A&E 1 Midterm Flashcards
prebycusis
high frequency hearing loss
young old
65- 74 y/o
middle old
75- 84 y/o
advanced old
85-99 y/o
elite old
100+ y/o
iatragenesis
any illness that occurs because of medical care
i.e. invasive procedures, increased length of stay, nosicomal infections
fragility
stage of age- related physiological vulnerability resulting from impaired homeostatic reserve and a reduced capacity of the organism to withstand stress
geriatric cascade
phenomenon of rapid decline resulting from frailty, acute illness, and stress of institutional care (acute hopsitalization)
nursing diagnosis
clinical judgement about indivdual, family or community responses to actual or potential health problems or life processes that the nurse is licensed to treat
the nursing process
ADPIE
asses, diagnose, plan, implement, evaluate
assessment
cluster data or defining characteristics to support nursing diagnosis
prevention begins with assessment
planning
- establish priorities
- anticipate and sequence nursing interventions
- identify short and long term outcomes
- think critically so that plan of care integrates all patient information
implementation
carry out the plan
can be nurse initialed, dependent, independent, physical initiated, interdependent, or collaborative
evaluation
discharge? modify plan? continue?
if outcomes are met, client goals are met
when does discharge planning start?
as soon as the patient enters the healthcare system
geriatric syndrome
unique features of common health conditions in older people that do not fit into discrete disease categories.
i.e. falls, delirium, incontience, frailty
intrinsic/ non modifiable risk factors of falls
older age, history of falls, gait impairment, balance disorders
orthostatic or postural hypotension, depression, muscle weakness, chronic conditions such as dementia, arthritis, parkinson’s
extrinsic/ environmental/ modifiable risk factors of falls
polypharmacy, loose carpets, use of canes or wheelchairs, inadequate lighting, footwear, certain restraints
katz index of daily living
assess functional status as a measurement of the client’s ability to perform activities of daily living independently
fulmer SPICES
S-sleep disorders P-problems eating or feeding I-incontenice C-confusion E-evidence of falls S- skin breakdown
purpose of fulmer SPICES
to obtain information necessary to prevent health alterations in older adult patient
Hendrick II fall risk model
to identify those at risk for falling
latent failure
arising from decisions that affect organizational policies, procedures, and allocation of resources. hidden under the systems of the hospital such as understaffing and equipment
active failure
direct contact with the patient
organizaitonal system failure
indirect failures related to management, organizational culture, protocols, transfer of knowledge, and external factors
technical failure
indirect failure of facilities or external resources
pressure ulcer
localized injury to the skin and underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear
elements of cause of pressure ulcer
pressure duration
pressure intensity
tissue tolerance
pressure is the major element in the cause of pressure ulcer
risk factors for pressure ulcers
impaired sensory preception impaired mobility alteration in LOC shear and friction moisture/ maceration decreased general health history of healed pressure ulcers uses of braces, collars, oxygen tubes etc
stage 1
defined area of redness or discoloration
stage 2
partial loss of skin thickness involving epidermis and or dermis, abrasion, blister, shallow crater
break of skin, no eschar, tunneling or underming
stage 3
FULL THICKNESS SKIN LOSS involving damage or necrosis of subcutaneous tissues and might extend through fat layer and under facia. deep crater
stage 4
FULL thickness skin loss, down to muscle and bone
underming and tracts associated with stage 4 ulcers
unstageable
FULL thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
deep tissue injury
skin not broken
not stage 1 because dark color
incontenince associated dermatitis
exposure to urine or stool
diffuse, in skin folds
not necrotic
pain and itchy
granulation tissue
healthy beefy pink; intermediate step in FULL thickness loss
does not mature into epithelial
serous
clear, water plasma
purulent
thick, yellow, green, tan or brown
sero-sanuinous
pale, read, watery; mixture of clear and watery fluid
sanguinous
bright red
interpretation of braden scale
low score, the higher the risk
nutrition and pressure ulcers
serum albumin and pre-albumin
assess for significant weight loss
nutrition intervention
hight protein, vitamin rich diet
pharmokenetics
how medications are absorbed, distributed, metabolized into cells, tissues, organs and how they are excreted
factors that affect absorption
route of admission, ability to dissolve, blood flow to site o administration, lipid solubility of medication
distribution depends on
circulation, membrane permeability, protein binding
biotransformation
turning drug into noneffective state
theraputic effect
expected or predictable
side effect
unintended, secondary effect
allergic reaction
unpredictable response
adverse effect
sever response to medication
idosyncratic reaction
over or under reaction to medication;; reaction specific to the individual
toxic effect
medication accumulates in the blood stream
standing or routine order
administered until dosage is changed or another medication is prescribed
PRN
given when client needs
stat
given immediately
single- one time
one time for specific reason
an order
drug, amount, route, frequency, purpose
3 D’s
Dementia
Delirium
Depression
Atelectasis
Collapse of alveoli
Negative nitrogen balance
When a patient is immobile, the body excretes more N than ingested (protein)
Hypostatic pneumonia
Inflammation of the lung from stasis or pooling of secretion
Orthostatic hypotension
An increase in HR of more than 15% and a drop in 15 mmHg or more in systolic BP
OR a drop in diastolic BP when a patient changes from supine to standing
Serous
Clear watery plasma
Purulent
Thick, yellow, green, tan or brown
Serosangineous
Pink, pale, watery
MIXTURE OF CLEAR AND RED FLUID
Sanguinous
Bright red fluid- indicates active bleeding
Biological half life
Time it takes for excretion process to lower the amount of unchanged medication by half
Parenteral medication
Non oral administration, but pass through skin and mucous membrane
For example: IM, IV, Subcutaneous
6 rights of medication
- Right medication
- Right dose
- Right patient
- Right route
- Right time
- Right documentation
