Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
195 Cards in this Set
- Front
- Back
|
What is the fastest growing age group in developed nations? |
The elderly (over 65 years). By 2050 will be 20% of the population. |
|
|
What are the biologic theories of aging? |
- The Wear and Tear Theory - Genetics Theory - Cellular Malfunction - Autoimmune Reaction |
|
|
What are the psychosocial theories of aging? |
- Disengagement theory (older adults gradually distance themselves from others) - Activity Theory (replace time spent at work with other activities) - Psychosocial Development (reflecting on life with integrity or despair) |
|
|
What are the options for housing for the elderly? |
- Aging in place (in their home and receive care) - Elder Friendly residences (homes big enough for wheelchairs, et al) - Elder Friendly communities (affordable housing with available care) - Retirement communities - Naturally occurring retirement communities (older adults living close to each other) - Continuing Care Retirement Communities - Assisted Living Facilities - Nursing Homes (with skilled and unskilled care, 70% are women and over half have some sort of dementia) |
|
|
What are the stages of development for older adulthood? |
- begins at 65 (with changes associated with retirement) - Young -old (65-74 years) - Middle -old (75-84 years increasing solitude) - Oldest -old (over 85 years - fastest growing age range, have sensory impairments, poor dental health, poor nutrition, decreased functional mobility) |
|
|
Name some characteristics of older adulthood. |
- it is the fastest growing age group - most health problems are chronic - chronic disorders affect independent living - the frail or fragile elderly are at a heightened state of vulnerability |
|
|
What is important to remember when assessing the older patient? |
- older patients have a lot of health history, don't rush them - remember which changes are related to the aging process and which are related to a disease process - your choice of communication techniques depends on visual or hearing impairments in the older adult |
|
|
When communicating with the older patient, what is important to remember? |
- face your patient and speak clearly - ensure the older adult has all required assistive devices prior to your assessment (hearing aides, glasses, etc.) |
|
|
What systems are affected by age related physical changes? |
- musculoskeletal - cardiovascular - respiratory - gastrointestinal - integumentary - genitourinary - neurological - sensory - cognitive - personality |
|
|
What are the musculoskeletal age related physical changes? |
- decreased muscle strength - decreased joint mobility - decreased muscle mass - decreased body mass - decreased bone mass |
|
|
What are the cardiovascular age related physical changes? |
- decreased cardiac output - increased systolic blood pressure - blood vessels thicker and more narrow |
|
|
What are the respiratory age related physical changes? |
- decreased elasticity of the chest wall - decreased cough reflex - lung tissue more rigid - chest diameter decreased (less lung volume) |
|
|
What are the gastrointestinal age related physical changes? |
- decreased saliva production - appetite changes - slower digestion (constipation) |
|
|
What are the integumentary age related physical changes? |
- decreased skin elasticity - thinning hair - decreased subcutaneous fat |
|
|
What are the genitourinary age related physical changes? |
- decreased GFR (glomerular filtration rate) - decreased bladder capacity |
|
|
What are the neurological age related physical changes? |
- decreased perfusion to the brain and spinal cord - fewer neurons - decreased REM sleep |
|
|
What are the endocrine age related physical changes? |
- less insulin - decreased thyroid hormone - less estrogen/ testosterone |
|
|
What are the sensory age related physical changes? |
- visual acuity decreased - decreased hearing - fewer tears - sense of balance changes - pain is different as we age |
|
|
What are the cognitive age related physical changes? |
- decreased short term memory - longer to react and process new information |
|
|
What is the personality age related physical change?
|
- more cautious |
|
|
What are the leading causes of death in the elderly? |
1. Heart Disease 2. Cancer 3. Stroke 4. Chronic Lower Respiratory Diseases 5. Alzheimer's Disease 6. Influenza and pneumonia - acute 7. Diabetes Mellitus (DM) |
|
|
Which of the following is a normal developmental change of aging? A. Confusion and dementia B. Dry Skin C. Joint Pain |
B. Dry Skin |
|
|
What is dementia? |
The irreversible gradual impairment of intellectual function. It has a significant impact on patient safety and ADLs. Affects 20% of adults over 70 years of age. |
|
|
What is delirium? |
Usually has a physiological cause such as a UTI in an elderly patient or dehydration in a patient of any age. Can affects patients in all stages of life. Is reversible. |
|
|
What is the biggest difference between dementia and delirium? |
Dementia is permanent, delirium is not |
|
|
How do you assess depression? |
SIG-E-CAPS |
|
|
What does SIG-E-CAPS stand for and what is it used for? |
It is a mnemonic for diagnostic criteria of depression. Ask the patient if they've had 2 or more weeks of Sleep increase/ decrease Interest diminished in formally pleasurable activities Guilt or low self esteem Energy Poor Concentration poor Appetite increase/ decrease Psychomotor agitation or retardation Suicidal ideation
|
|
|
What is a nurses responsibility regarding elder abuse? |
Elder abuse is of great concern. Suspicion of elder abuse MUST be reported to local authorities. |
|
|
What are older adults in acute care settings at increased risk for? |
- delirium - health care associated infections - dehydration - malnutrition - falls - bowel and bladder incontinence can cause skin impairments |
|
|
What are the causes of delirium in acute care settings that older adults are at increased risk for? |
- sleep deprivation - drugs - fever - infections - different environments |
|
|
What is stress? |
- a disturbance in a person's normal balanced state - caused by external and internal stimuli called stressors - can be harmful or motivating |
|
|
How is stress broken up into good and bad stress? |
- Eustress (good stress, is protective. Ex. a passionate kiss) - Distress (can threaten health. Ex. continual financial worries) |
|
|
What are the types of stressors? |
- External - Internal - Physiological - Developmental/ Situational - Psychological |
|
|
Describe external stressors. |
- Random - unpredictable Ex. hurricane, accident, death of a family member |
|
|
Describe internal stressors. |
- Disease - Anxiety - nervous anticipation - negative self talk |
|
|
Describe physiological stressors. |
- affects the body (structure or function) Ex. disease or mobility problems |
|
|
Describe developmental or situational stressors. |
- Associated with life stages Ex. college graduation |
|
|
Describe psychological stressors. |
- arise from life events Ex. work pressure, family arguments |
|
|
The hospitalized client states, “I need to know when I’m going to be discharged. I’m so upset and worried that I’m missing work.” The nurse knows this is an example of: 1. Eustress; no intervention is necessary 2. Psychological stress; the client should be prescribed antidepressants 3. Developmental stress; the client should talk to someone his own age 4. Distress; could affect the client’s health status |
4. The client’s statement indicates that he is experiencing distress. Even though it could be termed psychological stress, it is essential to gather more assessment data about the patient’s coping, personal support, other stressors, health status, and so on, before starting prescribed antidepressant therapy. |
|
|
What are coping strategies? |
thinking processes & behaviors a person uses to manage stressors. |
|
|
What are some adaptive coping strategies? |
Making healthy choices to reduce stress (going for a run). They directly reduce negative effects of stress Ex: Change in lifestyle; Problem-solving, exercise, hobbies |
|
|
What are some maladaptive coping strategies? |
Unhealthy choices that are a temporary fix and may have other harmful effects (causing more stress) Ex: substance abuse; overeating, smoking, drinking |
|
|
What are the three general approaches for coping, depending on the situation? |
- Alter the stressor (job change) - Avoid the stressor (dump the jerk!) |
|
|
Ability to adapt depends on the balance of what factors? |
1. available supports (strong support = better adaptation) 2. coping abilities & experience (developmental level & life experiences) 3. duration and strength of stressor (overall health status, # of illnesses & chronicity of illnesses) 4. perception of stress (realistic helps, unrealistic doesn't) |
|
|
What is General Adaptation Syndrome (GAS)? |
Nonspecific bodily responses shared by all people Response to distress as well as eustress Involves three stages |
|
|
What are the three stages of GAS? |
1. Alarm Stage 2. Resistance Stage 3. Either: Exhaustion OR Recovery |
|
|
Describe the alarm stage of GAS. |
It is the fight or flight Involves involuntary body responses which involves the endocrine system |
|
|
What are the involuntary bodily responses of the alarm stage of GAS? |
- Sympathetic nervous system kicks in epinephrine,norepinephrine - the cardiovascular system is affected and vasoconstriction happens heightening the BP - Respiratory system is affected dilating the bronchioles - the metabolic system increases availability of glucose - the urinary system retains sodium and water - GI system decreases peristalsis - the musculoskeletal system increases blood flow to the muscles |
|
|
Describe the resistance stage of GAS. |
The goal of the resistance stage is maintenance of homeostasis. Involves the use of coping mechanisms: - psychological - physical - the return of the vital signs to normal. Failure to contain, or adapt to, the stress leads to third stage. |
|
|
Describe the exhaustion stage of GAS. |
Exhaustion: - if adaptive mechanisms become ineffective/ nonexistent - decrease in BP, elevated pulse, respiration - usually ends in disease or death OR Recovery: if adaptation is successful
|
|
|
True or False? A client who is taking the drug atenolol (Tenormin) may not exhibit the expected rise in blood pressure and pulse during the alarm stage of the general adaptation syndrome. |
True Atenolol is a Beta-blocker, which means it blocks epinephrine from binding to the Beta receptors (which vasoconstricts & bronchodilates with epi). The alarm stage will normally vasoconstrict and bronchodilate, but not with a beta-blocker. |
|
|
What is LAS and what does it do? |
Local Adaptation Syndrome - Localized body response to stress involving specific body part: Examples: Tissue or Organ - Short-term attempt to restore homeostasis |
|
|
Give examples of LAS. |
- reflex pain response like from a hot stove - inflammatory response like an autoimmune disorder |
|
|
Name 3 common psychological responses to stress. |
1. Anxiety 2. Fear 3. Anger |
|
|
Name 4 less common psychological responses to stress. |
1. Difficulty concentrating 2. Irritability 3. Forgetfulness 4. Decreased self esteem |
|
|
What are ego defense mechanisms? |
Unconscious mental mechanisms that help to decrease the inner tension associated with stressors. (Example: denial). When overused, they are maladaptive. |
|
|
Give 3 examples of ego defense mechanisms. |
Denial – transforming reality with thoughts and feelings Displacement – involves displacing a feeling on the wrong person Rationalization – use of logical sounding excuses to cover up actions and feelings |
|
|
What can unsuccessful adaptation lead to? |
1. Crisis 4. Psychological disorders (mental illness) |
|
|
What is a somatoform disorder? |
The presence of disease with no known cause. |
|
|
What is stressed induced organic responses? |
Continual stress results in repeated CNS stimulation Which elevates certain hormones Resulting in long-term changes in body systems People who use maladaptive coping strategies (over eating, substance abuse) create additional stress on the body. |
|
|
Name some somatoform disorders. |
Hypochondriasis – paranoid sick all the time Somatization – stress in the form of physical illness Somatoform pain disorder – emotional pain displaced to become physical pain (nothing to fix it) Malingering – conscious effort to escape unpleasant situations (making excuses to stay in hospital) |
|
|
What are some stress induced psychological disorders? |
- Crisis |
|
|
How does a crisis develop? |
A precipitating even causes a drastic change in routine - the perception of the even is "a threat to self", even life threatening (social supports are inadequate and the usual coping methods are ineffective) - this causes high levels of anxiety - work and personal relationships deteriorate - there's a loss of self-esteem and an inability to function which causes - a crisis |
|
|
When does burnout occur? |
When nurses or other professionals cannot cope effectively with the demands of the workplace. |
|
|
How can burnout be prevented? |
Have realistic expectations of yourself & others Don’t feel you have to know everything Accept what you can’t change Stop negative talk and don’t complain it, adds to stress you & others |
|
|
Nurse’s need to Assess data about patient’s stressors. What, specifically, do they ask about? |
- Risk factors - Source, duration, lifestyle and lifechanges - Ask how they cope with stress |
|
|
What are some health promotion activities? |
- Promote adequate nutrition - Establish a routine including regular exercise – good stress reducer - Encourage participation in leisure activities - Teach client importance of getting enough sleep to feel rested - Help clients to manage time, balance responsibilities, prioritize tasks - Social interaction - Advise clients to avoid maladaptive behaviors: excess alcohol, caffeine, sweets, smoking, illegal drugs, junk food |
|
|
What are some interventions to relieve anxiety? |
- anger management - stress management techniques (meditation, massage, music) - change perception of stressors & self (positive self talk) |
|
|
What are some stress reduction interventions? |
Identify and use support systems Use of spiritual support Reduces stress in hospitalization (involve them in their own care and keep them informed and goals for discharge) Discuss stress management in the work place Crisis intervention if necessary Use of proper referrals: councilor, physician or spiritual leader |
|
|
The nurse should assess every client to determine if stress reduction interventions should be part of the plan of care. The rationale for this action is that: A. There are more persons experiencing mental illness now than in the past B. Life is so much more stressful than it has ever been C. The occurrence of stress in clients is unpredictable D. Clients often develop maladaptive coping strategies |
Correct answer: C The nurse recognizes that all clients respond differently to healthcare interventions. Therefore, it is important to assess every client’s level of stress to determine if interventions are required. |
|
|
What is nutrition? |
- Study of food: how it affects the body and influences health and how the body metabolizes food for energy - Adequate nutrition is essential to wellness and poor nutrition leads to diseases |
|
|
What are nutrients? |
- Building blocks for cells and tissues that Supply energy and Help manufacture, maintain, and repair cells - Found in foods - there are Micro and macro nutrients - Anabolism - Need enzymes to function like lactase |
|
|
What are micronutrients? |
Nutrients required in minute amounts - vitamins and minerals |
|
|
What are macronutrients? |
Nutrients required in large amounts - oxygen, |
|
|
What are the water soluble vitamins? |
B and C |
|
|
What are the fat soluble vitamins? |
A,D,E and K |
|
|
What do minerals do? |
Help with nerve conduction and help excrete byproducts of metabolism. |
|
|
What does water do? |
Makes up large percentage of body weight Solvent for chemical processes Transports substances Form for tissues Maintains body temperature |
|
|
What is BMR? |
Basal metabolic rate = the amount of energy needed at rest |
|
|
What factors affect nutrition? |
- Developmental stage (From infants to elders Including lactating women) - Educational level - Includes concepts of access - lifestyle choices (dieting, vegetarianism) - Ethnicity/ culture - religious practices - Disease process (requires more calories) - functional limitations (wheelchair bound patients need less calories) |
|
|
Identify the client with the greatest risk for developing protein-calorie malnutrition A. A client who has multiple sclerosis and is in a wheelchair. B. A client weighing 300 lb who has entered the hospital for cardiac bypass surgery. C. A client with a broken arm and femur from trauma who is running a fever of 101.5°F (38.6°C). D. A client who is of Native American heritage. |
Correct answer: C This client would have the greatest increase in metabolic demand for “energy”/nutrients and runs the greatest risk for not having those energy demands met. |
|
|
What's a diet that consists of "clear liquids"? |
Broth, water, apple juice - anything that can be seen through |
|
|
What's a diet of "full liquids"? |
Clear liquids plus milk and soups. |
|
|
What's a diet of "mechanical soft" foods? |
Soft cooked foods |
|
|
What's a "pureed" diet? |
Fully blended foods for people who have trouble chewing (applesauce, oatmeal, etc.) |
|
|
What BMI is considered overweight? |
A BMI between 25 and 29.9 |
|
|
What BMI is considered obese? |
A BMI over 30 |
|
|
What are some ways to obtain a diet history? |
- 24 hour recall - Food frequency questionnaire - A food diary |
|
|
How would a health care provider identify nutritional imbalances? |
Complete Physical Examination General survey Alterations in vital signs Poor skin turgor (pinch skin on back of hand), wound healing Concave abdomen/ascites Change in muscle mass Laboratory Results Changes in blood glucose, serum albumin, creatinine, hemoglobin |
|
|
The nurse knows the lab result that is the best indicator of a client’s nutritional status is the serum albumin. A. True B. False |
Correct answer: B, false The latest research shows that pre-albumin has a shorter half-life than albumin and is a better indicator of protein stores (and acute changes in those stores). |
|
|
What does the blood glucose test tell you? |
How much fuel for cells are in the blood - Hypoglycemia – not enough hyper- too much |
|
|
What does the albumin test tell us? |
Can detect if the patient has liver or kidney disease, or if the body isn't absorbing or getting enough protein. Can give us the average protein balance for the past 3 months. |
|
|
What does the prealbumin test tell us? |
Short term protein levels in the blood. Is more accurate to tell us acute changes. |
|
|
What does creatinine tell us? |
Tells us if there is a break down of muscle. |
|
|
Why is creatinine important in the elderly? |
There is a muscle loss in the aging so if creatinine levels are up, there is more muscle loss and that could be dangerous. |
|
|
What are some examples of etiologies for undernutrition? |
- difficulty chewing or swallowing - alcoholism - metabolic disorders - eating disorders |
|
|
What are some examples of etiologies for overnutrition? |
- overeating - lack of exercise - endocrine problems |
|
|
Name some interventions for an elderly person's undernutrition. |
- assist with feeding, try to find what they like to eat - refer to an agency for help in obtaining food for home care |
|
|
Name some interventions for an obese person's overnutrition. |
- Assist with calorie calculations and meal planning - Encourage exercise/lifestyle changes |
|
|
Name some interventions for undernutrition of a younger person. |
Encourage client to seek counseling for eating disorder management Devise strategies to improve client’s appetite Enteral nutrition (tube feeding) Parenteral nutrition (IV) |
|
|
What is malnutrition? |
Insufficient intake of protein, fat, vitamins, and minerals leading to impaired development or function |
|
|
Can an individual be overweight and malnourished? |
An individual can be malnourished with regard to certain vitamins and minerals without being underweight. |
|
|
What are some causes for malnutrition? |
- physical (can't feed oneself) - psychological (anorexia) - social (limited knowledge of good nutrition) - economic (can’t afford good food) |
|
|
What is enteral nutrition? What are the types of delivery? |
Delivery of liquid nutrition into the upper intestinal tract via a tube. - nasogastric (tube to the stomach) - nasojejunal (tube to the jejunum in the small intestine) - nasoenteric (tube to the duodenum) The placement must be checked before use |
|
|
What types of feeding can be done with enteral feedings? |
- Continuous feeding - Gravity feeding - Cyclic feeding – feeding at night so they’ll be hungry during the day - Intermittent feeding |
|
|
What kind of monitoring is needed for enteral feeding patients? |
- Tube placement |
|
|
What is parenteral feeding? |
IV nutrition through a PICC line with a solution of glucose, amino acids, vitamins, minerals and trace elements individualized for the patient. It consists of 10% to 70% dextrose in water, but typically not more than 20%. |
|
|
What kind of diet would you plan for someone on diuretic medication? |
- Low sodium foods - potassium rich foods - calcium rich foods |
|
|
What kind of diet would you plan for an alcoholic? |
One with multivitamins, in particularly, B vitamins and folic acid. |
|
|
What kind of diet would you plan for an overweight patient? |
- One with balanced nutrients and a variety of food choices - encourage physical activity - emphasize self-monitoring, cognitive strategies and behavior modifications |
|
|
What kind of diet would you plan for an underweight patient? |
- high protein, high calorie nutrient dense foods - high protein supplements - frequent small meals |
|
|
What affect does blood glucose have on the body and organs? |
- short term exposure can cause weakness & fatigue - long term exposure to high blood glucose can cause neuropathy in the extremities, weight loss, blurred vision, ketosis and renal failure. |
|
|
What is ketosis? |
Incomplete metabolism of fat due to inability to use carbohydrates as fuel. |
|
|
What is necessary to keep track of when a patient has an enteral feeding tube? |
Checking tube placement before each feeding is essential. This is done by aspirating stomach contents, measure the volume, inspect the color and check the pH and then replacing it back into the stomach. |
|
|
What responses should a nurse have to an angry patient? |
- don't take it personally - remain calm (don't bring in your own stress) - encourage the patient and family to express feelings verbally and appropriately - listen and don't get defensive - remember that anger and anxiety are normal - do not take responsibility for the patient's anger - help the patient identify what is causing the anger and try to meet those needs
|
|
|
If a patient seems violent, what are some good ways to stay safe? |
- don't let the patient get between you and the door - don't wear a stethoscope or dangling jewelry that you could be harmed with - don't turn your back to the patient - stay at least an arm's length away from the patient - do not go into an angry patient's room alone if they have the potential for violence |
|
|
How could we teach a patient relaxation techniques? |
Relaxation techniques involve teaching the patient to relax individual muscle groups. Progressive relaxation in a quiet meditative state or lying in bed relaxing and contracting muscle groups. Easy on joints, good for muscles and good for relieving tension. |
|
|
What is the difference between acute wounds and chronic wounds? |
Acute - heal uneventfully in expected time frame - examples include surgical incisions, burns, etc Chronic - does not heal within expected time frame or with few complications - examples include pressure ulcers, diabetic ulcers, non-healing surgical wounds - 6 months or longer to heal |
|
|
If a patient is lying in a supine position, what areas are at risk for pressure ulcers? |
- occiput (back of the head) - scapula - spinous processes - sacrum - heels (calcaneous) |
|
|
If a patient is in a side lying position, what areas are at risk for pressure ulcers? |
- side of ear - shoulder - medial/lateral elbow - trochanter (hip bone) - medial/lateral knee - medial/lateral malleolus (ankle) - medial/ lateral foot (metatarsals) |
|
|
If a patient is in a sitting position, what areas are at risk for pressure ulcers? |
- ischial tuberosities (the sitting bones) - elbow - sole of foot - posterior knee - coccyx (tail bone) - sacrum (end of spinal column before coccyx) |
|
|
What causes pressure ulcers? |
A lack of oxygen to the area due to pressure between the weight of the body and the surface the patient is lying on. Blood cannot get to the area and ischemia takes place and eventually necrosis. |
|
|
How can pressure ulcers be prevented? |
- reposition the patient every 2 hours in bed - heels off the bed - avoid position directly on trochanter (hip) - use lifting sheets - use foot splints - use of pillows and cushions - reposition every hour in chair - avoid extended periods of time in semi-fowler position |
|
|
What does a pressure ulcer look like at Stage I? |
- Intact skin with non- blanchable redness - Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area
|
|
|
What does a pressure ulcer look like at Stage II? |
- Partial thickness - Red Pink wound - Intact or open/ruptured serum (clear)-filled blister. |
|
|
How is a patient assessed for pressure ulcer risk? |
A Braden Scale with 6 subsets give a score from 6 to 23 The subsets include - sensory perception - moisture - activity - mobility - nutrition - friction-shear |
|
|
How often should a patient be assessed for pressure ulcer risk? |
At admission and at periodic intervals |
|
|
What groups are at the highest risk for pressure ulcers? |
Geriatrics: Over 65 years of age. Fractured hip, resident in long term care facility (heel ulcers) (knees too) Spinal Cord Injury Pediatrics: Equipment/devices (CPAP, casts). Neurological impairments (CP, SCI, spina bifida, kyphoscoliosis). |
|
|
How do nurses assess wound size? |
- Take measurement same way each time - Use centimeters |
|
|
How is wound depth determined? |
Distance from visible surface to deepest point in wound Use cotton-tipped applicator – pinch at top to know the depth |
|
|
What is undermining? |
separation of true skin from underlying tissue; Usually involves a large proportion of wound edge. Like a roof over the wound. Size and length is assessed. |
|
|
What is a tract? |
- limited to a small edge - Extends in one direction for considerable length, like a tunnel - size and length is assessed |
|
|
Name some safety hazards for the elderly patient living at home? |
- area rugs - stairs - extension cords - carbon monoxide exposure - fires |
|
|
What are some ways to keep an elderly patient safe in the home? |
- remove area rugs and extension cords - keep bed low to the ground - raise the level of the toilet - install grab bars - proper lighting |
|
|
When are restraints use? |
When there is a prescription for them. The primary care provider must renew the order for them every 24 hours |
|
|
What can be used in an effort to avoid restraints? |
- Chair and bed alarms - Frequent assessment and surveillance - Communicate - Anticipate unmet needs |
|
|
What are the safety hazards in the healthcare workplace? |
- Back injury - Radiation injury |
|
|
What are the preventions for the hazards in the healthcare workplace? |
- Body mechanics |
|
|
What are the steps to responding to a fire? |
R.A.C.E. - Rescue (anyone who needs rescuing) - Alarm (pull the alarm) - Confine (close the door to the room with the fire) - Extinguish (use the extinguisher if can) |
|
|
What is subjective data? |
- info given to the nurse by the patient and family - includes thoughts and feelings - can be perceived by the patient only - symptoms |
|
|
What is objective data? |
- physical assessment - labs and diagnostic tests - can be measured or observed by the nurse - objective data supports subjective data |
|
|
What is the difference between primary and secondary data? |
- Primary data is data obtained from the client - what is said and what is observed by the nurse - Secondary data is data from a medical record or another caregiver or family member. |
|
|
What's the difference between an initial assessment and ongoing assessments? |
The initial assessment takes place upon admission and ongoing assessments take place as needed after the initial database. |
|
|
What's the difference between open-ended and closed-ended questions? Give examples. |
Open ended questions encourage ongoing conversation and closed ended does not. An example of an open-ended question might be "tell me about your pain" and a closed ended question may be "are you in pain?". |
|
|
What's the difference between a medical assessment and a nursing assessment? |
A medical assessment focuses on disease and pathology and the nursing assessment focuses on the client's RESPONSE to disease, pathology and other stressors. |
|
|
What's the difference between a directive and a non-directive interview? |
Directive interviewing is used to obtain factual, easily categorized information and uses closed-ended questions (ex. questions with yes/no answers). Non-directive interviewing allows the client to take control the subject matter. The nurse's role is to clarify and summarize. Uses open-ended questions. |
|
|
List some active listening behavior. |
- lean forward - eye contact - face the patient - sit in front of the patient at same level - use open ended questions - repeat back what's being said |
|
|
How should a nurse prepare the space for an interview? |
- provide privacy - remove distractions - sit at same level as client |
|
|
How should a nurse prepare the client for an interview? |
- introduce yourself - call the client by name - tell the client what you'll be doing and why - assess readiness to discuss health issues - assess and provide for comfort - assess for anxiety - audio/ video tape only for research and only with permission |
|
|
How should a nurse prepare themselves for an interview? |
Know the purpose of the interview and how the data will be used Read the client's chart Form some goals and opening questions Schedule uninterrupted time Have your forms and equipment ready Compose yourself before entering the room |
|
|
Can nurses delegate assessment? To whom, why or why not? |
No, a professional nurse must perform the assessment portion of the nursing process. This is the only way for data to be reliable. As being part of the nursing process, if a CNA were to collect the data, it would be second or third hand information. |
|
|
What factors affect sensory function? |
- age/ stage of life - culture - illness - medications - stress - personality - lifestyle (PLASMIC) |
|
|
List some nursing diagnoses for sensory deficits. |
- Risk for falls related to visual impairment - Self-care deficit: bathing and Dressing r/t kinesthetic impairment - Chronic Confusion - Impaired memory |
|
|
List some examples of nursing goals and outcomes for sensory deficits. |
- Patient will verbalize the importance of taking anti-epileptic medication daily as ordered by physician. - Patient demonstrates proper use of hearing aid. - Patient demonstrates safe and effective use of cane while ambulating. |
|
|
List some examples of nursing interventions for sensory deprivation. |
- Focus is prevention - Support senses (e.g., glasses, hearing aids) - Orientation (Calendar; view of environment) - Provide stimuli (Regular contact; touch, Television/radio, Pet therapy, Smells) |
|
|
What is the nursing intervention for sensory overload? |
Minimize stimuli (less light & noise, less television / radio, calm tone, reduce noxious odors, provide rest, teach stress reduction) |
|
|
What are the nursing interventions for impaired vision? |
Attend to glasses Provide sufficient light Protect eyes in sunlight Magnifying lens/ large-print books Provide sufficient light Protect eyes in sunlight Evaluate (Ability to perform ADLs, Ability to remain safe in the environment, Need for assistance" seeing eye dog, Magnifying lens/ large-print books)
|
|
|
What are the nursing interventions for impaired hearing? |
Care of a hearing aid Closed-caption television Regular inspection of ear canals Teach techniques to improve communication Promote safety Assess for social isolation |
|
|
What are the nursing interventions for the confused client? |
- Reorient frequently (State your name; state day, date, time, Provide clocks, calendars, Visual clues to time, Use personal belongings) - Maintain safe environment - Communicate clearly, slowly (Respond to feelings, Use gestures) - Limit choices - Use alternative therapies |
|
|
What are the nursing interventions for the unconscious patient? |
- Continue orientation to reality - Safety measures (Bed in low position, Side rails up) - attend to body systems (eye care, range of motion, skin/ mouth care, urinary drainage, bowel management, nutrition) |
|
|
Name the seizure precautions. |
Goal is to protect patient from injury should seizure occur Explain precautions to patient Establish IV access if patient has frequent or prolonged seizure events Obtain bed with full length side-rails Cover headboard, side-rails with blankets or pads. Keep side-rails up and bed in lowest position Keep oral suction equipment set up and close to patient Place airway equipment near patient’s bed (tape to wall above head of bed) Assign patient to room near nurses’ station |
|
|
Mr. Arbor complains to the nurse that he is feeling anxious. He states, “I’m just so tired of all these tests they are doing, and it’s so noisy here at night.” Mr. Arbor’s pulse is 110 bpm, and his blood pressure is 140/70 mm Hg. Nursing actions should include which of the following? Turn on the television to provide distraction. Ask the client if he would like to discuss his anxiety further. Close the blinds, dim the lights, and ask the patient what other measures would help him rest. Call the physician and obtain an order for an anti-anxiety medication for PRN use. |
Correct answer: 3 These measures would most directly decrease the client’s sensory overload. |
|
|
For any patient with an altered level of consciousness, the Glasgow Coma Scale score will help the nurse in planning care. A. True B. False |
Correct answer: A, true The coma scale score correlates to the client’s ability to function. As the score decreases, he is less able to meet his own basic needs, requiring greater nursing intervention. |
|
|
What is pain? |
- an unpleasant sensory and emotional experience - can have destructive effects - can warn of potential injury - is a multidimensional experience - whatever the patient says it is and exists when the patient says it does |
|
|
What is the origin of superficial pain? |
The skin or subcutaneous tissue (paper cut) |
|
|
What is the origin of visceral pain? |
Deep organs, abdominal pain (ex. menstrual cramps, labor) |
|
|
What is the origin of somatic pain? |
Tendon, bone or nerves (fracture) |
|
|
What is the origin of referred pain? |
From another place - it moves (ex. pain shooting down the arm or up to the jaw from myocardial infarction) |
|
|
What is the origin of phantom pain? |
The nerve endings at the end of an amputated limb (where the pain feels like it's from). |
|
|
What is the origin of psychogenic pain? |
In the mind (with no identifiable cause). |
|
|
What are the factors that influence pain? |
- past experience with pain - emotions - developmental stage - sociocultural factors - communication skills (need to be assessed if can't communicate) - cognitive impairments - other illnesses contributing to pain, making the pain worse |
|
|
What is the most reliable indicator of pain? |
The patient's own testimony |
|
|
What is the difference between acute and chronic pain? |
- Acute is short in duration, with rapid onset, varies in intensity and may last up to 6 months - chronic is pain that lasts 6 months or longer and often interferes with ADLs |
|
|
What are the complications of pain? |
- sleep loss - irritability - cognitive impairment (can't concentrate) - functional impairment (can't do the job) - immobility - can cause destruction of both patient and their family |
|
|
How does the endocrine system react to unrelieved pain? |
- releases ACTH, ADH & GH causing weight loss |
|
|
How does the cardiovascular system react to unrelieved pain? |
- increased HR - increase in BP (these things increase coagulation in the blood) |
|
|
How does the musculoskeletal system react to unrelieved pain? |
- muscle fatigue - immobility |
|
|
How does the respiratory system react to unrelieved pain? |
- shallowed breathing (with splinting pain) |
|
|
How does the genitourinary system react to unrelieved pain? |
- The hormones released by the endocrine system decrease urine output - retention - fluid overload (increasing cardiac output) - HTN - hypokalemia (decreased potassium) |
|
|
How does the gastrointestinal system react to unrelieved pain? |
- increased GI secretions - increased motility |
|
|
How does the nurse assess pain? |
- obtain a complete pain history (onset, duration, cause, rate, description, alleviating and aggravating causes) - can use numeric or Wong-Baker scales - using nonverbal signs (such as crying, moaning, grimacing, increased BP/ pulse) - can use FLACC scale |
|
|
What is important to assess when a patient is on opioids? |
Opioids often cause constipation, so it is important to assess the patients bowel movements. |
|
|
How do opioids work? |
Opioids attach to specific proteins called opioid receptors, which are found in the brain, spinal cord, and gastrointestinal tract. When the drugs attach to certain opioid receptors, they block the transmission of pain messages to the brain. |
|
|
Why are opioids used for only a short term? |
They are highly addictive, tolerance and dependence happen quickly. |
|
|
Interventions for tactile perception impaired patients. |
- brushing hair - giving a back rub - touch when giving care as long as it is tolerated - for paralyzed patients be sure to inspect their skin |
|
|
Interventions for stroke patient care |
- assistance with ADLs (feeding, bathing, etc.) - assess for safety/ fall risk - fall risk prevention (cane, walker, etc.) |
|
|
When administering pain meds, when does a nurse reassess pain? |
Around the time that the med will peak. If it's an IV med, it will be sooner than if it's a PO med. |
|
|
Describe non-opioid analgesics. |
- most have an onset of action within 1 hour - all may be used for acute or chronic pain - include NSAIDs |
|
|
Describe NSAIDs. |
- Non-steroidal anti-inflammatory drugs - largest group of non-opioid analgesics - include Tylenol, Aspirin, Aleve, Advil - may cause gastric irritation |
|
|
Describe Aspirin |
- can reduce inflammation, fever and pain - reduces platelet aggregation, increases bleeding time, so patient may bruise easily |
|
|
What is the safest of all the non-opioids? |
- Acetaminophen (Tylenol) has very little anti-inflammatory affect - has fever reducing properties. - has few side effects - can be used in patients allergic to aspirin or other NSAIDs |
|
|
What are adjuvant analgesics? |
- Analgesics that are used for mild pain or in conjunction with opioids for moderate to severe pain - include anti-depressants, local anesthetics, neuroleptics, corticosteroids, topical agents, muscle relaxants, neuroleptics and anti-convulsants. |
|
|
What are opioids? |
- natural and synthetic compounds that relieve pain - either stimulate pain receptors or bind with them to block pain - most effective for certain types of pain such as visceral pain which is more generalized |
|
|
What are the most common side effects of opioids? |
- drowsiness - nausea - vomiting - constipation - large doses can lead to respiratory depression and hypotension |
|
|
For a post-op patient, what needs to be done when they first start opioids? |
- O2 saturation and transcutaneous CO2 monitoring to assess for sedation and respiratory depression every 1 to 2 hours for the first 12 to 24 hours. |
