104 FINAL Flashcards
physiological changes in aging adults
decreased cardiac output & lung elasticity, loss of muscle mass, slower reflexes, declined kidney function, thinner/less elastic skin & drier. hearing & visual loss, weakened immune system & hormonal production decreases
cognitive changes in aging adults
[mild changes is common] slower information processing, mild memory decline
mental health risks in aging adults
depression, anxiety, isolation, & substance abuse
generativity VS stagnation
30-64 yrs old; contribute to society, be a part of a family [outcome - sense of productivity OR stagnation & self absorption]
integrity VS despair
65 yrs and up; reflecting on life & coming to terms w past choices [outcome - acceptance or regret & despair]
evidence based practice tools that promote good physical & mental health in aging adults
balanced nutrition, preventative healthcare + screenings, medications, home modifications, counseling
common health problems in aging adults
fraility, impaired vision & hearing, incontinence, weak immune system, sarcopenia [loss of muscle mass], increased physical & emotional stress
sarcopenia
loss of muscle mass & strength, condition in aging adults
delirium
acute confusion that often occurs after hospitalization, or in response to infections, medications, surgery in aging adults
elder abuse
includes physical, sexual, psychological, emotional, or financial abuse, exploitation, & neglect
dementia
various disorders that progressively affect cognitive functioning [is chronic & develops gradually]
alzheimer’s disease
most common form of dementia; starts with memory problems & progresses to decline in self -care
sundowning syndrome
common in dementia pt’s; increased agitation, confusion, anxiety, or aggression that worsens around sunset
cascade iatrogenesis
a chain reaction of adverse events caused by medical treatment or hospitalization, particularly in frail older adults. [ex: pt is admitted for infection, sedatives are given, pt falls & breaks hip]
gerontology
scientific & behavioral study of all aspects of aging & its consequences
polypharmacy
use of multiple medications at a time, increases risk of adverse affects
fulmer SPICES tool
tool that identifies common problems in older adults that can lead to negative outcomes
S = sleep disorders
P = problems w eating/feeding
I = incontinence
C = confusion
E = evidence of falls
S = skin breakdown
dementia pt communication technique
validation therapy, do not reorient, redirect if needed
delirium pt communication technique
use reality orientation [Mr. Smith you are at a hospital right now]
nutrients
substance found in food that we need to grow, function, & stay healthy
essential nutrients
nutrients the body CANNOT make on its own
BMR - basic metabolic rate
of calories required to maintain body functioning at baseline [breathing, circulating blood, etc]
MACROnutrients
essential nutrients that supply energy & build tissue
what are the 3 macronutrients?
carbs, fats[lipids], protein
MICROnutrients
required in smaller amounts than macro, to regulate & control body processes
what are the micronutrients?
vitamins & minerals
primary function of carbohydrates
main source of ENERGY for body, easily & quickly digested, converted into glucose
sugars[simple carbs] & starches[complex carbs]
carbohydrate food sources
C - cereal, oatmeal
A - apples, berries [fruits]
R - real whole grains [brown rice, quinoa]
B - beans, nut, seeds
[corn, potatoes]
common deficiencies of inadequate carb intake
energy depletion, fatigue, poor cognitive function [can cause ketosis in extreme cases
primary function of proteins
tissue growth & repair [wound healing], structural material of every cell in body & can also be used as an energy source if insufficient carbs or fats available
protein food sources
meat, beans eggs, peanut butter, cheese, yogurt, milk, nuts, seeds, chicken, tuna, tofu
common deficiencies of inadequate protein intake
muscle wasting, weakened immune, stunted growth in children, fatigue
primary function of fats [lipids]
insulation, organ protection, vitamin absorption
fat[lipids] food sources
butters, oils, whole milk products, high-fat meats, nuts
what are the 2 categories of vitamins
fat soluble [carried into bloodstream by lipoproteins] & water soluble [absorbed directly into the bloodstream from GI tract
what are the fat soluble vitamins
vitamin A, vitamin D, vitamin K
what are water the soluble vitamins
vitamin B6, vitamin B9, vitamin B12, vitamin C
common deficiencies of inadequate fat intake
essential fatty acid deficiency - dry skin, hair loss, poor wound healing, impaired brain function
cant absorb vitamins properly, poor temp regulation, cognitive issues
vitamin B6
helps metabolize macronutrients, brain health, immune function
food sources for vitamin B6
salmon, organ meats, poultry, bananas, broccoli
vitamin B6 deficiencies
confusion, microcytic anemia, lowered immunity
vitamin B9 (folic acid)
red & white cell, DNA & RNA formation, protein metabolism
food sources for vitamin B9
seafood, liver, leafy green vegetables, nuts & seeds
vitamin B9 deficiencies
microcytic anemia, confusion, lowered immunity
vitamin B12
red blood cells formation, neurological function
vitamin B12 food sources
salmon, tuna, liver, animal products, eggs
vitamin B12 deficiencies
pernicious anemia, fatigue, weakness, cognitive decline
vitamin C function
wound healing, immune function, iron absorption
vitamin C food sources
citrus fruits, strawberries, broccoli, brussel sprouts
vitamin C deficiencies
delayed wound healing, bleeding tendency
vitamin A function
visual acuity, cell growth in skin & mucous membrane, immune function
vitamin A food sources
liver, carrots, fortified milk
vitamin A deficiencies
night blindness, rough; dry skin
vitamin D function
calcium & phosphorus metabolism, calcium absorption, bone health
vitamin D food sources
organ meats, fortified milk products, egg yolks, salmon
vitamin D deficiencies
poor dental & bone health, tetany-hypocalcemia
vitamin K function
blood clotting(prothrombin production) , bone health
vitamin K food sources
dark leafy vegetables, brussel sprouts, soybean oil
vitamin K deficiencies
delayed clotting, bleeding
mineral - iron function
oxygen transport
Iron food sources
oran meats, beef, poultry, shellfish, leafy greens, beans
Iron deficiencies
anemia, weakness, fatigue
mineral - Sodium function
maintains fluid balance
Sodium food sources
salt & processed foods
sodium deficiencies
dizziness, tachycardia, confusion
mineral - Calcium function
bone & teeth formation, muscle contraction, clot formation, nerve conduction
Calcium dietary sources
dairy products, leafy greens, salmon, tuna
Calcium deficiencies
tetany [muscle twitching] , osteoporosis
mineral - Potassium function
cardiac muscle contraction, acid base balance, nerve conduction
Potassium dietary sources
potatoes, vegetables, avocados, bananas, oranges
Potassium deficiencies
ECG changes, muscle cramps, weakness
water function in body
regulates temp, acts as a lubricant
50%-60% of adult body weight
factors that affect nutrition
age, biological sex, state of health, alcohol abuse, medications/supplements, economic factors, religion/culture
anthropometric data
measurement of the size & proportion of human body
examples - weight, height, waist circumference
nutritional screening
quickly identifies issues or risks [nutritional issues, malnourishment or risk for malnourishment]
[MNA] mini nutritional screening
tool used to complete nutritional screening on older adults
comprehensive nutritional assessment
dietary intake, diet Hx, lab data
24 Hr recall method - nutriton
have pt recall everything they ate or drank for the last 24 hrs
food diary/calorie counts
document food & drink, portions, over a period of time
food frequency record
ask pt average of time they ate a specific food per day/week/month etc
“how many times last week did u have a glass of milk”
diet history
usual eating patterns, appetite, allergies, special diets, bowel habits
Dysphagia
difficulty swallowing or inability to swallow
hemoglobin
responsible for carrying oxygen thru body
normal lab range - 12-18 g/dL
hematocrit
percentage of RBC in a persons blood
normal lab range - 46 - 52%
serum albumin
amount of albumin[protein produced by liver] concentration in the blood
normal lab range - 3.4-5.4
prealbumin
amount of prealbumin in blood [transport protein for thyroid hormones & vitamin A]
normal lab range - 19 - 38 mg/dL
interventions for nutritional problems
provide education
monitoring pt status
stimulating appetite [address pain/nausea, meal size/choices, presentation, oral hygiene]
assisting w eating
oral nutrition
regular diet
therapeutic diets [low sodium diet, high fiber diet]
modified consistency diet [clear liquid diet, pureed diet]
NPO
enteral nutrition
pt cant eat orally, deliver food directly into GI tract [usually thru NG tube, G tube, J tube]
short term enteral nutrition
less than 4 weeks
NG tube - nasogastric
NIT tube - nasointestinal
confirming NGT placement
Xray
tube measurement
aspirate assessment
carbon - dioxide monitoring
comfort measures for pt’s w/ NG tube
oral hygeine
keep nares clean
help prevent throat irritation [ sprays or lozenges]
enteral nutrition considerations
placement
positioning of pt
assess bowel sounds & tolerance
tube patency
parenteral nutrition
IV administration of nutrients thru bloodstream
parenteral nutrition considerations
-check VS
-monitor infusion site
-blood glucose levels
-change infusion/discard unused feeding solution set every 24hrs
-monitor D.W & I & O’s
where does the GI tract start & end?
mouth to anus
chyme
partially digested food, semi-liquid food mixture that forms in stomach after food is broken down by gastric juices
what is the function of the large intestine
absorbing water and electrolytes, producing and absorbing vitamins, and forming and propelling feces toward the rectum for elimination.
paralytic ileus
condition where intestines stop moving
recommended daily fluid intake
2,000 - 3,000 mL of fluid a day
recommended daily fiber intake
25 - 38 g of fiber
assessment of bowel elimination
- pt Hx [bowel pattern, aids to elimination, recent changes in bowel elimination]
- inspecting
- auscultating
- palpation
- inspect anus/rectum in a left sims position
proper stool collection
-make pt void first so no urine is in stool sample
-defecate in bed pan & do not place toilet paper in bed pan & do not use soaps
anal fissures
crack, tear in the skin or tissue caused by trauma or stretching
fecal occult blood testing [FOBT]
testing for blood in stool that cannot be seen
normal stool characteristics
brown, soft, semisolid, formed
direct visualization studies - bowel elimination
- colonoscopy
- sigmoidoscopy
indirect visualization studies - bowel elimination
- abdominal ultrasound
- abdominal CT scan
promoting regular bowel habits
- timing [pt has a bowel movement every day at 9am]
- positioning [sitting w knees slightly flexed - maybe use a stool]
- privacy
- nutrition [25-30g of fiber each day]
- exercise
bulk forming [laxative]
they combine w water in the intestine to soften the stool & increase the bulk of the stool
stool softeners [laxative]
they draw water into the stool which softens the stool [add moisture to stool]
stimulant [laxative]
increases intestinal motility & colonic secretions
osmotic [laxative]
draws water into intestine, stimulating bowel movement
lubricants [laxative]
lubricates intestinal tract & slows absorption of water into colon
ileostomy
content directly from ileum [loose, liquid stools]
colostomy
content from end of colon [formed feces]
layers of skin
epidermis [outer layer]
dermis [middle layer]
sub Q [fat cells]
melena stool
black, tarry stools, often a sign of gastrointestinal bleeding from the upper GI tract
erythema
redness of skin
edema
swelling caused by too much fluid trapped in body tissue
functions of the skin
- protection
- temperature regulation
- sensation
- vitamin D production
- absorption
- elimination
measuring wounds
length, width, & depth in cm & mm
tunneling - clockwise
undermining - clockwise
ex: Wound measuring 5 x 4 x 2 cm.
Tunneling noted at 2 o’clock, depth 3.1 cm.
Undermining from 3 o’clock to 7 o’clock, max depth 1.5 cm.”
open wound
intentional or unintentional
[incisions or abrasions]
closed wound
skin surface not broken, soft tissue damage or internal damage
[ecchymosis & hematomas]
ecchymosis
medical term for bruise
hematoma
localized collection of blood outside of blood vessels
acute wound
heals within days to weeks
[usually from trauma, surgery, or injury]
chronic wound
any wound that doesn’t heal along expected continuum
[diabetic foot ulcer, pressure ulcer]
phases of wound healing
- hemostasis
- inflammatory phase
- proliferation/repair phase
- maturation/remodeling phase
exudate
fluid that leaks out of blood vessels into surrounding tissues
granulation tissue
new tissue formed during a wounds healing process
necrosis
death of body tissue due to injury, infection, or lack of blood supply
eschar
dead tissue [black, dry, leathry tissue]
slough
dead tissue [soft, moist, stringy, yellow]
symptoms of infection in wound
purulent drainage, pain, redness, elevated WBC count, & increased body temp
dehiscence
partial or total separation of wound edges after closure
evisceration
emergency form of dehiscence; when internal organs protrude through wound
abcess
collection of infected fluid that has not drained
fistula
abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another
pressure injury
when soft tissue is compressed between a bony prominence & an external surface
ischemia
deficiency of blood in a specific area
stage 1 pressure injury
skin is intact, non-blanchable erythema
stage 2 pressure injury
partial thickness skin loss
[affects epidermis or dermis]
red/pink - no slough present
stage 3 pressure injury
full-thickness tissue loss, may see subQ
slough & tunneling/undermining
stage 4 pressure injury
full tissue loss, bone, muscle, tendon visible - slough, eschar, tunneling/undermining
unstageable
cant see wound bc covered in eschar or slough
deep tissue injury
intact, purplish, blood filled “blister”
undermining
wound is wider underneath [caved in around the edges underneath the top layer]
measured in a clock-face direction
tunneling
tube like pathway
measured by depth & direction
“tunnel at 6 o clock, 3 cm deep”
primary intention [wound healing]
wound edges = clean cut, straight, & well approximated
[incision, paper cut]
secondary intention
wound edges cant be closed [too much tissue loss or infection]
[deep burns, pressure ulcers]
tertiary intention
wound is left open due to infection, swelling, or contamination
[infected surgical wound, dog bite]
ABCDE rule [wounds]
A - assemetry
B - border
C - color
D - diameter
E - evolving
serous drainage
clear & watery
serosanguineous drainage
light pink
mixture of serum & blood cells
sanguineous drainage
red, blood
purulent
thick, opaque fluid usually dark green/yellow
local infection findings
pain, redness, swelling, induration, purulent drainage
systemic infection findings
elevated WBC count & fever
penrose drain
almost acts as a ‘wick’ place dressing over it to catch any drainage
JP drain [jackson pratt]
closed suction, collects fluid, [bulb looking]
hemovac drain
suctions, holds up to 400 mL
induration
hardened/firm tissue around wound
bacterial infection wound - nursing interventions
promote hand hygiene, prescribed antibiotics, apply WARM compress
viral infection wound - nursing interventions
moist/cool compress, start antivirals ASAP
fungal infection wound - nursing interventions
keep clean & DRY, apply cool compress, start antifungals, clean thoroughly w mild soap & water
surgical debridement
medical procedure that removes dead, damaged, infected tissue from a wound
autolytic debridement
body uses enzymes to remove necrotic tissue from wound
mechanical debridement
using dressings to remove
[wet to dry]
braden scale
used to assess risk for pressure injury
the lower the score, the HIGHER the risk
questions to ask urself when choosing a dressing
- is the wound wet or dry?
- does wound have depth? or shallow?
- is wound infected?
- is there a risk for contamination due to incontinence
enzymatic debridement
using chemicals to breakdown tissue
when to use transparent films dressing
Wounds that are small; partial thickness
May remain in place for 4–7 days, resulting in less interference with healing
- Stage 1 pressure injuries
*Wounds with minimal drainage
*Cover dressings for gels, foams, and gauze
*Secure intravenous catheters, nasal cannulas, chest tube dressing, central venous access devices
Hydrocolloid dressings
Partial- and full-thickness wounds
*Stage 2 and stage 3 pressure injuries
*Prevention at high-risk friction areas
*Wounds with light to moderate drainage
*Wounds with necrosis or slough
*First- and second-degree burns
*Not for use with wounds that are infected
Hydrogels
dressing
Partial- and full-thickness wounds
*Stages 2–4 pressure injuries
*Necrotic wounds
*First- and second-degree burns
*Dry wounds
*Wounds with minimal exudate
*Infected wounds
*Radiation tissue damage
alginates dressing
Partial- and full-thickness wounds
*May remain in place for 1–3 days
*Stage 3 and stage 4 pressure injuries
*Infected and noninfected wounds
*Wounds with moderate to heavy exudate
*Tunneling wounds; undermining
*Moist red and yellow wounds
*Not for use with wounds with minimal drainage or dry eschar
foam dressings
Partial- and full-thickness wounds
*May remain in place 3–5 days (7 days for foams with silver), depending on exudate
*Stages 2–4 pressure injuries
*Surgical wounds
*Absorb light to heavy amounts of drainage
*Use around tubes and drains
*Not for use with wounds with dry eschar
antimicrobial dressings
Antimicrobial or antibacterial action (reduce and/or prevent infection)
- Partial- and full-thickness wounds
*Stages 2–4 pressure injuries
*Burns
*Primary dressing over skin graft(s) and donor sites
*Draining, exuding, and nonhealing wounds of any kind (pressure injury, venous/arterial, diabetic, surgical)
*Acute and chronic wounds
collagen dressings
Protein (collagen derived from bovine, porcine, or avian sources) stimulates cellular migration and fosters new tissue development
*partial- or full-thickness wounds
*Stage 3 pressure injuries
*Infected and noninfected wounds
*Primary dressing over skin graft(s) and donor sites
*Tunneling wounds
*Moist red and yellow wounds
contact layer dressings
Placed in contact with base of wound, protecting base from trauma during dressing change
- Partial- and full-thickness wounds
*Require secondary dressing to secure
*Shallow, dehydrated wounds
*Wounds with eschar
*Wounds with viscous exudate
composite dressings
Combine two or more physically distinct products in a single dressing with several functions
*Partial- and full-thickness wounds
*Primary or secondary dressing
*Stages 1–4 pressure injures
*Wounds with minimal to heavy exudate
*Necrotic tissue
*Mixed (granulation and necrotic tissue) wounds
*Infected wounds
negative pressure wound therapy [NPWT]
Noninvasive device that applies pressure to the wound bed through a unit attached to a dressing/sponge (various foam densities)
- Partial- and full-thickness wounds
*May remain in place 2–3 days, depending on manufacturer recommendations
*Stage 3 and stage 4 pressure injuries
*Draining, exuding, and nonhealing wounds of any kind (pressure injury, venous/arterial, diabetic, surgical, dehisced)
function of alveolar system in lungs
GAS EXCHANGE
- oxygenates venous blood
- removes carbon dioxide from blood
cardiopulmonary system
function of respiratory & cardiovascular systems meeting demand of oxygen
cardiovascular & hematologic system function
carry nutrients & waste to & from body cells
pulmonary ventilation
movement of air in [inhalation] & out [exhalation] of the lungs
Ventilation has 2 phases: inspiration[active phase] & expiration[passive phase]
respiration
gas exchange between the atmospheric air in the alveoli & blood in the capillaries
perfusion
oxygenated capillary blood passes through body tissues
hypoxia
inadequate amount of oxygen available to the cells
assessment findings in chronic hypoxia
clubbing of the nails
dyspnea
shortness of breath
hypoventilation
decreased rate or depth of air movement
atelectasis
incomplete lung expansion/collapse of alveoli
bronchial lung sounds
larynx & trachea
high pitched, harsh ‘blowing’ sounds
bronchial-vesicular sounds
1 & 2 intercostal space
medium pitched, ‘blowing’ sounds
vesicular lung sounds
entirety of lung fields
soft, low pitched sounds
adventitious breath sounds
abnormal sounds
pulmonary surfactant
slippery liquid made by lungs - keeps alveoli from collapsing
pleura
double layered membrane - Helps the lungs slide smoothly against the chest wall during breathing
diffusion
movement of oxygen & carbon dioxide between the air & blood
* Oxygen diffuses from alveoli into capillaries in the lungs
* CO2 diffuses out of blood into the alveoli to be exhaled
Emphysema
is a type of chronic obstructive pulmonary disease (COPD) characterized by:
*Destruction of the alveolar walls
*Enlargement of air spaces beyond the terminal bronchioles
*Loss of elasticity in lung tissue → difficulty with exhalation
