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NRS 111A Foundations - MHCC > Med Surg Ch 5 > Flashcards

Med Surg Ch 5 Flashcards

1
Q

Illness Categories

A

Acute or Chronic

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2
Q

Chronic illness accounts for 70% of deaths in the US

A

True

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3
Q

Acute Illness Description

A

Diseases with rapid onset and short duration

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4
Q

Acute Illness Characteristics

A
  • Usually self-limiting
  • Responds readily to treatment
  • Complications infrequent
  • After illness, return to previous level of functioning
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5
Q

Chronic Illness Description

A

Diseases that are prolonged, do not resolve spontaneously, and are rarely cured completely

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6
Q

Chronic Illness Characteristics

A
  • Permanent impairments or deviations from normal
  • Irreversible pathologic changes
  • Residual disability
  • Special rehabilitation needed
  • Need for long-term medical and/or nursing management
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7
Q

Alzheimer’s Disease Impact

A
  • Affects 5.5 million people

* Sixth leading cause of death among all adults; fifth leading cause of death among those age 65 and above

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8
Q

Arthritis Impact

A
  • Affects 1 in 5 people
  • One of most common chronic illnesses
  • Leading cause of disability
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9
Q

Cancer Impact

A
  • Second leading cause of death

* Risk increases with age

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10
Q

Cardiovascular Disease, Including Heart Disease and Stroke Impacts

A
  • Affects about 17 million adults
  • Account for 31% of U.S. deaths annually
  • Heart disease is leading cause of death in United States
  • Heart failure is a common cause of hospitalization and rehospitalization
  • Stroke is fifth leading cause of death
  • Stroke is a common cause of serious disability
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11
Q

COPD Impacts

A
  • Affects many older adults

* Third leading cause of death

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12
Q

Diabetes Impacts

A
  • Affects >29 million Americans
  • 25% of adults in United States do not know they have diabetes
  • Seventh leading cause of death
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13
Q

HIV Impacts

A
  • 45% of those living with HIV in the United States are over 50 years old
  • Older adults more likely to receive diagnosis of HIV infection later in course of disease
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14
Q

Obesity Impacts

A
  • Affects about 1 in 3 adults

* Major contributor to other health problems and chronic diseases

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15
Q

Chronic Illness Trajectory Definition and Phases

A

theoretical model of chronic illness

-Phases: Onset, Stable, Acute, Comeback, Crisis, Unstable, Downward, Dying

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16
Q

CI Trajectory Onset Phase

A
  • Signs and symptoms are present

* Disease diagnosed

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17
Q

CI Trajectory Stable Phase

A
  • Illness course and symptoms controlled by treatment plan

* Person maintains everyday activities

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18
Q

CI Trajectory Acute Phase

A
  • Active illness with severe and unrelieved symptoms or complications
  • Hospitalization may be needed for management
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19
Q

CI Trajectory Comeback Phase

A

Gradual return to an acceptable way of life

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20
Q

CI Trajectory Crisis Phase

A
  • Life-threatening situation occurs

* Emergency services are necessary

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21
Q

CI Trajectory Unstable Phase

A
  • Unable to keep symptoms or disease course under control
  • Life becomes disrupted while patient works to regain stability
  • Hospitalization not required
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22
Q

CI Trajectory Downward Phase

A
  • Gradual and progressive deterioration in physical or mental status
  • Accompanied by increasing disability and symptoms
  • Continuous changes in everyday life activities
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23
Q

CI Trajectory Dying Phase

A
  • Patient has to relinquish everyday life interests and activities, let go, and die peacefully
  • Immediate weeks, days, hours preceding death
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24
Q

Tasks of People with Chronic Illness

A
  1. Prevent and manage a crisis
  2. Carry out prescribed treatment plan
  3. Control symptoms
  4. Reorder time
  5. Adjust to changes in course of disease
  6. Prevent social isolation
  7. Attempt to normalize interactions with others
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25
Q

Men and women reaching 65 years now have life expectancy of:

A

Men: 18 Years
Women: 20.6 years

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26
Q

Gender Differences - Older Adult Men

A
  • More likely to be married and living with spouse or partner
  • More likely to have health insurance
  • Higher income after retirement
  • Less likely to be involved in caregiving activities
  • Overall have fewer chronic health conditions
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27
Q

Gender Differences - Older Adult Women

A
  • More likely to live alone
  • More likely to be widowed
  • Less likely to have health insurance
  • More likely to live in poverty
  • Poverty rates highest among minority women
  • More likely to lack formal work experience, leading to lower income
  • More likely to rely on Social Security as major source of income
  • More likely to be caregiver of ill spouse or partner
  • Have a higher incidence of chronic health conditions such as arthritis, hypertension, stroke, and diabetes
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28
Q

Young-Old Adult Age Bracket

A

65-74 years

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29
Q

Old-Old Adult Age Bracket

A

85+ years

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30
Q

Frail Older Adult

A

Usually over 75 with multiple physical, cognitive, and/or mental conditions that interfere with self-management and the ability to independently perform ADLs.

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31
Q

Ageism

A

A negative attitude based on age

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32
Q

Aging Definition

A

Reflects the changes that occur over time. A multi-factorial process involving genetics, diet, and environment

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33
Q

Incidence of Chronic Illness Triples after age 45. T/F

A

True

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34
Q

Most people 65 or older have 1 or more chronic conditions

A

True

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35
Q

Most common chronic conditions

A
  • hypertension
  • heart failure
  • coronary artery disease
  • COPD
  • cancer
  • diabetes
  • osteoarthritis
  • Alzheimer’s disease
  • vision and hearing deficit
  • osteoporosis
  • stroke
  • Parkinson’s disease
  • stroke
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36
Q

Key barriers to HC access for rural older adults

A
  • transportation
  • limited supply of health care workers and facilities
  • lack of quality health care
  • social isolation
  • financial limitations
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37
Q

Key factors associated with homelessness

A
  • having a low income
  • having reduced cognitive capacity
  • living alone
  • living in a community that lacks affordable housing
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38
Q

Inter-professional approach for homeless

A

-social workers
-nurses
-physicians
-clerical workers
-transporters
to link shelters with:
-outreach
-primary care clinics
-Medicare and Medicaid Offices
-pharmacies
-senior centers
-area agencies on aging
-possible long-term care

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39
Q

Frailty Manifestations Criteria

A

(1) unintentional weight loss (10 pounds or more in a year);
(2) self-reported exhaustion;
(3) weakness (measured by grip strength);
(4) slow walking speed;
(5) low level of physical activity.

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40
Q

Risk Factors for Frailty

A
  • Disability
  • Smoking
  • Multiple Chronic Conditions
  • Dementia
  • History of Depression
  • Long-Term Medical Health Problems
  • Underweight
  • Older Adult
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41
Q

Common Health Problems of a Frail Adult

A
  • mobility limitations
  • sensory impairment
  • cognitive declines
  • falls
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42
Q

SCALES: Nutritional Assessment of Older Adults (Table 5.7)

A
  • Sadness, or mood change
  • Cholesterol, high
  • Albumin, low
  • Loss or gain of weight
  • Eating problems (e.g., mechanical problems, such as impaired swallowing, poor dentition)
  • Shopping and food preparation problems
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43
Q

Common Interventions for Older Adults Nutritional Needs

A
  • home-delivered meals,
  • dietary supplements,
  • Supplemental Nutrition Assistance Program (SNAP),
  • dental referrals,
  • vitamin supplements.
  • Because medications may affect appetite or interact with nutrients, perform a thorough medication review, including prescription drugs, over-the-counter (OTC) drugs, vitamins, minerals, supplements, herbs, and cultural remedies.
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44
Q

Ethnogeriatric Definition

A

Specialty area of providing culturally competent care to older adults

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45
Q

3 levels of Social Support for Older Adults

A
  • Family members are the primary and preferred providers of social support
  • semiformal support is found in clubs, religious organizations, neighborhoods, adult day care, and senior centers
  • older adults may be linked to formal systems of social welfare agencies, health facilities, and government support (generally nurses are part of the formal system)
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46
Q

Signs of Caregiver Stress

A
  • Irritability
  • Anger
  • Inability to concentrate
  • Fatigue
  • Sleeplessness
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47
Q

Elder Mistreatment (EM) Definition

A

intentional acts of omission or commission by a caregiver or trusted other that cause harm or serious risk for harm to a vulnerable older adult

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48
Q

Victims are unlikely to report mistreatment by trusted other due to

A
  • isolation
  • impaired cognitive or physical function
  • feelings of shame, guilt, or self-blame
  • fear of reprisal
  • pressure from family members
  • fear of long-term care
  • cultural norms
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49
Q

Reasons HCP’s may underreport Elderly mistreatment

A
  • failure to suspect or recognize EM
  • perceived inability to successfully intervene
  • desire to avoid responsibility for further action
  • ageism
50
Q

Family members are responsible for up to 90% of domestic elderly mistreatment

A

True

51
Q

Adult children who abuse, neglect, or exploit their parents are often:

A
  • dependent on their parents for housing or financial support
  • have a history of violence
  • are unemployed
  • disabled from substance abuse or mental illness
52
Q

Risk Factors for domestic elderly mistreatment

A

(1) physical or cognitive dysfunction that leads to an inability to perform ADLs (and therefore produces dependence on others for care),
(2) any psychiatric diagnoses, including dementia and depression,
(3) alcohol misuse and abuse,
(4) decreased social support;
(5) living with a large number of household members other than a spouse
(6) low income.

53
Q

Types of Elder Mistreatment

A

-Abandonment
-Financial Abuse
-Neglect
-Physical Abuse
-Psychological Abuse
-Sexual Abuse
-Violation of Personal Rights
-

54
Q

EM Abandonment Characteristics

A

Desertion of an older person by a person who has assumed responsibility for providing care or by a person with physical custody.

55
Q

EM Abandonment Manifestations

A

Older adult’s reports of being abandoned; deserting an older adult at a hospital or skilled nursing facility, shopping center, or other public place.

56
Q

EM Financial Abuse Characteristics

A

Denying access to personal resources, stealing money or possessions. Coercing to sign contracts or durable power of attorney. Making changes in will or trust.

57
Q

EM Financial Abuse Manifestations

A

Living situation below level of personal resources. Sudden change in personal finances, sudden transfer of assets.

58
Q

EM Neglect -Basic Needs - Characteristics

A

Failure or refusal to provide basic life needs, including food, water, medications, clothing, hygiene. Failure to provide physical aids such as dentures, eyeglasses, hearing aid. Failure to ensure safety.

59
Q

EM Neglect -Basic Needs - Manifestations

A

Older adult’s report of being neglected. Untreated or infected pressure injuries on sacral area, heels. Weight loss, malnutrition. Laboratory values showing dehydration. Poor personal hygiene. Lack of adherence with medical treatment.

60
Q

EM Neglect - Social - Characteristics

A

Failure to provide social stimulation. Leaving alone for long periods. Failure to provide companionship.

61
Q

EM Neglect - Social - Manifestations

A

Depression, withdrawn behavior, agitation. Ambivalent attitude toward caregiver or family member.

62
Q

EM Physical Abuse Characteristics

A

Slapping, striking, restraining, incorrect positioning. Over sedation with medications.

63
Q

EM Physical Abuse Manifestations

A

Bruises, bilateral injuries (upper arms, ankles, wrists), repeated injuries in various stages of healing, burn marks, over sedation. Use of several emergency departments.

64
Q

EM Psychological Abuse Characteristics

A

Berating verbally, harassment, intimidation, threats of punishment, or deprivation. Childlike treatment, isolation.

65
Q

EM Psychologic Abuse Manifestations

A

Depression, withdrawn behavior, agitation. Ambivalent attitude toward caregiver or family member.

66
Q

EM Sexual Abuse Characteristics

A

Nonconsensual sexual contact, including touching inappropriately. Forced sexual contact.

67
Q

EM Sexual Abuse Manifestations

A

Older adult’s report of sexual abuse. Unexplained vaginal or anal bleeding, bruised breasts, unexplained sexually transmitted or genital infections.

68
Q

EM Violation of Personal Rights Characteristics

A

Denying right to privacy or right to make decisions about health care or living environment. Forcible eviction.

69
Q

EM Violation of Personal Rights Manifestations

A

Sudden inexplicable changes in living situation, confusion.

70
Q

Nursing Management for when Elder Mistreatment (EM) is suspected

A
  • Screen for possible elder mistreatment, including domestic violence.
  • Conduct a thorough history and head-to-toe physical assessment. Document your findings, including any statements made by the older adult or accompanying adult.
  • If the older adult appears to be in immediate danger, develop and implement a safety plan in collaboration with the interprofessional team involved in the person’s care.
  • Identify, collect, and preserve physical evidence (e.g., dirty or bloody clothing dressing sheets).
  • After obtaining consent, take photographs to document physical findings of suspected abuse or neglect. If possible and appropriate, do this before treating or bathing the alleged victim.
  • If you suspect that mistreatment is occurring, report your findings to the state agency and/or law enforcement as mandated by the laws in your state.
  • Initiate appropriate consultations with social work, forensic nursing, and adult protective services.
71
Q

Medicare is

A

a federally funded health insurance program for people age 65 years and older. Options A, B, C, D

72
Q

Part A Medicare

A

covers inpatient hospital care and partially covers skilled nursing facility care, hospice, and home health care. “free” because workers support Medicare through payroll taxes.

73
Q

Part B Medicare

A

partially covers outpatient care, physicians’ or primary care providers’ services, and home health care. It also covers some preventive services, such as mammograms.
-voluntary and has a monthly premium and an annual deductible before payment begins.

74
Q

Part C Medicare

A
  • also called “advantage plans”

- offered by private companies approved by Medicare to provide Part A & B benefits

75
Q

Part D Medicare

A
  • available to Medicare enrollees and provides a prescription drug benefit.
  • Members pay a yearly deductible, monthly premium, and copayment.
  • People with lower incomes and limited assets may qualify for extra help to pay for prescriptions.
76
Q

Medicare does NOT cover

A
  • long-term care
  • ADL or IADL care
  • dental care or dentures
  • hearing aids
  • eyeglasses
77
Q

Medicaid is

A

a state-administered, need based program to help eligible low-income people, including Medicare beneficiaries

78
Q

Adult Day Care

A

Provides social, recreational, and health-related services to people in a safe, community-based environment.

  • includes daily supervision, social activities, opportunities for social interaction and ADL help for cognitively impaired and those who have trouble independently performing ADLs
  • provide services based on need
79
Q

Adult Day Health Care Centers

A

may offer respite to allow continued employment for the caregiver and delay institutionalization of older adults. States set standards and regulate centers. Medicare does not cover costs. Adult day health care is tax deductible as dependent care.

80
Q

Home Health Care (HHC) can be

A

a cost-effective care alternative for older adults who are homebound, have health needs that are intermittent or acute, and have supportive caregiver involvement.

81
Q

Factors to precipitate placement in LTC facility

A

(1) rapid patient deterioration,
(2) caregiver inability to continue care because of stress and burnout,
(3) a change in or loss of the family support system.
(4) Progressive dementia, urinary incontinence, or a major health event (e.g., stroke) can hasten long-term care placement.

82
Q

Relocation stress syndrome

A

associated with disruption, confusion, and challenges that older adults face when moving to a new environment. May have anxiety, depression, and disorientation

83
Q

Programs for All-Inclusive Care (PACE)

A

provide care for adults 55+. Include prescription medications, wound care; physical, occupational, recreational, and speech therapy; adult day care; dental; podiatry; social services; and home health care. Respite care, hospitalization, short-term rehabilitation, and long-term care are provided as needed

84
Q

Gerontologic Nursing

A

the care of older adults based on the specialty of the body of knowledge of gerontology and nursing. These specialty nurses provide care for older adults using a whole-person (physical, psychologic, functional, developmental, socioeconomic, cultural) perspective.

85
Q

Comprehensive Geriatric Assessment Focus

A

determine appropriate interventions to support and enhance health, quality of life, function, and independence of older adults

86
Q

Comprehensive Geriatric Assessment Includes

A
  • medical history
  • functional assessment - ADLs and IADLs
  • medication review
  • cognitive and mood evaluation
  • social resources
  • social-environmental assessment
  • physical examination
  • recommended diagnostic tests
  • Fall risk assessment
87
Q

Care Team Providers for Comprehensive Geriatric Assessment can include

A
  • Health care provider
  • nurse
  • social worker
  • physical and/or occupational therapist
  • dietician
  • podiatrist
  • ophthalmologist
  • dentist
  • pastoral care representative
88
Q

Factors Increasing Fall Risk

A
  • prescription and nonprescription medications
  • infection
  • orthostatic hypotension
  • dehydration
  • electrolyte imbalance or other laboratory abnormalities
  • arthritis
  • changes in gait, balance, and mobility
  • neurologic impairment (e.g., stroke, Parkinson’s disease)
  • decreased muscle strength
  • decreased visual acuity
  • environmental hazards
  • feet abnormalities or poor footwear
  • clutter or slippery floors
  • incorrect use of assistive devices
  • incorrect bed position
89
Q

Comprehensive Geriatric Assessment - Planning

A
  • Identify older adults strengths and abilities
  • include caregivers in planning
  • priority goals may contain gaining a sense of control, feeling safe, and reducing stress
90
Q

Comprehensive Geriatric Assessment - Implementation

A
  • adjust approach based on physical, functional, and mental status
  • Give careful explanations
  • Safety is a top concern
91
Q

Health Promotion in Older Adults - 3 areas

A

(1) increased participation in health promotion and disease prevention activities
(2) reduction in diseases and health-related issues,
(3) increased use of services that reduce health hazards.

92
Q

SPICES Geriatric Assessment Tool

A 
Sleep Disorders
Problems with eating or feeding
Incontinence
Confusion
Evidence of falls
Skin breakdown
93
Q

Nursing Management Care of the Hospitalized Older Adult

A
  • Identify older adults at risk for consequences of medical and/or surgical treatments).
  • Consider discharge and postacute needs early in the hospital stay, especially assistance with activities of daily living and medications.
  • Encourage the development and use of interprofessional teams, special care units, and providers who focus on the special needs of older patients.
  • Implement standard protocols to screen for at-risk conditions common in the hospitalized older adult, such as urinary tract infection and delirium.
  • Implement mobility and exercise programs to prevent functional decline.
  • Monitor for and prevent skin integrity changes.
  • Implement measures focused on safety (e.g., fall prevention).
  • Refer patients to the appropriate community-based services.
94
Q

Transitional Care Model (TCM)

A

an evidence-based, innovative approach to care coordination and management of the complex needs of an older adult
-a transitional care nurse delivers and coordinates care by nurses and other team members throughout potential and acute episodes of illness.

95
Q

Decreased functional or disability leads to

A
  • increased self-care deficits
  • increased rates of institutionalization
  • decreased quality of life
  • higher mortality rates
96
Q

Factors Influencing Rehab of Older Adults

A
  • Anxiety or fear
  • preexisting conditions associated with decreased reaction time, visual acuity, fine motor ability, physical strength, and cognitive function
  • poor nutrition
  • financial issues
  • lack of motivation, deconditioning
97
Q

Common causes of accidental death in older adults

A
  • fire
  • motor vehicle accidents
  • falls
98
Q

By age 75-80 there is how much % decline in the renal clearance of drugs

A

50%

99
Q

Polypharmacy - MedSurg Definition

A

the use of multiple medications by a person with more than one health problem

100
Q

Potential Medication Errors by Older Adults Include

A

(1) taking both brand and generic medications,
(2) refilling medications too soon or too late (resulting in taking the medication incorrectly)
(3) drug-drug interactions

101
Q

Effects of Aging on Drug-Receptor interaction

A

Brain receptors become more sensitive, making psychoactive drugs very potent

102
Q

Effects of Aging on Metabolism

A
  • Liver mass shrinks
  • Hepatic blood flow and enzyme activity decline
  • metabolism drops 1/2 to 2/3 the rate of young adults
  • enzymes lose the ability to process some drugs, prolonging the half-life
103
Q

Effects of Aging on Absorption

A
  • gastric emptying rate and gastrointestinal motility slow

- absorption capacity of cells and active transport mechanism decline

104
Q

Effects of Aging on Circulation

A
  • Vascular nerve control is less stable
  • antihypertensive, example, may overshoot, dropping BP too low
  • Digoxin, example, may drop the heart rate too low
105
Q

Effects of Aging on Excretion

A
  • In kidneys, renal blood flow, glomerular filtration rate, renal tubular secretions and reabsorption, and number of functional nephrons decline
  • age-related changes increase half-life for renally excreted drugs
  • Oral antidiabetic drugs, among others, stay in the body longer
106
Q

Effects of Aging on Distribution

A
  • lean body mass falls
  • adipose stores increase
  • total body water declines, raising the concentration of water-soluble drugs, lie digoxin, which can cause heart dysfunction
  • Plasma protein levels decrease, reducing sites available for protein-bound drugs and raising blood levels of free drug
107
Q

Drug Therapy Causes of Medication Errors by Older Adults (table 5.11)

A
  • Decreased vision
  • Forgetting to take drugs
  • Use of nonprescription over-the-counter drugs
  • Use of medications prescribed for someone else
  • Lack of financial resources to obtain prescribed medication
  • Refusal to take medication because of undesirable side effects
  • Failure to understand instructions or importance of drug treatment
108
Q

Second highest rate of suicide

A

Those over the age of 75

109
Q

Depression is associated with

A
  • females
  • divorced or separated
  • low socioeconomic status
  • poor social support
  • recent adverse and unexpected event
  • loss of self-esteem
  • loss of spouse or partner
110
Q

Problems associated with depression

A
  • pain
  • lethargy
  • insomnia
  • agitation
  • weight loss
  • dementia
111
Q

Drug Therapy Safe Medication Use by Older Adults (Table 5.12)

A
  • Assess cognitive function and monitor for changes.
  • Try to reduce medication use that is not essential by consulting the HCP and pharmacist.
  • Assess ability to self-administer medication and overall medication use, including prescription drugs; OTC drugs; pain treatments; antihistamines; cough syrups; vitamins, minerals, and supplements; sleep remedies; and herbal remedies.
  • Assess alcohol and illicit drug use.
  • Encourage the use of written or electronic medication-reminder systems.
  • Encourage the use of 1 pharmacy.
  • Work with HCPs and pharmacists to set up routine drug profiles on all older adult patients.
  • Advocate for low-income prescription support services.
112
Q

Comprehensive Geriatric Evaluation - Assessment

A

directs you to continue your plan of care or revise it. Focus on functional improvement and quality of life

113
Q

Evaluating Nursing Care for Older Adults (Table 5.13)

A
  • Is there an identifiable change in function, mental status, or signs and symptoms of exacerbation of chronic condition(s)?
  • Does the person consider his or her health state to be improved?
  • Does the person think the plan is helpful?
  • Do the person and caregiver think the care is worth the time and cost?
  • Can you document positive changes that support the interventions?
114
Q
  1. Examples of primary prevention strategies include

a. colonoscopy at age 50
b. avoidance of tobacco products.
c. teaching the importance of exercise to a patient with hypertension.
d. intake of a diet low in saturated fat in a patient with high cholesterol.

A

B

115
Q
  1. A characteristic of a chronic illness is that it (select all that apply)
    a. has reversible pathologic changes.
    b. has a consistent, predictable clinical course.
    c. results in permanent deviation from normal.
    d. is associated with many stable and unstable phases.
    e. always starts with an acute illness and then progresses slowly.
A

C & D

116
Q
  1. Among older Americans in the United States
    a. more than 30% live in nursing homes.
    b. women are less likely to live in poverty.
    c. the number of those who completed college is lower than in previous decades.
    d. those 85 years or older account for the fastest growing segment of the population.
A

D

117
Q
  1. An ethnic older adult may feel a loss of self-worth when the nurse (select all that apply)
    a. prohibits visits from a faith healer.
    b. informs the patient about ethnic support services.
    c. allows a patient to rely on ethnic health beliefs and practices.
    d. emphasizes that a therapeutic diet does not allow ethnic foods.
    e. uses a medical interpreter to provide explanations and teaching.
A

A & D

118
Q
  1. An important nursing action to help a chronically ill older adult is to
    a. avoid discussing future lifestyle changes.
    b. ensure the patient that the condition is stable.
    c. treat the patient as a competent manager of the disease.
    d. encourage the patient to “fight” the disease as long as possible.
A

C

119
Q
  1. Older adults who become ill are more likely than younger adults to
    a. report symptoms to their health care providers.
    b. refuse to carry out lifestyle changes to promote recovery.
    c. seek medical attention because of limitations on their lifestyle.
    d. alter their daily living activities to accommodate new symptoms.
A

D

120
Q
  1. An appropriate care choice for an older adult who lives with an employed daughter but needs help with activities of daily living is
    a. adult day care.
    b. long-term care.
    c. a retirement center.
    d. an assisted living facility.
A

A

121
Q
  1. Nursing interventions directed at health promotion in the older adult are primarily focused on
    a. disease management.
    b. controlling symptoms of illness.
    c. teaching positive health behaviors.
    d. teaching about nutrition to enhance longevity.
A

C

NRS 111A Foundations - MHCC (3 decks)

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