening before conditions deteriorate.

Laboratory Values Interpretation 📊

Electrolyte imbalances and their classic presentations:

Hypokalemia (K+ <3.5 mEq/L):

• Causes: Diuretics, vomiting, diarrhea, inadequate intake
• Signs: Muscle weakness, leg cramps, constipation, cardiac dysrhythmias
• ECG changes: Flattened T waves, presence of U waves, ST depression
• Treatment: Potassium supplements (never IV push!), increase dietary K+

Hyperkalemia (K+ >5.0 mEq/L):

• Causes: Renal failure, K+-sparing diuretics, tissue breakdown, metabolic acidosis
• Signs: Muscle twitching, paresthesias, life-threatening dysrhythmias
• ECG changes: Tall peaked T waves, widened QRS, prolonged PR interval
• Treatment: Calcium gluconate (cardiac protection), insulin + glucose, sodium polystyrene (Kayexalate), dialysis

Hyponatremia (Na+ <135 mEq/L):

• Signs: Confusion, lethargy, headache, seizures (severe)
• Treatment: Fluid restriction for dilutional hyponatremia; isotonic saline for true deficit
• ⚠️ DANGER: Never correct too rapidly! Risk of osmotic demyelination syndrome

Hypernatremia (Na+ >145 mEq/L):

• Signs: Thirst, dry mucous membranes, restlessness, seizures
• Treatment: Hypotonic fluids (0.45% NaCl or D5W), correct slowly

Diagnostic Tests and Procedures 🔍

Pre-procedure responsibilities:

• Verify informed consent is signed
• Confirm NPO status if required
• Assess allergies (especially contrast dye, iodine, shellfish)
• Obtain baseline vital signs
• Remove jewelry, dentures, prosthetics as indicated
• Teach patient what to expect
• Administer pre-procedure medications as ordered

Post-procedure monitoring:

• Monitor vital signs per protocol
• Assess for complications specific to procedure
• Check access sites for bleeding/hematoma
• Monitor level of consciousness
• Resume diet/activity as ordered
• Encourage fluids (especially after contrast dye to enhance elimination)

Contrast dye precautions:

• Metformin (Glucophage): Hold for 48 hours after contrast administration (risk of lactic acidosis)
• Renal function: Check creatinine before procedure; risk of contrast-induced nephropathy
• Hydration: IV fluids before and after to protect kidneys
• Allergy history: Pre-medicate with antihistamines and steroids if prior reaction

Potential Complications Recognition 🚨

Postoperative complications to monitor:

POSTOP COMPLICATIONS TIMELINE

Immediate (0-24 hours)
├─ Hemorrhage ⚠️
├─ Shock
├─ Airway obstruction
├─ Aspiration
└─ Hypothermia

Early (1-3 days)
├─ Atelectasis 🫁
├─ Pneumonia
├─ Thrombophlebitis
├─ Urinary retention
└─ Paralytic ileus

Late (>3 days)
├─ Wound infection 🦠
├─ Dehiscence/Evisceration
├─ Pulmonary embolism
└─ Deep vein thrombosis

Hemorrhage recognition:

• Early signs: Tachycardia, restlessness, decreased urine output, cool/clammy skin
• Late signs: Hypotension, decreased LOC, weak/thready pulse
• Remember: Blood pressure drops LAST - don't wait for hypotension!

Wound dehiscence vs. evisceration:

• Dehiscence: Separation of wound layers (often with "popping" sensation and serosanguineous drainage)
• Evisceration: Protrusion of internal organs through wound
• Emergency intervention: Cover with sterile saline-soaked gauze, place patient supine with knees flexed, NPO, notify surgeon immediately

Pulmonary embolism (PE) - sudden onset of:

• Dyspnea and tachypnea
• Pleuritic chest pain
• Tachycardia
• Feeling of impending doom
• Hemoptysis (late sign)
• Immediate action: High-flow oxygen, position upright, notify provider, prepare for anticoagulation

Core Concepts: Physiological Adaptation 🫀

Physiological adaptation addresses the body's response to illness and the nursing care needed to support compensatory mechanisms.

Fluid and Electrolyte Balance ⚖️

Fluid compartments:

• Intracellular fluid (ICF): 2/3 of total body water, inside cells
• Extracellular fluid (ECF): 1/3 of total body water
  • Intravascular (plasma): Inside blood vessels
  • Interstitial: Between cells and tissues
  • Transcellular: CSF, synovial fluid, GI secretions

Fluid volume deficit (FVD/Dehydration):

• Causes: Insufficient intake, excessive losses (vomiting, diarrhea, hemorrhage, burns)
• Assessment: Poor skin turgor, dry mucous membranes, decreased urine output, concentrated urine, increased heart rate, decreased blood pressure, weight loss
• Lab findings: Increased BUN, increased hematocrit, increased urine specific gravity (>1.030)
• Treatment: Oral rehydration if able; IV isotonic fluids (0.9% NaCl or Lactated Ringer's)

Fluid volume excess (FVE/Fluid overload):

• Causes: Excessive IV fluids, heart failure, renal failure, liver cirrhosis
• Assessment: Edema (dependent or generalized), weight gain (1 L fluid = 1 kg/2.2 lbs), distended neck veins, crackles in lungs, dyspnea, increased blood pressure
• Lab findings: Decreased BUN, decreased hematocrit, decreased urine specific gravity
• Treatment: Fluid restriction, diuretics (furosemide), treat underlying cause

IV fluid types:

Fluid Type	Examples	Movement	Uses
Isotonic	0.9% NaCl (NS), Lactated Ringer's	Stays in intravascular space	Volume replacement, blood transfusions
Hypotonic	0.45% NaCl, D5W*	Shifts into cells	Cellular dehydration, hypernatremia
Hypertonic	3% NaCl, D10W, TPN	Pulls fluid from cells	Severe hyponatremia, cerebral edema

*D5W is isotonic in bag but becomes hypotonic once dextrose is metabolized

Acid-Base Balance 🧪

Normal arterial blood gas (ABG) values:

• pH: 7.35-7.45
• PaCO₂: 35-45 mmHg
• HCO₃⁻: 22-26 mEq/L
• PaO₂: 80-100 mmHg
• SaO₂: 95-100%

ABG interpretation using the "ROME" mnemonic:

• Respiratory Opposite: pH and PaCO₂ move in opposite directions
• Metabolic Equal: pH and HCO₃⁻ move in the same direction

Compensation: The body system NOT causing the problem tries to fix it

• Partial compensation: pH still abnormal but moving toward normal
• Full compensation: pH returns to normal range (7.35-7.45)
• Respiratory system compensates in minutes to hours
• Renal system compensates in hours to days

Shock States 🚨

Shock is inadequate tissue perfusion resulting in cellular hypoxia.

Types of shock:

SHOCK CLASSIFICATION

📉 HYPOVOLEMIC SHOCK
   └─ Decreased intravascular volume
      ├─ Hemorrhage (trauma, GI bleed)
      ├─ Dehydration (vomiting, diarrhea)
      └─ Burns (fluid shift to interstitial space)

💔 CARDIOGENIC SHOCK
   └─ Pump failure
      ├─ Myocardial infarction
      ├─ Heart failure
      └─ Dysrhythmias

🦠 DISTRIBUTIVE SHOCK
   └─ Massive vasodilation
      ├─ Septic (infection → systemic inflammatory response)
      ├─ Anaphylactic (severe allergic reaction)
      └─ Neurogenic (spinal cord injury → lost sympathetic tone)

🚫 OBSTRUCTIVE SHOCK
   └─ Physical obstruction to blood flow
      ├─ Pulmonary embolism
      ├─ Cardiac tamponade
      └─ Tension pneumothorax

Shock stages:

1. Initial stage: Cellular hypoxia begins; no obvious signs
2. Compensatory stage: Body activates compensatory mechanisms
   • ↑ Heart rate, ↑ respiratory rate
   • Peripheral vasoconstriction
   • Urine output begins to decrease
   • Patient anxious, restless
3. Progressive stage: Compensatory mechanisms fail
   • ↓ Blood pressure
   • ↓ Level of consciousness
   • ↓ Urine output (<0.5 mL/kg/hr)
   • Cool, clammy, mottled skin
4. Refractory stage: Irreversible organ damage
   • Multiple organ dysfunction syndrome (MODS)
   • Death imminent without aggressive intervention

Shock management priorities:

1. Airway maintenance and oxygenation
2. IV access (two large-bore IVs)
3. Fluid resuscitation (crystalloids first, then blood products if hemorrhagic)
4. Vasopressors if hypotension persists (norepinephrine, dopamine)
5. Treat underlying cause
6. Monitor: Vital signs continuously, urine output, level of consciousness, lab values

Common Medical Emergencies 🆘

Diabetic Ketoacidosis (DKA):

• Pathophysiology: Insulin deficiency → cells can't use glucose → breakdown of fats → ketone production → metabolic acidosis
• Classic triad: Hyperglycemia (>250 mg/dL), metabolic acidosis (pH <7.3), ketones in blood/urine
• Signs: Kussmaul respirations (deep, rapid breathing), fruity breath odor, dehydration, altered LOC
• Treatment: IV insulin infusion, aggressive fluid replacement (0.9% NaCl), potassium replacement (insulin drives K+ into cells), treat precipitating cause

Hyperosmolar Hyperglycemic State (HHS):

• Pathophysiology: Extreme hyperglycemia (>600 mg/dL) without significant ketosis
• Signs: Severe dehydration, altered mental status, seizures possible
• Treatment: Similar to DKA but requires more fluid replacement; typically seen in Type 2 diabetes

Myocardial Infarction (MI):

• Classic symptoms: Crushing substernal chest pain radiating to left arm/jaw, diaphoresis, dyspnea, nausea
• Atypical presentation: Women, elderly, diabetics may have vague symptoms (fatigue, indigestion, back pain)
• MONA protocol:
  • Morphine for pain
  • Oxygen if SpO₂ <90%
  • Nitroglycerin (sublingual or IV)
  • Aspirin 160-325 mg (chew for faster absorption)
• Priority: Rapid ECG, cardiac biomarkers (troponin), prepare for cardiac catheterization
• Time is muscle! Goal: Door-to-balloon time <90 minutes

Stroke:

• BE FAST assessment:
  • Balance loss
  • Eye vision changes
  • Face drooping (one side)
  • Arm weakness (one side drifts down)
  • Speech difficulty (slurred)
  • Time to call 911 (note time of symptom onset!)
• Types:
  • Ischemic (85%): Blockage of blood vessel
  • Hemorrhagic (15%): Bleeding in brain
• Critical: CT scan immediately to differentiate type before treatment
• tPA (alteplase): Clot-buster for ischemic stroke ONLY; must give within 3-4.5 hours of symptom onset

Seizures:

• Types: Generalized (tonic-clonic, absence) vs. Focal (partial)
• Status epilepticus: Seizure lasting >5 minutes or repeated seizures without regaining consciousness - medical emergency!
• During seizure: Protect from injury, turn to side (if possible), note duration and characteristics, DO NOT restrain or put anything in mouth
• After seizure: Monitor airway, position on side, reassure patient during postictal period (confusion, drowsiness)
• Treatment: Benzodiazepines (lorazepam, diazepam) for status epilepticus

Example 1: Dosage Calculation with IV Drip Rate 💧

Scenario: Your patient is ordered 1000 mL of 0.9% Normal Saline to infuse over 8 hours. The IV tubing has a drop factor of 15 gtt/mL. Calculate the drip rate in drops per minute.

Solution:

First, calculate mL/hour:

• mL/hour = Total volume ÷ Time in hours
• mL/hour = 1000 mL ÷ 8 hours = 125 mL/hour

Then, calculate drops per minute:

• Drops/minute = (mL/hour × Drop factor) ÷ 60 minutes
• Drops/minute = (125 × 15) ÷ 60
• Drops/minute = 1875 ÷ 60 = 31.25
• Answer: 31 gtt/min (round to nearest whole number)

Step	Calculation	Result
1	1000 mL ÷ 8 hours	125 mL/hour
2	125 × 15 (drop factor)	1875
3	1875 ÷ 60 minutes	31.25 gtt/min
4	Round to whole number	31 gtt/min

💡 Tip: With microdrip tubing (60 gtt/mL), the drops per minute equals the mL per hour! This makes calculations much simpler.

Example 2: ABG Interpretation 🧪

Scenario: A patient presents with the following ABG results:

• pH: 7.28
• PaCO₂: 58 mmHg
• HCO₃⁻: 26 mEq/L
• PaO₂: 65 mmHg

Analysis:

Parameter	Value	Normal Range	Interpretation
pH	7.28	7.35-7.45	Acidotic ↓
PaCO₂	58	35-45	Elevated ↑ (matches acidosis)
HCO₃⁻	26	22-26	Normal
PaO₂	65	80-100	Hypoxemia

Diagnosis: Uncompensated Respiratory Acidosis

Explanation:

1. pH is LOW (acidotic)
2. PaCO₂ is HIGH (respiratory cause - patient is retaining CO₂)
3. HCO₃⁻ is normal (kidneys haven't started compensating yet)
4. Low PaO₂ indicates the patient is also hypoxemic

Clinical correlation: This pattern is classic for COPD exacerbation or respiratory depression from opioids. The patient is hypoventilating, retaining CO₂, leading to respiratory acidosis.

Nursing interventions: Improve ventilation, position patient upright, encourage deep breathing/coughing, oxygen therapy (carefully in COPD - don't suppress respiratory drive), possible mechanical ventilation if severe.

Example 3: Recognizing Fluid Overload 💧

Scenario: Your post-operative patient received 3 liters of IV fluids during surgery. On assessment 4 hours post-op, you note:

• Weight gain of 3 kg since pre-op
• Distended neck veins even when sitting upright
• Bilateral crackles in lung bases
• Shortness of breath with minimal exertion
• Blood pressure 158/94 (baseline 128/78)
• Urine output 180 mL in last 4 hours

Analysis: This patient shows multiple signs of fluid volume excess (FVE):

FLUID OVERLOAD ASSESSMENT

⚖️ Weight:
   Pre-op: Unknown
   Current: +3 kg gain
   Significance: 1 kg = 1 L fluid
   → Patient has ~3 L excess fluid

🫁 Respiratory:
   ✓ Crackles (fluid in alveoli)
   ✓ Dyspnea (decreased gas exchange)
   → Pulmonary edema developing

💓 Cardiovascular:
   ✓ Distended neck veins (↑ CVP)
   ✓ Hypertension (↑ intravascular volume)
   → Circulatory overload

🚽 Renal:
   ✓ Decreased urine output
   (45 mL/hr - should be at least 30 mL/hr)
   → Kidneys overwhelmed or failing

Priority interventions:

1. Position patient in high Fowler's (sitting upright) to ease breathing
2. Administer oxygen to maintain SpO₂ >90%
3. Notify provider immediately - likely need diuretic (furosemide)
4. Restrict fluids as ordered
5. Strict I&O monitoring
6. Daily weights (same time, same scale, same clothing)
7. Monitor for worsening: pink, frothy sputum indicates severe pulmonary edema

💡 Teaching point: Rapid weight gain in hospitalized patients is almost always fluid, not fat. Track daily weights carefully!

Example 4: Medication Error Prevention 💊

Scenario: You receive an order: "Morphine 10 mg IV push for pain." Available: Morphine 15 mg/mL vial. As you prepare to draw up the medication, you notice the patient's respiratory rate is 10 breaths/minute.

Critical thinking process:

1. Calculate dose: 10 mg ÷ 15 mg/mL = 0.67 mL
2. Assess patient parameters: Respiratory rate is 10/min
3. Recall contraindication: Opioids should be held if respiratory rate <12/min
4. Decision: Do NOT administer medication

Correct action:

• Hold the medication
• Notify the provider about low respiratory rate
• Reassess pain using non-pharmacological interventions
• Document: "Morphine 10 mg IV held due to respiratory rate of 10/min. Provider notified. Patient repositioned and relaxation techniques encouraged."
• Continue monitoring and reassess respiratory rate

⚠️ Key point: Even with a valid order, nurses are accountable for assessing whether administration is safe at that moment. Use clinical judgment!

Other opioid administration safety checks:

• Verify respiratory rate >12/min
• Check level of consciousness (don't give if overly sedated)
• Assess pain level before and after administration
• Have naloxone (Narcan) readily available as reversal agent
• Monitor oxygen saturation
• Use caution with elderly patients and those with respiratory disease

Common Mistakes to Avoid ⚠️

Calculation Errors 🧮

❌ Mistake: Forgetting to convert pounds to kilograms before weight-based dosing

• Example: Ordered: Medication 5 mg/kg for 110-lb patient
• Wrong: 110 × 5 = 550 mg (used pounds instead of kg!)
• Correct: 110 lbs ÷ 2.2 = 50 kg → 50 × 5 = 250 mg
• Why it matters: This error results in a more than 2× overdose - potentially fatal!

❌ Mistake: Confusing IV rate in mL/hr with drops/min

• These are completely different! Always verify which unit is being asked for.

❌ Mistake: Not double-checking insulin and heparin doses

• These high-alert medications require independent double-check by another nurse

Lab Value Misinterpretation 📊

❌ Mistake: Thinking "K+ of 5.5 is close enough to normal"

• Reality: Even mild hyperkalemia can cause lethal dysrhythmias
• Critical value (>6.5) requires immediate intervention, but elevation above 5.0 needs monitoring and treatment

❌ Mistake: Ignoring sodium levels in symptomatic patients

• "Sodium is only a few points off" - but neurological symptoms with hyponatremia can be severe
• Always correlate lab values with clinical presentation

❌ Mistake: Focusing only on abnormal values without considering the whole picture

• Elevated BUN with normal creatinine? Check hydration status (likely dehydration)
• Elevated BUN AND creatinine? Think kidney dysfunction

Medication Administration 💊

❌ Mistake: Crushing extended-release or enteric-coated tablets

• Destroys the controlled-release mechanism → drug dumping → toxicity
• Look for abbreviations: XR, SR, ER, CD, CR, LA - never crush these

❌ Mistake: Mixing incompatible medications in the same IV line

• Some medications precipitate when combined (e.g., phenytoin with dextrose solutions)
• Always flush line between incompatible medications

❌ Mistake: Not checking for allergies before EVERY medication administration

• Cross-reactivity exists (penicillin allergy → may react to cephalosporins)
• Always ask about allergies AND type of reaction

Fluid and Electrolyte Management ⚖️

❌ Mistake: Rapid correction of chronic electrolyte imbalances

• Hyponatremia: Correcting too fast → osmotic demyelination syndrome (brain damage)
• Hyperglycemia: Correcting too fast → cerebral edema
• Rule: Chronic problems require slow corrections

❌ Mistake: Using D5W to replace fluid volume in hypotensive patients

• D5W becomes hypotonic once dextrose is metabolized
• Hypotonic solutions worsen hypotension by shifting fluid OUT of vessels
• Use isotonic solutions (0.9% NaCl or Lactated Ringer's) for volume replacement

Emergency Situations 🚨

❌ Mistake: Delaying intervention while waiting for provider orders in true emergencies

• Examples: Anaphylaxis, cardiac arrest, severe hemorrhage
• Nurses can initiate emergency protocols per facility policy
• Don't wait for permission to start CPR or give epinephrine for anaphylaxis!

❌ Mistake: Not recognizing early signs of shock

• Waiting for blood pressure to drop means the patient is already decompensating
• Early signs: Tachycardia, restlessness, decreased urine output, skin changes
• Intervene early - it's harder to reverse once shock progresses

Key Takeaways 🎯

Basic Care Priorities

✅ Aspiration prevention requires head of bed elevation 30-45° for all tube feedings and for 1 hour after ✅ Immobility complications develop rapidly - reposition every 2 hours and assess Braden Scale ✅ Normal urine output is 0.5-1 mL/kg/hr (approximately 30 mL/hr minimum for average adult) ✅ Catheter care includes keeping bag below bladder level and monitoring for CAUTI signs

Pharmacology Essentials

✅ Always convert pounds to kilograms (÷2.2) before weight-based dosing calculations ✅ Six Rights of medication administration are your safety foundation - never skip steps ✅ High-alert medications (insulin, anticoagulants, opioids) require extra vigilance and double-checking ✅ Hold opioids if respiratory rate <12/min; hold digoxin if heart rate <60/min (unless otherwise ordered) ✅ Microdrip tubing (60 gtt/mL) makes calculations easy: drops/min = mL/hr

Lab Value Priorities

✅ Potassium imbalances affect cardiac function - monitor ECG and treat promptly ✅ Never correct chronic hyponatremia rapidly - risk of osmotic demyelination syndrome ✅ Critical lab values require immediate provider notification - don't wait ✅ Always correlate lab results with clinical assessment - numbers alone don't tell the whole story

Emergency Recognition

✅ Shock compensation means tachycardia and tachypnea appear BEFORE hypotension ✅ Anaphylaxis treatment = epinephrine IM immediately, don't wait for full symptom development ✅ Stroke time window for tPA is 3-4.5 hours - note exact time of symptom onset ✅ DKA triad: hyperglycemia >250, acidosis, ketones - treatment includes insulin, fluids, K+ replacement ✅ Pulmonary embolism presents suddenly with dyspnea, chest pain, sense of doom

Fluid and Electrolyte Management

✅ Isotonic fluids (0.9% NaCl, LR) for volume replacement stay in vascular space ✅ 1 kg weight change = 1 liter of fluid - rapid weight gain indicates fluid retention ✅ ABG interpretation: pH first (acidosis vs alkalosis), then determine respiratory or metabolic cause ✅ Fluid overload signs: crackles, dyspnea, distended neck veins, weight gain, hypertension

Did You Know? 🤔

💡 The average person produces about 1.5 liters of urine per day, but critically ill patients may produce much less due to stress response and hormonal changes (ADH and aldosterone release).

💡 Potassium cannot be given IV push - it must always be diluted and given slowly because rapid administration can cause cardiac arrest. This is why concentrated potassium vials have bold warning labels!

💡 The "golden hour" in trauma care isn't exactly 60 minutes - it's a concept emphasizing that survival rates dramatically improve with rapid intervention in the first critical period after injury.

💡 Microdrip IV tubing was specifically designed to make calculations easier for pediatrics and critical care - since 60 gtt/mL matches 60 minutes in an hour, the math simplifies to drops/min = mL/hr!

📚 Further Study

For additional practice and deeper understanding of Physiological Integrity concepts:

1. NCSBN Learning Extension (https://www.ncsbn.org/learning-extension.htm) - Official NCLEX prep with detailed rationales for physiological integrity questions

2. RegisteredNursing.org NCLEX Practice (https://www.registerednursing.org/nclex/) - Free practice questions organized by client needs categories with video explanations

3. Lab Values and Diagnostic Tests (https://www.labce.com/) - Interactive modules for interpreting laboratory results and understanding diagnostic procedures

Remember: Physiological Integrity is the foundation of nursing practice. Master these concepts through repeated practice, and you'll be well-prepared not just for the NCLEX-RN, but for your entire nursing career! 🎓💙