OA Nursing Process Flashcards
1
Q
Middle-old
A
75-84
2
Q
Old-old
A
85-99
3
Q
Elite-old
A
100+
4
Q
After 2 days in a nursing home/ hospital
A
The body starts to weaken and breakdown
5
Q
The aging process
A
- each person ages at a different rate and each person adapts to the aging process individually.
- knowledge of the changes with the aging process enables the nurse to accurately differentiate between normal and abnormal findings in assessing the OA
6
Q
OA population in America 65 years or older
A
~40.4 million Americans 65 or older
~>71 million by 2030
~80 million by 2050
7
Q
________ has the highest percentage of people 65 and older.
A
Florida
8
Q
Percentage of OA in homes/rent/nursing homes?
A
77% own homes
21% rent
3.1% nursing homes
9
Q
Young-old
A
65-75
10
Q
Benign skin lesions are
A
Common
11
Q
Senile lentigines
A
Benign skin lesions. Age spots; irregular pigmented lesion with rough surface
12
Q
Seborrheic keratosis
A
Benign skin lesion. Raised, pigmented, warty lesions with “stuck on” appearance.
13
Q
Skin tags
A
Benign skin lesions. Raised tag of skin in high friction areas.
14
Q
Musculoskeletal
A
- Increased pain with joint movement. Joint cartilage erodes Synovial fluid thickens - Decreased muscle mass - Tendons less elastic - Decreased muscle tone and strength
15
Q
Physical changes of aging (systems)
A
- Neurological
- sensory
- pulmonary
- cardiovascular
- gastrointestinal
- genitourinary
- musculoskeletal
- skin
16
Q
GI System
A
- Inadequate nutrition
- Decreased bowel mobility
- constipation ( this is the #1 complaint from PT)
- Dependence on Laxatives
- increase fluids
- High residue/High fiber diets
17
Q
MDS ( minimum data set)
A
- Used in long term care settings
- periodic, multidisciplinary assessment
- validates need for care and justifies reimbursement
- review in your clinical rotation with staff
18
Q
Who does not pay for nursing home cost?
A
Medicare
19
Q
Musculoskeletal functional implications
A
- greater osteoarthritis pain and limited motion ….deconditioning.
- Loss of muscle mass with general weakening.
20
Q
Patient history
A
- Face pt and ask questions one at a time.
- If answers seem inappropriate, clarify answer or restate question.
- Ask for a list of medications or pharmacy containers.
- Questions must be specific to obtain accurate information. Ask about specific systems.
- Review a typical day.
- Ask about values, preferences and meds.
21
Q
Assessment and Environment
A
- Allow an adequate amount of time for the pt to answer questions and report information during the health interview.
- Bright glare free lighting.
- Warm room
22
Q
Older adults
A
- Heterogeneous population with varying needs.
- Chronological age is a constant age
- Functional age varies
23
Q
Chronological age
A
Constant age
24
Q
Functional age
A
Varies
25
Assessment of the OA
- Each system is effected
- Progressive and gradual
- NORMAL AGING-CHANGES THAT OCCUR IN ALL OLDER PEOPLE.
- concept of health for OA
26
Concept of health for OA
"The ability to live and function effectively in society and to exercise self-reliance and autonomy to the maximum extent feasible, but not necessarily as total freedom from disease" Healthy people 2000+
27
Physical assessment techniques
- Avoid unnecessary or prolonged exposure of body parts to prevent excess heat loss.
- Assist with position changes.
- Palpate and percuss gently to avoid trauma to frail skin.
- Do not move joints beyond the point of pain to avoid injury.
- pt may demonstrate rapid fluctuations in condition due to changes in the OA.
28
Neurological functional implications
- Slowed speed of cognitive processing
- Increased risk of sleep disorders, neurological diseases and delirium.
- Increased risk of sensory overload or deprivation
29
Neurological changes
- Changes from decreased velocity of nerve impulse condition and decreased sensory perception.
- Responses to stimuli take longer.
- Slowing of autonomic nervous system may contribute to orthostatic hypotension.
30
Sensory changes
```
~Alterations in taste/smell (Gustatory/Olfactory)
-med side effects
-poor dentition
-improperly fitting dentures
-other systemic problems
~Dry mouth common
```
31
Sensory Functional Implications
- Increased risk for falls, burns and motor vehicle accidents.
- Increased risk for social isolation, boredom, depression.
- Increased risk of communication difficulties due to hearing loss.
- lower metabolic rate: lower baseline temp
- febrile response muted; may have infection without a febrile response.
32
Cardiovascular functional Implications
- Decreased cardiac reserve
- Increased risk arrhythmias
- Increased risk postural hypotension
- Increased risk varicose ties of lower extremities
- Increased risk dependent edema of lower extremities
33
Pulmonary Functional implications
~Lung sounds diminished in bases
- Decreased cough reflex with risk aspiration pneumonia
- Increased risk of infection and bronchospasm with airway obstruction
34
Pulmonary; Diminished lung expansion from:
- Weakness of respiratory muscles
- Calcification of rib articulations
- Stiffness of chest wall
- kyphosis
35
Genitourinary system
- Decreased bladder capacity
- Weakened muscles
- Incontinence not a normal sign of aging
- May not empty completely
- Urinary urgency and more frequent nighttime voiding
- Males: BPH (benign prostatic hypertrophy) - inability to start stream, voiding smaller amounts, more frequent urination.
36
Braden scale to predict pressure sore risk
```
-Risk level
No risk
Risk
Moderate risk
High risk
Very high risk
-Interventions
```
37
No risk range
19-23
38
Risk range
15-18
39
Moderate risk range
13-14
40
high risk range
10-12
41
Very high risk range
Less than or equal to 9
42
Braden scale
```
1= Highly impaired
Highest #= no impairment
-Sensory perception
- Moisture
- Activity
-Mobility
-Nutrition
-Function and shear
```
43
Sensory perception (Braden scale)
(1-4)
| Ability to respond meaningful to pressure-related discomfort
44
Moisture (Braden scale)
(1-4)
| Degree to which skin is exposed to moisture
45
Activity (Braden scale)
(1-4)
| Degree of physical activity
46
Mobility (Braden scale)
(1-4)
| ability to change and control body position
47
nutrition (Braden scale)
(1-4)
| usual food intake pattern
48
Friction and shear (Braden scale)
(1-3)
49
Skin risk
```
~Increased risk pressure ulcers
-immobile
-malnourished
-multiple comorbidities
~Critical to assess bony prominences and areas of pressure.
```
50
Skin changes
- Loss of elasticity and subcutaneous tissue.
- Dry skin with scaly apperance
- Wrinkling skin
- Skin is thinner, more transparent
- Increased or decreased pigmentation common
51
Skin Changes Hydration/weight
- Skin turgor is NOT reliable test of hydration for OA
- Most reliable test of hydration is a scale
- Weigh the pt daily before breakfast with same scale
- 1 liter of body fluid is approximately 1 kg or 2.2 pounds
52
Musculoskeletal Morse fall scale assessment for long term care facilities.
```
Functional Implications....Increased risk of falls with injury
-Risk level
Low risk
Medium risk
High risk
-interventions
```
53
(Morse fall scale) Low risk range
0-24
54
(Morse fall scale) medium risk range
25-44
55
(Morse fall scale) High risk range
45 and higher
56
Musculoskeletal Morse fall scale Function implications
```
Function implications...Increased risk of falls with injury
~Variables
-history of falling(25)
-secondary diagnosis (15)
Dizziness
Parkingson's
Neuropathy
Osteoarthritis
Hypertension
-Ambulatory aid
Crutches/cane/walker (15)
Furniture (30)
-IV or IV access (20)
-Gait
Weak(10)
Impaired (20)
-mental status
Overstimulates or forgets limitations (15)
```
57
Musculoskeletal bone changes
~Profound effect on bone mineralization with menopause.
-Bone resorption out paces bone building.
~30% of bone mass lost by age 80 in women
~ Increased fractures in weight bearing bones and vertebrae
58
S4 is _______ in older adults
Normal
| Due to valve issues
59
S3 is _____ in older adults
Abnormal
| S3 is abnormal: due to CHF and fluid overload
60
cardiovascular Heart anatomy changes
- Left ventricle thicker and less compliant
- Thickening leads to decrease diastole filling and decrease cardiac output by 30 to 40 %
- tachycardia poorly tolerated
- thickened myocardium prone to irritability, arrhythmias and ischemia
61
Cardiovascular changes
```
~Fibrosis and sclerosis of cardiac muscle can lead to cardiac arrhymias
-Premature beats
~Stenotic or incompetent valves
-Increased BP
-Arterial insufficiency
-Abnormal heart sounds
```
62
Cardiovascular changes cont.
~decreased baroreceptor sensitivity can lead to postural hypotension.
~A drop of >15 mmHg in systolic BP when changing from lying to standing.
63
Cardiovascular changes vessels/arteries
```
~Aging blood vessels
-Calcified and tortuous
~Arteries
-Lose elasticity and vasomotor tone
-Less able to regulate blood flow
~Increased peripheral resistance....Increased BP.
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