Holistic Care for the High-Acuity Client

Question 1

Which enteral feeding method is used for chronic tube feeds

Answer 1

PEG tube (Abdominal wall to stomach)

Question 1

What are the 3 ENTERAL FEEDINGS

Answer 1

Nasogastric tube
Dobhoff tube (nose through stomach to intestine for high risk of aspiration)
PEG tube (Abdominal wall to stomach)

Question 2

What additional piece of nursing care do you need to provide when pt is doing enteral feeds

Answer 2

regular accuchecks (only care if G is over 180)

Question 3

Expected physiologic changes at the end of life

Answer 3

o Cardiovascular and VS changes
o Decreased efficacy of drugs
o Incontinence
o Cool, clammy skin
o Altered mental status

Question 4

nursing interventions at the end of life

Answer 4

 Pain relief
 Manage comfort
* Decrease N/V, respiratory, constipation
 Emotional support
* Active listening
* Educate family in dying process
* Provide family updates, involve family in care and decisions
 Communicate
* Goals, advance directives

Question 5

What is the preferred method of nutrition for high-acuity clients

Answer 5

o PO intake preferred but CONTRAINDICATED IN NEURO PATIENTS

Question 6

How do you give Total Parenteral Nutrition (TPN)

Answer 6

Delivered via central line
IJ/Subclavian line (central line)

Question 7

When should you give a pt TPN

Answer 7

indicated for pancreatitis/pancreas issues

Question 8

when do you change tpn lines

Answer 8

Lines are changed every 24-72 horus

Question 9

How do you assess for signs/symptoms of nutrition intolerance

Answer 9

HYPER/HYPOGLYCEMIA
ASPIRATION
DECREASED APPEARANCE OF HEALTH/poor healing

Question 10

difference between delirium and dementia

Answer 10

Delirium develops quickly as opposed to dementia which develops slowly

Question 11

What sx is often correlated with closeness to death

Answer 11

Increase in delirium days increases risk for death—those with delirium have five times the risk for death than those who do not

Question 12

• Differences between palliative care, hospice, end of life care and withdrawal of care

Answer 12

o PALIATIVE CARE: (STILL LIVING LIFE, JUST NEED SOME EXTRA PAIN/NEURO MANAGEMENT)
 Interdisciplinary approach to relieve suffering and improve quality of life
 ESPECIALLY FOR DEMENTIA PTS
 WHAT ARE GOALS, HELP REACH GOALS; NOT ALWAYS END OF LIFE CARE

o HOSPICE: (NO MAINTENANCE/CURATIVE DRUGS)
 PROGNOSIS OF 6 MONTHS OR LESS TO LIVE (BOTH IN/OUTPATIENT ENVIRONMENT)
 DOESN’T ALWAYS MEAN THEY’RE GOING OT DIE WITHIN 6 MONTHS, SOMETIMES IMPROVE AND ARE TAKEN OFF
 NO MORE CURATIVE, FOCUS ON COMFORT (NO MORE CHOLESTEROL MEDS FOR CHRONIC ISSUE)

o END OF LIFE CARE: (AWAKE)
 death is imminent
 Can receive both hospice and palliative care at this time
 Care shifts to physiological and emotional comfort and support

o WITHDRAWAL OF CARE: (NOT AWAKE)
 life-supporting measures such as dialysis, ventilator support, vasopressor support, etc.
 Normally accompanied with medications to sedate, relieve pain and dry secretions etc. to help ease symptoms associated with EOL

Question 13

What can cause delirium

Answer 13

infectious process

adverse drug reactions (benzos aka: pam/olam)

metabolic conditions (UTI)

lack of sleep

Question 13

Describe nurse therapeutic communication at the end of life

Answer 13

o ACKNOWLEDGE ISSUE w/out judgment and try to include family to remove causative force (anxiety, pain, or lack of sleep)
o CONNECT THEM TO RESOURCES by communicating needs to members of the team to orchestrate holistic care
o Communicate changes QUICKLY
o WHAT CAN WE DO BEFORE DRUGS (Pastoral care, social work, client and family education, palliative care)

Question 14

What med should you avoid when trying to help an elderly, high-acuity pt sleep

Answer 14

BENZOS (ANTIPSYCHOTICS) CAN CAUSE DELIRIUM IN OLD PEOPLE.

TEMP RELEIF OF SYMPTOMS THAT FADE AND MAKE SX WORSE
UNLESS THEY TAKE REGULARLY

IF RX FOR SLEEP FIND SOMETHING ELSE

Question 15

what makes pain worse?

Answer 15

anxiety. take care of that and pain may be managed

Question 16

PRIORITY WITH tx DELIRIUM

Answer 16

IDENTIFYING THE UNDERLYING CAUSe

Question 17

what pain meds are not to be used for chronic pain

Answer 17

Opioids

Question 18

what do you give with pain meds

Answer 18

nausea meds

Question 19

Opioids cause

Answer 19

constipation and respiratory depression

Question 20

when do opioids start working

Answer 20

Onset: Usually takes about 30 to 60 minutes to start working.

Peak Effectiveness: Generally reaches peak effectiveness around 1 to 2 hours after administration.

Question 21

what is expected for older adults cognition in an inpatient setting

Answer 21

depression, dementia, delirium, pain

Question 22

When do you use sedation for high-acuity pts

Answer 22

on a vent, combat delirium

Newer approach to use as little as possible and only if completely necessary. goal is to have zero sedation and be on ventilator, walking and such

Question 23

Name 2 COMMON SEDATION ASSESSMENT TOOLS FOR THE HIGH-ACUITY CLIENT

Answer 23

Richmond Agitation and Sedation Scale (RASS)
Pasero Opioid-Induced Sedation Scale (POSS)

Question 24

name some HIGH-ACUITY SEDATION COMPLICATIONS

Answer 24

*PTSD AND BENZOS DON’T GO TOGETHER
Causes delirium, resp distress, interacts w/ PTSD meds

Keep in mind, things take a while to work so don’t stack meds that may result in overdose

Question 25

EXPECTED CHANGES IN Neurological system FOR THE OLDER ADULT CLIENT

Answer 25

Decrease in neurotransmitter production
More permeable blood-brain barrier
Dilation of the ventricles

Question 26

EXPECTED CHANGES IN Cardiovascular system FOR THE OLDER ADULT CLIENT

Answer 26

Decreased elasticity and increased stiffness of arterial walls
Loss of conductive tissue
Calcification of valves

Question 27

EXPECTED CHANGES IN Respiratory system FOR THE OLDER ADULT CLIENT

Answer 27

Calcification of costal cartilage
Decreased chest wall compliance
Less oxygen carried by RBCs
Loss of lung elasticity and recoil

Question 28

EXPECTED CHANGES IN Gastrointestinal system FOR THE OLDER ADULT CLIENT

Answer 28

Wearing of teeth
Decreased saliva production
Decreased thirst response
Decreased LES function
Decreased digestive function
Decreased absorption in GI tract
Reduction of blood flow to liver

Question 29

EXPECTED CHANGES IN Genitourinary system FOR THE OLDER ADULT CLIENT

Answer 29

Decreased GFR
Decreased creatinine clearance
Higher risk for UTIs
Incontinence

Question 30

EXPECTED CHANGES IN Integumentary system FOR THE OLDER ADULT CLIENT

Answer 30

Loss of elasticity of connective tissue
Decreased subcutaneous tissue
Thinning of dermal and subdermal layers
Fragile blood vessels
Reduction of lean body mass

Question 31

EXPECTED CHANGES IN Musculoskeletal system FOR THE OLDER ADULT CLIENT

Answer 31

Decreased muscle mass
Joint stiffness
Decreased mobility
Loss of bone mass

Question 32

Name some ATYPICAL PRESENTATIONS IN OLDER ADULT HIGH-ACUITY CLIENTS

Answer 32

COMPENSATORY MECHANISM DON’T WORK AS WELL so rapid onset of sx

older pts deteroiorate quicker

UTI’S CAUSE WEIRD SX like delirium

EARLY WARNING SIGNS MASKED BY COMORBIDITIES OR MEDS

Question 33

As a patient population, older adults are more likely to have _______.

Answer 33

COMORBIDITIES: ASK WHAT DOCS THEY’RE SEEING AND ASK FOR CURRENT MED LIST/HX

Polypharmacy: If has multiple chronic illnesses may be on large amount of meds

Abnormal sensitivities/reactions to drugs: Certain drugs can increase the risk for delirium, hypotension, or can impair renal or hepatic function

physiologic changes: Decreased absorption
Altered liver and kidney function

Question 34

Name some common acute and chronic conditions that land people in a high-acuity inpatient setting

Answer 34

Acute issues (trauma, stroke, aneurysm etc.)

chronic conditions (heart failure, kidney disease, diabetes, COPD)

Question 35

Stress can cause what kind of complications

Answer 35

Delirium, GI bleed, Venous thromboembolism (VTE)