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OA Exam 1 > OA: Nursing Process > Flashcards

OA: Nursing Process Flashcards

1
Q

Each person ages..

A

at a different rate and adapts to the aging process individually

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2
Q

Knowledge of the aging process enables the nurse to…

A

accurately differentiate between normal and abnormal findings in assessing the OA

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3
Q

Who are the older adults?

A

Heterogeneous population with varying needs

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4
Q

Young-old

A

65-75

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5
Q

Middle-old

A

75-84

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6
Q

Old-old

A

85-99

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7
Q

Elite-old

A

100+

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8
Q

aging in place

A

in home as long as possible

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9
Q

FL has the highest percentage of…

A

ppl 65 and older

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10
Q

Normal aging

A

changes that occur in all older people

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11
Q

When assessing an older adult, what considerations should you remember?

A
  • allow adequate time for patient to answer questions and report information
  • bright, glare-free lighting
  • warm room
  • clarify answers or restate if you dont understand
  • list of meds
  • review typical day
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12
Q

Avoid prolonged…

A

exposure

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13
Q

Assist with…

A

position changes

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14
Q

Palpate and percuss gently to avoid…

A

trauma to frail skin

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15
Q

Do not move joints beyond point of pain to…

A

avoid injury

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16
Q

Patient may demonstrate rapid fluctuations in..

A

condition due to changes in older adult

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17
Q

Holistic/Comprehensive Assessment

A

essential to understanding the health needs of the older adult

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18
Q

Holistic/Comprehensive Assessment should be done…

A
  • yearly assessment
  • after any abrupt change
  • when hospitalized for acute illness or injury
  • nursing home placement or change in living status
  • when 2nd opinion is wanted
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19
Q

Fulmer Spices Assessment Tool

A

conditions that warrant further assessment for fall risk

S: sleep disorders
P: problems with eating and feeding
I: incontinence
C: confusion
E: evidence of falls
S: skin breakdown
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20
Q

When is Fulmer Spices used?

A

on admission to prompt fall risk precautions if needed

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21
Q

MDS

A

minimum data set

-periodic, multidisciplinary assessment

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22
Q

What does MDS validate for?

A

need for care and justifies reimbursement

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23
Q

Patience is..

A

a virtue when obtaining a hx from an older adult

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24
Q

Thought and verbal processes are…

A

slower than those of younger clients

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25
Q

Allow adequate…

A

time to answer questions and report information

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26
Q

When an OA client comes in for assessment with a large bag full of multiple medications, what nursing dx is apparent?

A

At risk for ADR related to polypharmacy

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27
Q

Neurological changes in the OA:

-Changes from decreased velocity of…

A

nerve impulse conduction and decreased sensory perception

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28
Q

Responses to stimuli…

A

take longer

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29
Q

Slowing of the ANS may contribute to…

A

orthostatic hypotension

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30
Q

orthostatic hypotension

A

aka postural hypotenstion

-stand up—> drop in BP (>15mmHg in sys)

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31
Q

Functional implications of Neurological changes in the OA

A
  • slowed speed of cognitive processing
  • increased risk of sleep disorders, neurological dz, and delirium
  • increased risk of sensory overload or deprivation
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32
Q

Sensory changes in the OA

A
  • alterations in taste/smell

- dry mouth is common

33
Q

Alterations in taste/smell related to..

A
  • med side effects
  • poor dentition
  • improperly fitting dentures
34
Q

Functional implications for Sensory changes in the OA

A
  • increased risk for falls, burn, and car accidents
  • increased risk for social isolation, boredom, and depression
  • increased risk of communication difficulties due to hearing loss
  • lower BMR
  • lower temp
  • febrile response muted, may have infection without febrile response
35
Q

Cardiovascular changes in the OA

A

-Left ventricle thicker and less compliant

36
Q

Thickening of the left ventricle leads to…

A

decreased diastole filling and cardiac output by 30 to 40%

37
Q

Tachycardia is ________ in the OA

A

poorly tolerated

38
Q

Thickened myocardium prone to…

A

irritability, arrhythmias, and ischemia

39
Q

Fibrosis and sclerosis of cardiac muscle can lead to…

A

cardiac arrhythmias (premature beats)

40
Q

What happens to the valves of the heart in the OA?

A

they become stenotic and incompetent

41
Q

Due to the valves becoming incompetent, what happens…?

A
  • increased BP
  • Arterial insufficiency
  • Abnormal heart sounds: S4 normal due to valve issues
  • S3 abnormal due to CHF and fluid overload
42
Q

decreased baroreceptor sensitivity can lead to…

A

postural hypotension

43
Q

Postural hypotension

A

aka orthostatic hypotension

-A drop of >15mmHg in systolic BP when changing from lying to standing

44
Q

Aging blood vessels become…

A

calcified and tortuous

45
Q

What happens to the arteries in an OA?

A
  • lose elasticity and vasomotor tone

- less able to regulate blood flow

46
Q

Increased peripheral resistance leads to….

A

Increased BP

47
Q

Functional Implications of Cardio changes in the OA

A
  • decreased cardiac reserve
  • increased risk for arrhythmias
  • increased risk for postural hypotension
  • increased risk for varicosities of lower extremities
  • increased risk for dependent edema of lower extremities
48
Q

Pulmonary changes in the OA

A

diminished lung expansion

49
Q

What causes diminished lung expansion in the OA?

A
  • weak respiratory muscles
  • calcified rib articulations
  • stiff chest wall
  • kyphosis
50
Q

kyphosis

A

A forward rounding of the back.

hunchback

51
Q

Functional implications of pulmonary changes in the OA?

A
  • lung sounds diminished in the bases
  • decreased cough reflex with aspiration pneumonia risk
  • increased risk of infection and bronchospasm with airway obstruction
52
Q

Musculoskeletal changes in the OA

A

-profound effect on bone mineralization with menopause

53
Q

30% of bone mass…

A

lost by age 80 in women

54
Q

increased pain with joint movement due to…

A
  • eroding joint cartilage

- synovial fluid thickening

55
Q

Muscle mass, tone, and strength…

56
Q

What happens to tendons in the OA?

A

Become less elastic

57
Q

Functional implications of musculoskeletal changes in the OA

A

-increased risk of fall

58
Q

Morse Fall Scale Assessment

A
  1. hx of falls (25 pts)
  2. 2nd dx (15 pts)
  3. Ambulatory aid: crutches (15 pts) furniture (30 pts)
  4. IV or IV access (20 pts)
  5. Gait: weak (10) impaired (20)
  6. Mental status: overestimates or forgets limits (15 pts)
59
Q

Risk levels of Morse Fall Scale Assessment

A

Low (0-24)
Med (25-44)
High (45+)

60
Q

GI changes in the OA

A
  • inadequate nutrition
  • decreased bowel motility
  • constipation
  • dependance on laxatives
  • increase fluids
61
Q

What diet is recommended for the OA?

A

high residue/high fiber diets

62
Q

GU changes in the OA

A
  • decreased bladder capacity
  • weakened muscles
  • may not empty completely
  • urinary urgency
  • more frequent nighttime voiding
63
Q

Incontinence…

A

not a normal sign of aging

64
Q

Males risk with GU changes in the OA

65
Q

BPH

A

Benign Prostatic Hypertrophy

  • inability to start stream
  • voids smaller amounts
  • more frequent urination
66
Q

Skin changes in the OA

A
  • loss of elasticity
  • loss of SubQ tissue
  • wrinkly skin
  • thin and transparent skin
  • increased or decreased pigmentation is common
67
Q

Skin turgor in OAs

A

not a reliable hydration test

68
Q

Most reliable hydration test in OAs..

A

daily weight before breakfast with same scale

69
Q

1 liter of body fluid is approx…

A

1 kg or 2.2 lbs

70
Q

Benign skin lesions are…

71
Q

seborrheic keratosis

A

raised, pigmented, warty lesions with “stuck on” look

72
Q

skin tags

A

raised tag of skin in high friction areas

73
Q

senile lentigines

A

age spots

-irregular pigmented lesion with rough surface

74
Q

OAs have increased risk of PUs due to..

A
  • immobile
  • malnourished
  • comorbidities
75
Q

Critical to assess _______ in OAs with risk of PU

A

bony prominences and areas of pressure

76
Q

Braden Scale

A

Used to predict pressure sore risk

(SMAMNF)

  1. Sensory perception (1-4)
  2. Moisture (1-4)
  3. Activity (1-4)
  4. Mobility (1-4)
  5. Nutrition (1-4)
  6. Friction and Shear (1-3)
77
Q

How is the Braden Scale rated?

A

1=impaired to 4=no impairment

78
Q

Risk Evaluation of Braden Scores

A 
No risk: 19-23
Risk: 15-18
Moderate risk: 13-14
High risk: 10-12
Very high risk: 9 or less

OA Exam 1 (6 decks)

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