126 midterm 1 Flashcards
Ages for ‘young-old’
65-74
Ages for ‘middle-old’
75-84
Ages for ‘old-old’
85+
C-Diff
HAI causing diarrhea from bacteria, life-threatening
HAI
Health associated infection, AKA nosocomial
Flu
Respiratory illness from virus, mild-severe
normal flora
microorganisms contributing to health
asepsis
keeping away disease
polypharmacy
the use of multiple medications
Physical Neurological changes in older adult
decreased: brain weight/volume, white matter, # of neurotransmitters. Ventricular system enlarges
Integumentary changes
- easier skin tears
- less moisture
- wrinkles, less collagen and elastic fibers
- decreased melanin
- poor temp regulation
MSKL changes
- decreased: bone mass, osteoblast activity
- osteoclast activity remains the same
- easier breaks, longer healing
respiratory changes
*increased stiffness of chest wall
* decreased muscle mass
* enlarged alveolar ducts
cardiovascular changes
- pacemaker tissue damage and decreased muscle
- weaker valves
GI changes
*decreased smell and taste
* shrinkage
* gum recession
GU changes
- shrinkage
- incontinence (NOT a normal part of aging, sign that something is wrong!)
Leading cause of death in older persons?
Cancer and heart disease
Systemic infection (define and describe s/s of infection)
Pathogen is distributed throughout the body
S/S: HR>90, RR>20, 36<temp>38, decreased LOC, changes in WBC count.
Risk factors: immunocompromised, >65yo, recent surgery</temp>
Local infection (define and describe s/s of infection)
An infection limited to a specific body part
S/S: heat, redness, swelling, pain, immobility
Atypical S/S of an older adult infection
delirium, falls, dehydration, decreased appetite, decreased function, incontinence, dizziness
Stages of infection (hint: not the same as chain of infection)
- Incubation: pathogen enters the body but no symptoms present
- Prodroma: Mild/non-specific symptoms, transmission may occur
- Illness: Specific S/S arise
- Convalescence: acute symptoms disappear, homeostasis returns
Chain of infection
- Infectious agent
- Reservoir
- Portal of exit
4.Mode of transmission - Portal of entry
- Host
Contact precautions
gown and gloves
droplet
surgical mask and eye protection
airborne
n95 mask/ eye protection
splash
full face protection and gown
health equity
elimination of systemic health disparities associated with social advantages and disadvantages
gender equality
equal treatment for all regardless of gender
cultural humility
lifelong learning, interpersonal respect and reflection
cultural safety
recognizing power and resource distribution
implicit bias
unknowingly
explicit
knowingly/recognized
ethnocentrism
thinking ones culture is superior to anothers
4Rs
realize, recognize, respond, resist re-traumatiing
6 guiding principles of TIP
safety
trust and transparency
peer support
empowerment of voice and choice
collaboration and mutuality
cultural and historical and gender issues
interpersonal comms
you-another
intrapersonal comms
you-you
transpersonal comms
you-spirit
intimate space
0-1.5ft
personal space
1.5-4ft
social space
4-12ft
public space
12+ ft
SOLER of active listening
s: sit facing pt
o: open posture
l: lean forward
e: eye contact
R: relax
Subjective information
Verbal descriptions of patients health. (e.g. feelings, perceptions, and self-reported symptoms)
aphasia
inability to understand or produce language
delirium
- acute onset, lasts hours to weeks, altered consciousness, impaired attention, reversible
- S/S: confusion and hallucinations, cant focus, change in behaviour, day/night mix up
Objective data
Observations or measurements of a patient’s symptoms
(e.g. Observed behaviour, measurement of vitals, vomiting)
What is NANDA
North American Nursing Diagnoses Association
What does NANDA do
Establish a list of common patient problems to create “Nursing Diagnoses” which are separate from “Medical Diagnoses”
CAM and PRISME
CAM stands for ‘confusion assessment model’, if the patient is CAM+ suspect delirium, and follow with PRISME.
P: pain, psychosocial
R: restraint, retention
I: infection, impaction, impaired cognition, intake-oral
S: sleep disturbance, sensory change, social isolation
M: medication, metabolic, mobility
E: environment
What is a Nursing Diagnosis
The second step of the nursing process.
A clinical judgement about an individual’s responses to actual and potential health problems.
Collaborative Problem
An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s status.
What is the nursing process acronym
ADPIE
“Decision making, critical thinking skills, evaluating outcomes, and collecting data” are part of which nursing process step?
Assessment
Dementia
- generalized impairment of intellectual function*
insidious onset (mnths-yrs), progressive, intact consciousness, normal attention, irreversible
“Point of Care Risk assessment, viewing charts, and looking at other client information” is part of which nursing process step?
Assessment
Lewy body dementia
abnormal buildup of proteins
vascular dementia
caused by stroke
mixed dementia
many causes
Alzheimer’s
most common dementia
Depression
acute or insidious, could be chronic, lasts months to years, clear consciousness, usually reversible
* sadness/despair lasting more than 2 weeks
Types of nursing assessments
Interview, primary assessments, focused assessments, head-to-toe assessments, PAIN ASSESSMENTS etc.
The following are examples of?
Client was found on the bathroom floor
Client has T of 36.5 Celcius
Client’s abdomen is distended
Objective Data
GDS acronym stands for?
geriatric depression scale
The following are examples of?
Client stated feeling anxious
Client feels their dressing is saturated
Client repots 8/10 pain
Subjective Data
Information the client/patient says are examples of what type of data?
Primary
Examples of Secondary Data?
Family
Physician
Allied Health
Charts
Tertiary Data Examples?
Nurse experience
Literature
Which assessment do you do when you first meet the client
Primary
Physical Assessment Skills
Auscultation of heart and lung
Palpation of body
Percussion
“Analyzing data, identifying health problems and client needs” are part of which nursing diagnoses process?
Diagnose
Nursing Diagnoses vs Medical Diagnoses
Nursing diagnoses are clinical judgements about responses from actual or potential health problems
(e.g. ineffective airway clearance)
Medical Diagnoses is the identification of signs and symptoms
(e.g. Pneumonia)
Planning in the nursing process involves…
Setting priorities
Creating client-centered goals
Creating plan of care
Implementation of the nursing process involves
Treating symptoms
Preventing complications
Promoting health
Implementing nursing interventions
Assessments for Delirium/confusion Diagnoses
CAM and PRISME
Fill in the blank:
Diagnoses - Acute Confusion
Plan (goal) - Client to clear from confusion
Implementation - ?
Ensure PRISME assessed and interventions/preventions are maintained
Which nursing process involves “re-assessing client, determine if outcomes were met, modifying plan of care”
Evaluation
6 Cultural Considerations
Age
Ethnicity
Status
Religion
Gender
Way of Life
Note: DO NOT IMPOSE ON PERSONAL VALUES AND BELIEFS
“Being objective, avoiding personal judgements, using approved abbreviations” are part of?
Proper documentation practice
What does DAR stand for?
Data, Action, Response
Primary data source
The client only
Secondary data sources
family, chart, physician, pt/ot
Tertiary data sources
nurse experience and literature
what is the action of tapping the body for vibrations and density?
percussion
what assessment skill is being utilized when using the stethoscope
auscultation
when are the ABCDEs done?
beginning of shift as a QPA and anytime the patients status changes
what does ABCDE stand for?
A: airway
B: breathing
C: circulation
D: disability
E: environment/expose
What is CAGE?
a series of questions to ask patients struggling with substance abuse
What does CAGE stand for?
Cut off
Annoyed
Guilty
Eye opening
“patient has an ineffective airway clearance” is an example of what kind of diagnosis? hint: medical, nursing, or collaborative problem?
nursing diagnosis
“patient is at risk for sepsis caused by pneumonia” is an example of what kind of diagnosis? hint: medical, nursing, or collaborative problem?
collaborative problem
“patient has pneumonia” is an example of what kind of diagnosis?
medical
PoC stands for?
Plan of Care
In the ‘triangle of priorities’ or Maslow’s hierarchy of Needs, where is top priority and where is low priority?
The top priority is at the bottom of the triangle with physiological needs. Low priority is on the top with Self-actualization
Which of the following is an action taken by a nurse in the assessment phase of the nursing process:
Creating long- and short-term goals
Reviewing laboratory results
Proposing diagnoses
Reviewing laboratory results
Which phase of the nursing process does the nurse use clinical judgement to identify a client’s response to actual or potential health issues?
Diagnosis
Implementation
Assessment
Diagnosis
The nurse records the client’s breakfast intake as “tea 240 mL, milk 125 mL, 1 egg, 1 slice of toast.” The nurse knows that this documentation is part of which phase of the nursing process?
Assessment
Cognitive changes in an older adult that is NOT normal includes?
Loss of language and calculation skills
Poor judgement
Some causes for delirium are infection, electrolyte imbalance, and dehydration (PRISME)
These can lead to?
Death
Poor health outcomes
Increase length of stay in hospitals etc.
How to manage delirium?
Find and treat underlying cause
Dont argue with the patient’s hallucinations
Keep routines simple
Keep environment calm
Is pain normal in aging individuals?
No
Transduction of Pain Pathways
- Nerve detects pain
- Signal goes from PNS to CNS
- Perception of pain
- Modulation (signals and response alteration)
Active vs Passive ROM
Active - unsupported ROM by the patient
Passive - supported ROM from HC provider
Which organ system is responsible for:
Support
Protection
Movement
Storage of Minerals
A Site of Hematopoiesis
Sketelal
Neuropathic pain feels like?
Burning, Prickling, Electrical, Shooting pains
Which type of Neurpathic Pain
is referenced by these conditions?
Spinal Cord Injury
Phantom Limb Pain
Spinal Tumor
Deafferentation
how much does Ayva love Vonn?
More than the whole Universe
NSAID and Non opioids are for what insensity of pain?
Mild to moderate
Opioids are for what intensity of pain?
Moderate to severe
Which type of medication was not intended for pain management use?
Co analgesics
What are risk factors for osteoporosis?
Increased caffeine intake
Low BMI
Low exercise
Risk factors for osteoarthritis
Obesity
Trauma
Overuse of joint
Why might an older adult hide pain?
Fear
Don’t want to be a nuisance
Anxiety
“Is it worth telling?”
