Exam 1 Study Guide Flashcards
Respiratory:
Define bronchiectasis?
There is permanent abnormal widening of the airways due to inflammation.
Respiratory:
Define elastic recoil
The lungs ability to expand and contract
Respiratory:
Define vital capacity
Maximum amount of air that can be expelled following maximum inspiration.
Respiratory;
Define kyphosis
Curvature of the spine causing bowing of upper spine
Pneumonia IS A LEADING CAUSE OF DEATH IN OLDER ADULTS what are the contributing factors:
o Poor chest expansion and more shallow breathing
o Lowered resistance to infection
o Reduced Mobility (laying down)
o Increased mucus formation and bronchial obstruction (secretions)
o Increased incidents of hospitalization and institutionalization (long-term care) leads to increased nosocomial pneumonia.
o Changes due to aging may mask signs and symptoms:
o Pleuritic pain -less severe in older adults
o Lower Temperature -may not show fever because they tend to have lower temperature
Interventions for pneumonia:
PREVENTION IS KEY
o Encourage good fluid intake importance is to keep hydrated
o Manage bronchial secretions
o Prevent obstructions
o Preventative measures for infections if needed ask for a swallow test
o Instruction in breathing exercises
o Raise HOB at least 30 degrees (unless it is contraindicated)to help prevent pneumonia
o Educate and instruct patient to turn, cough and deep breath every two hours
o Health Promotion: Vaccines: Pneumonia and Influenza
Symptoms of pneumonia in older adults:
o Slight cough o Fatigue o Rapid respiration o Confusion * alerted LOC o Restlessness o Behavioral changes *
What are the risks due to adequate respiration of the aging adult?
o The trachea stiffens due to calcification of its cartilage. This reduces the ability to cough because it blunts the laryngeal and coughing reflexes.
o Reduced number of nerve endings may lead to a weaker gag reflex.
o The lungs become smaller in size and weight. Connective tissues needed for effective respiration and ventilation in the lungs weaken. This leads to decreased elastic recoil. Respiration then requires the use of accessory muscles. This leads to lungs being stiffed.
o Alveoli are less elastic, develop fibrous tissue, contain fewer functional capillaries and have less surface area. This reduces gas exchange.
o Loss of skeletal muscle strength in the thorax and diaphragm. This combined with the loss resilient force (tissues) that holds the thorax in slightly contracted leads to Kyphosis or a look of having a “barrel chest”.
o These changes add up to a reduction in vital capacity. = Less air exchange and more secretions remaining in the lungs.
*respirations are easier to count for the older adult
What are other age related changes in respiratory:
o Decreased response to hypoxia and hypercapnia.
o Different normal baseline temperature
o Baseline is lower, a fever may be lower for them.
Nursing considerations for repsiratory:
o Less effective gas exchange (hypoxia, )
o Easily fatigued r/t decreased respiratory efficiency
o Reduced airway clearance risk for asthma
o Increased potential for infection
Assessment for respiratory system:
o Breathing patterns
o Breath sounds
o Palpate the chest for fremitus
o Chest expansion
o Cough
o Deep breathing
o Respiratory rate
o O2 saturation
o Secretions can lead to an infection, if not able to swallow can aspirate and lead to aspiration pneumonia
o Mental status / behavioral changes will see when they get an infection, sometimes it is key.
o Pneumonia and UTI are leading causes of death in elderly they become septic
Labs to know
Other assessments to know chart:
Cardiovascular
Define physical deconditioning
Decline in cardiovascular function due to physical inactivity
Nursing considerations for cardiovascular:
o Poor peripheral circulation
o Capillary refill
o Easily fatigued
o Inadequate circulation to heart tissue
o Will damage the muscles
o Shortness of Breath
o Reduced cardiopulmonary tissue perfusion
o Hypotension
o Tachycardia
o Edema
o Dyspnea
o Delirium lack of oxygen will cause a mental status change
o Restlessness
o Pallor a little blueish due to lack of oxygen
o Memory disturbance a change, an addition to.
What are the risks of adequate circulation related to aging adults:
o Heart valves increase in thickness and rigidity R/T sclerosis and fibrosis
o Aorta becomes dilated
o Slight ventricular hypertrophy
o Myocardial muscle loses some of its contractile strength causes a reduction in cardiac output, meaning it is less efficient with increased activity or demands on the heart. Because it is stiffening and losing its strength. Not allowing chambers to empty as they should.
o Example: more people tend to die at night or early morning. They got up and went to the bathroom = heart attack because of increased activity in the heart
o Diastolic filling and systolic emptying require more time to complete the cycle.
o Calcification and reduced elasticity of vessels. Becomes less sensitive to baroreceptors Reduces regulation of blood pressure. Reduced arterial BP leads to decreased tissue profession.
o Changes are usually gradual and become more apparent when the older adult is placed under increased activity. Consider early morning walks to restroom – increased death
Nursing assessment for cardiovascular:
o Blood Pressure (orthostatic) Lying, Sitting, Standing
o For orthostatic BP you always need a second person. As patient can fall and break hip= death
o Palpate carotid arteries
o ECG
o Exercise tolerance
Nursing interventions for cardiovascular:
o Monitor for S/S of hypotension o Encourage fluids o Hypotension, fluid drops = BP drops o Fall Precautions o Health Promotion: Medication, Diet, Exercise (as appropriate)
Cardiovascular
Define Postural (orthostatic) Hypotension
decline in systolic blood pressure of 20mm Hg or more after rising and standing for 1 minute
they stand up they hit the floor, big problem for older population
Dehydration:
o Dehydration- can cause UTI, elderly’s do not drink enough water, elderly with some cognitive impairment that can be in a wheelchair will not realize they are thirsty and not think about it. Kind of push it off. Encourage fluids every other hour unless there is a volume issue and fluids are being restricted. Think of granny how she only drinks about half a bottle of water a day
o Dehydration symptoms: orthostatic hypotension, weight loss, tachycardia, hyperthermia, weakness, nausea, anorexia, oliguria, dry mucus membranes and skin, poor skin turgor, increased thirst.
Hydration:
Hydration is important for many reasons example:
• Fluid intake can thin secretions
• Can help with hypotension, fluid drops= BP drops
• Proper hydration can help with bowel elimination
• Fluid intake can help prevent UTIs
• Hydration improves skin
Genitourinary:
Define nocturia
Voiding at least once during the night
What are urinary elimination changes related to aging:
o Hypertrophy of the bladder muscle and thickening decreases the ability of the bladder to expand and reduces capacity, leading to urinary frequency and nocturia. Kidney circulation improves when a person is in a recumbent position and increase the need to void. This is not a normal part of aging and is related to other aging issues.
o Retention of urine due to neurological inefficiencies and a weaker bladder that does not empty properly.
o Woman: fecal impaction like constipation
o Men: prostatic hypertrophy
o Reduced filtration efficiency of the kidneys affects the body’s ability to eliminate drugs and causing higher blood urea nitrogen levels.
o Incontinence Also not a normal part of aging, but usually caused by age-related physical or mental disorders. It is common but not normal
o If a man is having a UTI is is a very serious issue, try to find underlying problem.
Nursing considerations for GU:
o Potential for adverse drug reactions or toxicity because they are not clearing their systems o Pain o Risk for Infection - UTI o Risk for Falls they are up in middle of night, fall and trip its dark o Need for toileting assistance o Potential for skin breakdown o Sleep disruption o Potential for social isolation
Nursing assessment for GU
o Renal Function o Ability to void o BP for Hypotension o Fall Risk o Pain o Frequency mainly means UTI for female (urgency too) o Urgency o Constipation o Inactivity o Dehydration big cause of UTI for elderly o Indications of drug toxicity o Mental status change
- *Person in wheelchair and with cognitive issues is at higher risk for dehydration they are not likely to go and think of getting fluids on their own
GU interventions:
o Encourage fluids
o Fall Precautions watch those on blood thinners
o Monitor for drug toxicity
o Health Promotion: Bladder training and fluid intake
What is primary prevention
- healthy lifestyle behaviors -PREVENTATIVE; exercising, refraining from smoking/drinking
- stress management
- active social engagement
- cognitive stimulation
- immunizations
What is secondary prevention?
- evidence-based SCREENING guidelines -ex: screening an older adult for diabetes by checking BG & hgb A1c
- annual wellness visits -physical exam & labs
- personalized prevention plan - presenting a diabetic person with a diet plan
6 Psychosocial theories?
- Role
- successful aging = adapting to changing roles
- resistance may predict poor adjustment
- Activity
- successful aging = maintaining a productive life (physically & mentally); maintain involvement in activities/ hobbies that they have enjoyed all their life
- Disengagement
- successful aging = transfer control to younger generation
- society distances itself from the older adult and the older adult disengages from society
- now considered controversial
- Continuity
- successful aging = maintain & continue previous behaviors & roles or find replacements
- Age-stratification
- individuals of similar age (cohorts) have most similarities
- for example, baby boomers age similarly to other baby boomers
- Modernization
- older people lose power & status due to advances in technology, etc.
- widely challenged because older adults CAN learn new technologies, while others can feel left behind
What is health disparity?
Differences in the state of health and in health outcomes between groups of persons
What is health inequity?
Excess burden of illness or the differences between the expected incidence and prevalence. Excess burning prevalence in one group occurs higher than in another group.
What is cultural knowledge?
Knowledge means what the nurse brings to the caring situation and what the nurse learns about all older adults, their families, their communities, their behaviors, and their expectations.
What is cultural awareness?
The development of cultural proficiency with increased awareness of our own beliefs and attitudes and those commonly seen in the community of healthcare. Respect others religions
Reducing health disparities:
Cultural skills: use of communication
Unspoken Communication: handshakes, eye contact, hugs (always ask their preferences). be aware that your body language, etc, are extremely communicative
Spoken Communication: jargon, idioms, inflection (always get a professional interpreter)
*Box 4-10 (guide for working with interpreters)
Smell and taste
Define hyposmia
Decrease in smell acuity
Changes in smell and taste related to aging:
o Decrease neurons that send signal to the brain
o Difficulty distinguishing smells
o Decrease in taste secondary to change in smell acuity
Musculoskeletal
Define sarcopenia
The decline walking speed and/or grip strength related to decrease musle mass/function
Musculoskeletal changes related to aging:
o Decline in muscle fibers leads to reduced muscle mass, causing a decrease in strength and endurance.
o Decreased flexibility of joints and muscles related to changes in connective tissue
o Change of ROM = falls risk
o Tendon and ligament stiffening
o Redistribution of fat
o Narrowed intervertebral disks
o Decline in walking speed (sarcopenia)
o Increased latency/contraction of muscles
Assessment in musculoskeletal:
o Range of motion o Strength o Gross and fine motor skills o Stability o Ability to perform ADLs= when ADLs start slipping they become more dependent on other people
Nursing considerations in musuloskeletal
o Gait and balance instability o Decreased range of motion o Decreased mobility o Risk of fractures o Risk of falls o Pain o Decreased strength and endurance o Deceased activities and socialization – Risk for isolation
Interventions in musculoskeletal
o Encourage appropriate activity
o Walking for 5 min or others 20 min. It’s individualized to what they can handle, start slow and increase (depending on patient)
o Encourage and educate on good nutrition
o Consider mobility aids (walker, cane, maybe wheelchair) approach carefully bring around fall risk, this is time to do patient education and teaching.
o Fall Prevention
Polypharmcy:
oApproximately five or more medications
oIncrease risk for morbidity and mortality
oThe more prescribed medications taken, the greater the possibility of interactions
Reasons that polypharmcy occurs (SATA)
Risks
- # of providers
- Presence of chronic illness
- Use of over counter meds
- Disability that impacts a patient not taking medications
Polypharmacy prevention:
Communication between provider/nurse/pt , always ask the pt what all meds they take and have currently stopped taking.
This includes ointments, eye drops, herbs, and such……
Polypharmacy and OTC
Can cause more interactions and side effects with other prescribed medications; if patient must take them consult the providers first.
Herbs and supplemnt regulation:
- Regulated by Dietary Supplement Health and Education Act
- Herbal manufacturers label herbs as foods
- NOT FDA regulated
- Good Manufacturing Practices required since 2007
- Preparation and storage, product identification, purity, strength, composition
How do antipsychotics affect the hypothalamic and thermoregulatory pathways:
- Neuroleptic Malignant Syndrome – Assess Body Temp.
- Known for side effects – Watch your patient closely
- Sedation
- Hypotension
- Extrapyramidal and anticholinergic side effects (EPSEs)
- Movement
- Drying
Antipsychotic typical and atypical medications:
- Typical - haloperidol (never used in dementia with Lewy bodies)
- Atypical – Seroquel newer most affective (fewer EPS symptoms)
Assessment of older adult:
UNSURE ON THIS CARD, IF ANYONE KNOWST LET ME KNOW SO I CAN CHNAGE IT
- ” Brown Bag”- bring meds into appointments
- Discuss each medication with the patient
- Stop/Start tool
Gastrointestinal
Define presbyesophagus
Age-related chnages to the esophagus causing reduced strength of esophageal contractions and slower transport of food down the esophagus.
What are gastrointestinal issues related to aging?
o Tongue atrophies decreases taste sensation
o Difficulty swallow can choke more easily, and can’t swallow their meds that easily. Now issue is can they take their pills now?? Taste can result in eating more or less or more salt since they can’t taste anymore which can lead to GI issues (malnutrition, obesity, high levels of salt)
o Saliva production decreases may cause swallowing to be more difficult
o Degenerative changes in the smooth muscle lining of the lower esophagus (presbyesophagus).
o Can lead to GERD, sit patient up to eat and after eating don’t let them lay down right away. They need to eat small and more frequent meals during the day and snacks.. overeating = aspiration=pneumonia.
o Weaker esophageal contractions
o Weakness of sphincter
o Decreased esophageal motility
o Decreased stomach motility
o Decreased elasticity of the stomach reduces the amount of food the stomach can accommodate.
o The stomach has a higher pH r/t a decline in hydrochloric acid and pepsin causing increased incidence of gastric irritation in older adults.
o Reduced pepsin interferes with absorption of protein.
o Reduced hydrochloric acid interferes with absorption of calcium, iron, folic acid, and vitamin B12.
o Decreased sensory perception may lead to i ncreased incidence of constipation, as can inactivity, reduced food and fluid intake, and low fiver diet. o Pancreas fibrosis, atrophy, and reduced pancreatic secretions may affect the digestion of fats.
Nursing considerations in Gastrointestinal:
o Constipation o Big cause of UTI in females o Diarrhea o Vomiting o Acute pain (gurgling, constipated) o Dehydration o Inactivity o Insufficient nutritional intake
- ask when was your last movement?
- always watch for any changes, many times older patients won’t tell you what is wrong…
Assessment of GI:
Inspect, listen (auscultate), palpate, percussion o Abdomen o Bowel sounds o Tenderness o Distension o Dietary intake, food and fluids o Elimination patterns o Swallowing ability can’t chew well more likely to. choke o Chewing ability o Weight
Interventions for GI:
o Provide food the patient likes and can tolerate
o Keep patient sitting up after meals
o Health Promotion: Diet
Nervous system changes related to aging
o Atrophy of the brain and spinal cord r/t loss of nerve cell mass
o Dementia
o Decline in nerve cells
o Reduced nerve conduction
o Slowed central processing
o Approximately 20 percent reduction in cerebral blood flow
o Decreased peripheral nerve function
o Decreased sensation ex. Hot water that may burn their skin (can not recognize)
o Decreased cranial nerves
Nursing considerations in nervous system:
o Delayed response time to stimuli and in reflexes o Risk for falls/injury o Decreased taste and smell o Dulled tactile sensation o Risk of cognitive impairment o Pain o Nerve pain is the worst pain and harder to treat o Reduced Activity o Social isolation o Restricted mobility o Risk for CVA o TIA= major CVA o Constantly looking for signs and symptoms of TIA to prevent CVA: - Slurred speech - Drooping of face - Disorientation - Weakness of extremities - Gaze - Pupil reaction - Run a quick neuro check • Grip strength • Pupils check
Assessment in nervous system:
o Cognition
o Independence
o Ability to perform ADLs
Interventions in nervous system:
o Encourage and educate on use of assistive devices
o Falls prevention
Beers’ criteria 2019 list:
Will not be on test need to know “a guide to recognize wether a medication should be avoided by your patient
- Potentially inappropriate
- Potentially inappropriate for older adults w/certain conditions
- Should only be taken with caution
- Avoid
- Not meant to be policy
What is pain:
- Defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described as such”
- Pain is what the patient says it is.
- Multidimensional, sensory, psychosocial, emotional, personal, and spiritual components
- Categorized as either acute, or chronic and persistent
- Neuropathic (Box 27-1)
What does box 27.1 NEUROPATHIC say?
Pain in the older adult:
- Reported by more men than women
- Barriers to pain management (Box 27-4)
- Persistent pain (Box 27-5)
- Decrease in density of both myelinated and unmyelinated nerve fibers.
•Delaying sensation of pain from the periphery and there is slower resolution once triggered
Barriers to pain management box 27.4:
Pain with cognitive impairments in older adults:
- Consistently untreated or undertreated for pain
- Receive less pain medication, even when they experience the same acutely painful events
- Providing comfort
- careful observation of behavior
- Watch for and know when subtle changes occur
- Give attention to caregiver reports
- Pain cues in persons with communication difficulties (Box 27-6)
Pain cues in persons with communication difficulties
BOX 27.6 :
What is IDP
Iatrogenic disturbance pain
Be aware of pain that can be caused by caring for the older adult - pain that is caused by us as a result of caring for the patient, not intentional.
How to promote healthy aging:
- Pain management is that in which both pharmacological and nonpharmacological interventions work in harmony
- The basic approach considers what has worked in the past and been effective without causing harm
Assessment of pain in older adults:
- pain diary
- old cart
- assess for coexisting depression and anxiety
- can make anxiety worse
What is OLD CART:
NOT ON EXAM JUST NEED TO KNOW
- Onset
- Location
- Duration
- Character
- Aggravating
- Relieving
- Treatments
How to rate the intensity of pain?
- Rating scales - standard of care
- Scales may not be reliable for persons with delirium or more severe impairments
- Tools for comprehensive review of pain (Box 27.9)
Assessment of pain in cognitively impaired/nonverbal
- Persons with impaired communication skills with noncommunicative patients (Box 27-10)
- It is recommended that attempts are made to use standard assessment instruments first even when the person has advanced dementia
- The Pain Assessment in Advanced Dementia (PAINAD) Scale developed for use for those who either cannot express or cannot reliably express pain (Table 27-1)
-PACSLAC-2: behavioral assessment tool that may be helpful as an initial pain screen
Persons with impaired communication skills with noncommunicative patients (Box 27-10)
What are some non-pharmacological interventions?
always start with non-pharmalogical interventions first
- Heat/cold
- Transcutaneous electrical nerve stimulation
- Acupuncture and acupressure
- Relaxation, meditation, and guided imagery
- Music
- Activity
- Cognitive-behavioral therapy
What is wellness
The concept of wellness incorporates all aspects of one’s being Such as
- phsyical: ability to walk, feed self, general ADLs - emotional: living alone, lose and grief - intellectual: dementia - social: living alone - spiritual: faith/religion - cultural: are they still able to interact culturally - environmental: are they in a healthy living situation
What does the wellness models suggest?
That every person has an optimum level of functioning for each position on the wellness continuum to achieve a good and satisfactory existence.
Medication food interactions:
Calcium in dairy
- Levothyroxine
- Tetracycline
- Ciprofloxacin
- Spironolactone
- Increase potassium (K+)
Medication food interactions
Green leafy vegetables:
Decreases anticoagulant effects
Medication-food interactions
Grape fruit juice
Causes issues with statin
- leaving it in the body longer which can lead to liver and kidney damage
Medication food interaction:
- Altered absorption
- Alrered distribution
- Altered excretion
- Additive effects
- Altered absorption
* Binding - Altered distribution
* Receptor displacement - Altered excretion
* Medication related pH changes
* Increase/Decrease in active transport - Additive effects
- Especially dangerous in CNS effects (worry about falls and respiratory distress
Adverse drug reactions and events:
- May range from minor to fatal
- Inappropriate medications
- Allergic reactions
Movement disorders that we need to watch for:
*recognize what is not right and figure out if you have a problem
Extrapyramidal syndrome EPS
Use of dietary supplements and herbal products:
CoQ10:
- Use: For people who can’t take statins
- Caution: Do not take with Warfarin
- Adverse Reactions: Elevated liver function tests, mild GI upset
Use of dietary supplements and herbal products:
Garlic:
- Use: Decreased blood clots and reduced total serum cholesterol and low-density lipoprotein
- Caution: With use of anticoagulants
- Adverse Reactions: severe allergic reactions, increased flatulence, and upper gastrointestinal (GI) irritation with nausea and heartburn (GI bleed)
Use of dietary supplements and herbal products:
Ginkgo Biloba
- Use: Cognitive function, memory
- Caution: With use of anticoagulants
- Adverse Reactions: Bleeding (GI)
Use of dietary supplements and herbal products:
St. John’s wort
- Use: Mild or moderate depression, anxiety, pain
- Caution: Warfarin, Contraindicated with other antidepressants Esp. SSRIs
- Separate SJW and other antidepressants by two weeks
- Adverse Reactions: Serotonin syndrome, photosensitivity
Use of dietary supplements and herbal products:
Melatonin
- Use: Promote sleep
- Caution: When taking other medications that can cause drowsiness
- Adverse Reactions: Headache, nausea
- Do not take with PRILs
Use of dietary supplements and herbal products:
Ginseng
- Use: Promotes overall wellbeing and immunity
- Caution: With use of anticoagulants
- Adverse Reactions: Box 10-1 (gi bleed)
Use of dietary supplements and herbal products:
Glucosamine and chondroitin sulfate
- Use: Support cartilage and connective tissue, has anti-inflammatory effects
- Caution: With allergies, diabetes, and asthma
- Adverse Reactions: Nausea, GI upset
Dietary supplements for select conditons
- Hypertension: Coenzyme Q10, Fish oil, Garlic, Green tea, Melatonin
- HIV: SJW
- GI Disorders: Psyllium, Milk thistle, Probiotics
- Cancer: Calcium (colorectal), Fish oil (endometrial) , Garlic (colorectal, prostate), Ginseng (breast, stomach, lung, liver, ovarian)
- Alzheimer’s disease: Ginkgo
Diabetes and herbal supplements:
- Herbs have been used to manage diabetes since before the 1921 discovery of insulin.
- Some of the nearly 400 different plants that affect blood glucose are still used.
- There is not enough evidence to support the use of herbal supplements for treating diabetes
- Cinnamon
Important note to know about supplemets and herbs:
The more supplements, herbs and other drugs that the client is taking, the increased likelihood an interaction will occur.
Implications for Gero nursing
Educate
- Talk with and help patients to understand herbal supplements.
- Discuss the side effects, adverse reactions, and possible interactions between herbs, supplements, medications, and foods.
- Review product safety
- Offer relevant information and correct use of product
- Seek to discontinue if side effects occur
- Urge the patient to discontinue use if possible interactions or harmful side effects.
What are the ways the body uses medications? (SATA)
- Absorption: How the medication is taken into the body.
- Distribution: How the medication is dispersed throughout the body.
- Metabolism: How the medication is broken down.
- Excretion: How the medication is removed from the body.
Route of administration for absorption ?
Oral, sublingual, transdermal
It is best to take medication with :
Water
Age related changes that affect absorption?
- Reduction of saliva
- Difficulty swallowing
- Slowed Motility (Not a normal part of aging, but a common condition in the aged)
- Reduction in gastric acids
- Delayed stomach emptying
Distribution
systemic circulation:
Transportation to target cell receptors.
Distribution
targets organs:
-Hight blood flow: brain, kidneys, lungs, and liver
•Rapid reception, increased concentrations of medications
-Low blood flow: skin, muscles, fat
•Lower concentrations of medications
Age related changes that affect distribution:
- less body water
- increased body fat
- decreased availability of plasma proteind
Distribution
common in the aged
- peripheral vascular disease
- chonic illnes
- acute illness
Metabolims:
biotransformation-
transforms substances making them more easily eliminated from the body.
Age related changes that affect the metabolism:
- Reduction of liver mass
- Reduction of liver perfusion (30% to 40%)
- Reduces the amount of medication metabolized during the first pass
Excretion is done through
o As metabolites or Unchanged
o Through: Lungs, sweat, bile, feces, breast milk, hail, saliva, tears, semen, and urine (the renal system)
-Most common system is renal system
Age related chnages in excretion:
- Reduction of Glomerular Filtration Rate (measured by CrCl)
- Prolonged medication half-life
Pharmacological interventions:
- Erase the “memory of pain”
- Around the Clock (ATC)
- PRN medications for break through pain
- Start Low, Go Slow, But Go
- Pain Control Choices: Non-opioid, Opioid, Other
- REASSESS FOR AFFECTIVENESS
How do you evaluate the effectiveness of pharmacological interventions:
- Quantitatively measured – repeat intensity scale;
- Qualitative observations
- Adjust interventions
Skin:
Define turgor
Elasticity
Skin:
Define pressure injury
Localized damage to skin and underlying soft tissue resulting from pressure, shear, and/or friction
What are skin changes related to aging:
o Reduced thickness of the dermis o Reduced vascularity of the dermis o Decrease rate of epidermal turnover o Degeneration of elastic fibers o Increased coarseness of collagen o Reduction of melanocytes o Reduced blood supply o Results in increased fragility of the skin
Nursing consideration of skin:
o Risk for skin tears o Risk for wounds o Risk for infection o Risk for pressure injury o Bruising o Decreased Turgor o Slow healing o Decreased fat and muscle in the feet o Unsteady gait = fall risk
Nursing assessment of skin:
o Temperature o Color o Lesions o Bruising o Turgor o For signs of infection, rash
Nursing interventions of skin:
o Encourage fluids hydration improves skin
o Prevention
o Educate on care
o Control environment temperature and humidity
*Moisturize skin to prevent skin from cracking early.
