第 5 章，共 6 章26% 占考试比重

Physiological Integrity

Physiological Integrity is the largest content area and covers basic care and comfort, reduction of risk, and the physiological adaptation to illness. The LPN/LVN gathers data on body systems, provides basic care, monitors for complications, and reports changes to the RN. This chapter reviews common conditions and the observations and interventions that keep clients safe.

Basic Care and Comfort

Meeting fundamental needs such as mobility, nutrition, elimination, and skin care supports recovery and prevents complications. The LPN/LVN provides much of this hands-on care.

Prevent pressure injuries

Reposition immobile clients at least every 2 hours and keep skin clean and dry; avoid vigorous massage of reddened areas.

Support safe swallowing

Position clients upright and provide thickened liquids as ordered for dysphagia to prevent aspiration.

Elevate for tube feeding

Keep the head of the bed at least 30 degrees during enteral feeding to reduce aspiration risk.

Promote elimination

Monitor intake and output and maintain closed urinary drainage systems below bladder level.

Monitoring and Data Collection

The LPN/LVN collects and reports data that signal improvement or deterioration. Recognizing abnormal findings allows early intervention.

Report worsening heart failure

A sudden weight gain suggests fluid retention and should be reported promptly.

Recognize fluid imbalances

Dry mucous membranes and poor turgor suggest deficit; edema and crackles suggest overload.

Watch urine output

Report output persistently below 30 mL per hour as it may indicate impaired perfusion.

Monitor neurovascular status

After casting, report severe unrelieved pain and numbness that may indicate compartment syndrome.

Reduction of Risk and Postoperative Care

Preventing complications after surgery and during treatment is a core nursing role. Early mobilization, breathing exercises, and vigilant monitoring reduce risk.

Prevent respiratory complications

Encourage incentive spirometry, coughing, and deep breathing to prevent atelectasis and pneumonia.

Protect surgical sites

Maintain positioning such as abduction after hip replacement to prevent dislocation.

Recognize embolism

Sudden dyspnea, chest pain, and confusion after a long-bone fracture may signal fat or pulmonary embolism.

Monitor invasive devices

Report continuous bubbling in a chest tube water seal and never clamp a chest tube unnecessarily.

Physiological Adaptation: Endocrine and Metabolic

Endocrine and metabolic disorders alter energy, fluid balance, and organ function. The nurse recognizes characteristic patterns and emergencies.

Treat hypoglycemia promptly

For glucose around 55 mg/dL with symptoms, give 15 grams of fast-acting carbohydrate and recheck.

Recognize thyroid patterns

Hypothyroidism causes fatigue, cold intolerance, and constipation; hyperthyroidism causes the opposite.

Watch for post-thyroidectomy hypocalcemia

Tingling around the mouth and muscle twitching require prompt reporting.

Teach diabetic foot care

Daily foot inspection and well-fitting shoes prevent injury and support ulcer healing.

Physiological Adaptation: Cardiac, Respiratory, and Others

Many acute and chronic conditions affect the heart, lungs, and other systems. The nurse tailors oxygenation, positioning, and monitoring to the condition.

Titrate oxygen carefully in COPD

Use low-flow oxygen such as 2 L per minute to avoid suppressing respiratory drive.

Position for breathing

Use semi-Fowler's or Fowler's position for ascites and respiratory distress.

Recognize transfusion reactions

Fever, chills, and flank pain require stopping the transfusion and notifying the RN.

Identify common presentations

Right lower quadrant rebound pain suggests appendicitis, and burning with frequency suggests urinary tract infection.

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Last updated: July 2026