exam 2 Flashcards
three initial approaches to gather info
self-report ~ if pt is competent and can give accurate info
report by proxy- from spouse, child, etc
direct observation- assessment pieces i gather
assessment if older adults
more complex, detailed, takes longer
lots of specifics, body systems wear down has more chronic illness, pt my have slower recall time
do head to toe
this begins as soon as we see them
what assessment piece do we begin with
review of pts chief complains
LEARN model for healthcare
Listen
Explain- analyze and prioritize a hypothesize
Acknowledge
Recommend
Negotiate
normal assessment findings of older adults
thin skin- tenting
low temp
high frequency hearing loss
cerumen impactations
reduced pupil responsiveness, saggy eye lids
decrease of taste, mouth dryness
slight edema
osteoarthritis
bilateral strength
FAN CAPES: comprehensive assessment of older adults
Fluids- hydration status
Aeration- o2 status at rest and activity
Nutrition- diet, can they get food and prepare it
Communication
Activity- fall risk?
Pain- do they have any? what kind?
Elimination- continent or incontinent? do they need extra assistance
Socialization- peers
mini mental state examination
looks at orientation and short term memory
clock drawing test
they draw a clock and we see if they have. good number recognition, how well they can see
the global deterioration scale
Looks at ability to perform increasingly complex task. Start simple and get harder
geriatric depression scale
assess mood and for depression
geriatric ability
Assess what they can do on own, and what they need assistance with. also assess safety
keep monitoring, things can change weekly
activities of daily living examples
Bathing , dressing, feeding, toileting, transferring oneself, feeding onself, controlling bowel and bladder function
instrumental activities of daily living examples
Ability to use telephone, travel, manage money, taking meds, packing a suitcase, prepare meals, do housework
OARS
provides info related to social and economic resources, mental and physical health, and ADLS
fulmer SPICES acronym
for cues requiring nursing action
Sleep
Problems eating
Incontinent
Confusion
Evidence of falls
Skin breakdown
OASIS
Created by government. Used to improve quality and communication for home health. Determined disbursement for home health agency
OASIS risk for hospitalization
history of falls
unintentional weight loss
multiple hospitalizations
multiple ER visits
decline in mental, emotional or behavioral status
difficulty complying with medical instructions
taking 5 or more meds
reports exhaustion
documentation
required. document everything
demonstrates quality of care
provides a way to have continuity of care between all providers
what group is largest user of prescription and OTC meds
adults over age 65
pharmacokinetics
the movement of a drug throughout body from point of its admin
changes in absorption in elderly
increased gastric pH
changes in intestinal motility (faster=less absorption, slower=increased absorption)
changes in metabolism in elderly
decreased liver function- increased amount of drug in system
changes in excretion in elderly
decreased kidney function, increased half life
absorption
amt of time between drug admin and absorption depends on bioavailability amount of drug that passes through body, route of admin
distribution
med must be transported to receptor site on the target organ to have an affect
depends on the availability of plasma protein in the form of lipoproteins, globulins, and albumin
what are age related changes in distribution related to
body composition, increased body fat, and decreased total body water
metabolism
process by which the drug modifies the chemical structure of drug
primarily occurs in liver
excretion
medications are excreted in sweat, saliva, and other secretions, as well as mainly by kidneys
pharmacodynamics
interaction between a drug and the body
decreased response to beta adrenegeric receptor stimulators and blockers, like BP meds
increased sensitivity to anticholinergics, benzodiazepines, opioid analgesics, warfarin, diltiazem, verapamil
chronopharmacology
relationship between biologic rhythms to variations in the body response to drugs
problems with meds and older adults
polypharmacyq
drug interactions
adverse effects
misuse of drugs
herb to avoid with antihypertensive and antivirals
garlic
herb to avoid for antidiabetics and antidepressants, antihypertesnive
ginko
common herbs to avoid in many drugs
St johns wort
ginseng
what drug can u not use with citrus juice
CCB
what drug not to use fiber
digoxin
common food to avoid for drug
grapefruit juice
polypharmacy
taking 5 or more meds
concern for drug interactions and adverse effects
caused by multiple conditions, multiple providers
mental status adverse effects
delirium, confusion, lethargy
CONTACT PROVIDER IMMEDIATELEY.
Beers list
identifies drugs that carry a higher than usual risk for adults and should be used w caution
ex- benzodiazepines, sliding scale insulin, antispasmodics, trycylic antidepressants, digoxin
Neuroleptic malignant syndrome
most common with Haldol. MED EMERGENCY
Increased temp, muscle rigidity, tachycardia
adverse effects for antidepressants
ataxia, dizziness= fall risk
why avoid benzodiazepines (antianxiety drugs)
decreased metabolism. may cause drowsiness, dizziness, ataxia, cognitive deficits, memory impairment
antipsychotic adverse effect
potential cardiac risk, neuroleptic malignant syndrome, extrapyramidal syndrome (EPS)
best medication assessment of older adults
brown bag approach- bring all of there meds in
pt education of meds
- Provide guidance on
- Right drug, right dose, right time
- Easy open bottles: watch for little kids
- Measuring and cutting devices
- Proper storage
Potential side effects: go over dangerous ones, may need a list
monitoring meds
assess and document changes in physical and functional status
measure blood levels
obtain baseline measures
observe for adverse effects
what causes constipation in older adults
decreased activity, pain meds, decreased hydration
nutritional needs in older adults
- May require fewer calories= doing less activity
- Need higher level of nutrients
- Decreased saturated fats
- Increased protein- for wound healing
- Consistent fiber intake- 25g/day
Increased Vitamin B12- increases energy
what causes malnutrition
not consuming enough nutrients,
inflammation
factors effecting nutritional fulfillment
life long eating habits
socialization
socioeconomic deprivation- more $ to eat healthy
transportation
Supplemental Nutrition Assistance Program (SNAP)
program where they can get extra money for food or food delivered to them
does excessive drinking increase or decrease eating
decrease
where should essential nutrients come from
foods rather than supplements
physiological changes affecting nutrition
- Decreased movement of food in the esophagus
- Decreased sense of smell
- Decrease in the number of taste buds
chronic health conditions that can decrease food intake
- Gastroesophageal reflux disease (GERD)
- Diverticular disease
Dysphagia
- Diverticular disease
possible causes of dysphagia
CVA, Parkinson’s, Alzheimer’s
what to worry about w dysphagia
aspiration
interventions for dysphagia for nutrition
postural change- sit up
diet modification- thickeners
hand feeding
G tubes (do oral care)
how much water should older adults have daily
1.5L (1500mL)
why are older adults at more risk for dehydration
- Decreased thirst
- Decreased cognitive function
- Decreased mobility
- Use of medication that cause increased urination- Lasix makes them more likely to be dehydrated
signs and symptoms of dehydration
- Weight loss
- Concentrated urine- amber colored
- Orthostasis- blood drops in BP due to volume depletion
- Sunken eyes
- Rapid pulse rate
- Longitudinal furrows in the tongue
Confusion
interventions for dehydration
- Assess fluid intake and output
- Make fluids accessible and consistently available
- Allow for adequate time at meals
- Provide a variety of fluid options
- Monitor for fever, diarrhea, vomiting
- Limit NPO status
- Decrease use of diuretics
Maintain adequate documentation of intake and output
rehydration
for mild to moderate - oral hydration or hypodermoclysis (infusion into subcut space)
for moderate to severe- IV therapy
monitor for F&E imbalance
oral care
annual dental exams
use adaptive toothbrushes and floss if needed
maintain adequate fluids
avoid alcohol and tobacco
perform dental care- constant wear unless sleeping. use soft brush
Aminocaproic Acid ( Amicar)
hemostatic agent, fibrinolysis inhibitor. For management of hemorrhage due to systemic hyperfibrinolysis or urinary fibrinolysis. Inhibits activation of plasminogen. Monitor BP, pulse, and resp status, neuro status, i&o. monitor platelet count and clotting factors. Assess for recurring bleeding
Apixaban ( Eliquis)
anticoagulant, factor xa inhibitors. Prevention and treatment of embolism. Monitor for bleeding and hypersensitivity reactions. Antidote is andexanet alfa
Rivaroxaban (Xarelto)
anticoagulants, antithrombotic. factor xa inhibitor Treats and prevents thromboembolic events. Monitor for bleeding. Avoid St johns wort. Antidote is andexanet alfa
Dabigatran (Pradaxa)
anticoagulant, thrombin inhibitor. Prevents clot formation. Monitor for bleeding, hypersens reactions, GI upset. Reversal use idarucizumab
urinary incontinence
Loss or urine controls. Interrupts daily living
often undiagnosed and underreported.
key component of elimination in elderly
being control
why is treatment not sought in urinary incontienence
embarasessment, normal aging, uneducated
stats reported of UI at home vs facility
> 50% of women and 25% of men living at home
50 % of women and men in a facility. Men deteriorate more quickly in long term care due to loss of independency
risk factors for UI
cognitive impairment
limitations in daily activity
institutionalization
disease- diabetes
meds
stroke
obesity
consequences of UI
increased risk for injury
skin breakdown
increased social isolation, shame
decreased sexual activity
loss of independence
transient (acute) UI
sudden onset, persistant for 6 months or less
typically due to treatable factor like UTI
Established (chronic) UI
could be sudden or gradual onset.
happens repeatedly, doesn’t just go away simply
could be stress, urge, mixed, functional, overflow
stress UI
sneeze, laugh, cough. More in women
urge UI
feeling like they have to all the time
nocturia
wetting bed or getting up at night for bathroom
overflow UI
more common in men w BPH, bladder is so full but difficulty voiding, causes leaking
functional UI
inability to get to toilet
mixed UI
multiple reasons cause UI
care for UI
scheduled voiding
kegel exercises
lifestyle modifications- decrease caffiene, stop drinking before bed
adult briefs
anticholinergics, beta3 agonist, and antimuscarinics
surgery for UI
colposuspenison
slings-Compensating for uterus not being there, puts a sling there to help bladder go back to old position. For women with hysterectomy’s
last resort for UI
catheters, especially the inserted ones.
external arnt as bad
UTI can occur 48 hours after catheter insertion
common UTI symptom in older adults
confusion
most common cause of bacterial sepsis in older adults
UTI
most common GI concern of older adults
constipation
seen more in hospitals due to narcotics and not moving as much
s/s of fecal impaction
malaise, urinary retention, elevated temp, incontinence, alteration in cognitive status, fissures, hemorrhoids, intestinal blockage
treatment of fecal impaction
oil retention enema or digital removal
how to promote bowel function
increase fluid and fiber
promote exercise
regularity of bowel evacuation
why should we cautiously use enemas and laxative
could become dependent on them, and they could cause rebounds
what is fecal incontience often associated with
UI
fecal incontinence care
biofeedback
surgery
meds
habit training
diet alterations
environmental manipulation
sphincter training schedules
5 stages of sleep
Awake
N1- NREM
N2- NREM
N3- NREM
REM- neurotransmitters are reduced and repaired
each N stage is a deeper stage
what sleep stage do elderly experience decreased of
N3, REM
sleep architecture
predictable pattern of normal sleep
Sleep disorders
insomnia
sleep apnea
restless leg syndrome
REM sleep behavior
circadian rhythm sleep disorder
insomnia
DIFFICULTY going to sleep and staying asleep
requires that a person has difficulty falling asleep for at least 1 month and that it impairs daily functioning due to difficulty sleeping.
occurs in about half of those with dementia. can effect dementia caregivers if living at home
promotion of sleep
Relaxation therapy, turn of electronics, exercise regularly, avoid caffeine, alc, tobbaco
sleep apnea
a condition in which people stop breathing while sleeping followed by by arousal. Causes fragmented sleep and daytime sleepiness
risk factors are high BMI, large neck circumference
S/S- loud snoring, gasping, choking when waking, morning headaches, poor memory, personality changes
self rating sleep scales
pgh sleep quality index
epworth sleepiness scale
treatment of sleep apnea
depends on type
weight loss
smoking cessation
avoid alc, sedatives
avoid supine sleeping
use CPAP
restless leg syndrome
a sensorimotor neurologic disorder characterized by unpleasant leg sensations that disrupt sleep
s/s= parathesia, crawling sensation, tingling, pain, burning, indescribable sensations
meds- antidepressants, neuroleptics
nonpharm- stretching, hot baths, relaxation, avoiding alc
rapid eye movement sleep behaivor disorder
loss of voluntary muscle atonia during REM sleep, violent behaivors while dreaming. risk for injury
associated w parkinsons, Alzheimer, lewy body, supra-nuclear palsy
treatment-Clonazepam (benzodiazepine) be careful!!!
circadian rhythm sleep disorders
normal sleep occurs at abnormal times
treatment is alterations in light exposure, expose to light more to keep awake, darken when need sleep
how much activity do older adults need
Need a minimum of 30 minutes, 5 times a week (150 mins weekly)
what do aquatic exercises help w
muscle strength, circulation, endurance
what do yoga and tai chi help with
balance and flexibilty
xerosis
Extremely dry, cracked, itchy skin
Associated with dehydration and environment
use creams, oils, tepid water
pruritis
Itchy skin.
Often a symptom of chronic condition. Common in diabetics, renal failure, hepatic disease, iron deficiency anemia
can be aggravted by many things like detergent’s, clothing, sweating, exercise, anxiety
helpful measures include rehydration, compression, epsom salt, oatmeal
scabies
Itchy skin caused by burrowing mites Contagious
Red tracks observed
treated by lotions and creams, cleanse rooms, linens, etc
purpura
Appears as bruising. Blood vessels become weekend and rupture
common in dorsal forearms and hands
skin tears
painful, acute, accidental wounds
common in thin, fragile skin
3 categories
avoid adhesive products, be gentle, have at risk individual wear long sleeves
3 categories of skin tears
1- skin tear without tissue loss
2- skin tear with partial tissue loss
3- skin tear with complete tissue loss where epidermal flap is absent
common causes of skin tears
equipment injury
patient transfers
ADLs
treatment and dressing changes
seborrheic keratoses
benign growth- skin tags
common around trunk, face, neck, scalp, armpits. could be in single or multiple lesions
more common in men and dark skinned people
actinic keratoses
precancerous lesion- watch closely
related to years of UV exposure
found on face, lips, hands and forearms
single or multiple rough, scaly, sandpaper like patches on an erythematous base.
early recognition and treatment is important
herpes zoster
shingles
occurs along a nerve pathway or dermatone
begins w/ itching, tingling, pain
treated by oral antivirals
vaccine is available
candidacies
Common in skin folds where it stays moist and dark, such as under breast, in axilla, groin area
could occur due to abx use
whose at risk for skin cancer
pale or freckled skin
fair or red hair
blue eyes
basal cell carcinoma
most common SC
slow growing
treatment is usually surgery with excision or mohs micrographic surgery
squamous cell carcinoma
2nd most common SC
high risk for mid 60s chronic exposure to sun, like farmer
found on head, neck, hands
lesions are firm, irreg, fleshy, pink colored nodules that become red and scaly
treatment- electrodessication and curettage, mohs surgery, cryotherapy, topical 5 fluorouacil
melanoma
less than 2% of skin cancers but accounts for most SC deaths
atypical, large, irreg
appears on legs and back of women and on backs of men
metastasizes quickly
ABCDE
for melanoma
Asymmetry
Border irregular
Color variation
Diameter greater than size of a pencil eraser
Elevation and enlargement
pressure injuries
localized damage usually over bony prominence
often occurs on sacrum, heels, greater trochanters
could also be on elbows, ankle, knees, occiput
prevention is key.
we dont restage in healing, we call it a healing stage _
Stages of ulcers
- Stage 1- Red nonblanchable area
- Stage 2- damage to epidermis and dermis
- Stage 3- damage to epidermis, dermis, hypodermis
- Stage 4- into muscle, could possibly see bone
- Unstageable- slough or eschar. We cant truly see
prevention of pressure injury
skin assessments, repositioning, appropriate support devices
skin change at end of life
occurs in last days or weeks of life
- Hypoperfusion of tissues
- Mottling - due to decreased blood flow
- Red - Yellow - Purple area
Becomes darker and spreads over time
what does braden scale assess
sensory perception, moisture, activity, mobility, nutrition, friction or shear
The lower score the more at risk, the highest score is a 23
