Foundations Test #3

Front 1

Discuss the factors influencing growth and development

Back 1

Human growth and development is a complex pattern of movement that involves change in biological, cognitive, and socioemotional processes. An individual’s biological inheritance and environmental experiences influence these processes.

Front 2

Describe the psychological theory by Erikson

Back 2

Erik Erikson constructed a theory of development that differed from Freud’s in two major views. Erikson maintained that development occurred throughout the life span and that it focused on psychosocial stages rather than psychosexual stages

According to Erikson’s eight stages of development, individuals need to accomplish a particular task before successfully mastering the stage and progressing to the next one. Each task is framed with opposing conflicts, such as the adolescent’s need to develop a sense of personal identity challenged by many confusing choices. These core conflicts remain throughout life.

Each stage builds upon the successful resolution of the previous developmental conflict. Readiness for the task is necessary for success. Tasks once mastered are challenged and tested again during new situations or at times of conflict. For example, an individual builds trust with an infant through consistent, reliable caregiving; yet the concept of trust is tested when an infant is hospitalized or after the birth of a new baby.

Front 3

Describe common physiological changes of aging (physical)

Back 3

Integumentary: Loss of skin elasticity (wrinkles, sagging, dryness, easily tears), pigmentation changes, glandular atrophy (oil, moisture, sweat glands), thinning hair (facial hair: decreased in men, increased in women), slower nail growth, atrophy of epidermal arterioles
Respiratory: Decreased cough reflex; decreased removal of mucus, dust, irritants from airways (decreased cilia); decreased vital capacity (increased anterior-posterior chest diameter); increased chest wall rigid-ity; fewer alveoli, increased airway resistance; increased risk of respiratory infections
Cardiovascular: Thickening of blood vessel walls; narrowing of vessel lumen; loss of vessel elasticity; lower cardiac output; decreased number of heart muscle fibers; decreased elasticity and calcification of heart valves; decreased baroreceptor sensitivity; decreased efficiency of venous valves; increased pulmonary vascular tension; increased systolic blood pressure; decreased peripheral circulation
Gastrointestinal: Periodontal disease; decrease in saliva, gastric secretions, and pancreatic enzymes; smooth muscle changes with decreased esophageal peristalsis and small intestinal motility
Musculoskeletal: Decreased muscle mass and strength, decalcification of bones, degenerative joint changes, dehydration of intervertebral disks (decreased height)Neurological: Degeneration of nerve cells, decrease in neurotransmitters, decrease in rate of conduction of impulses

Front 4

Define/Describe dementia

Back 4

Dementia is a generalized impairment of intellectual functioning that interferes with social and occupational functioning. Cognitive function deterioration leads to a decline in the ability to perform basic and instrumental activities of daily living. Unlike delirium, a gradual, progressive, irreversible cerebral dysfunction characterizes dementia.

Bolla and Fille (2000) describe four major types of dementia: Alzheimer’s disease (50%), diffuse Lewy body disease (DLBD) (15%), frontal-temporal dementia (15%), and vascular dementia (10%). Other causes of dementia, such as infection or trauma, account for another 10% of cases.

Front 5

Define/Describe delirium

Back 5

acute confusional state, is a potentially reversible cognitive impairment that is often due to a physiological cause. Physiological causes of delirium can include electrolyte imbalances, cerebral anoxia, hypoglycemia, medications, drug effects, tumors, subdural hematomas, and cerebrovascular infection, infarction, or hemorrhage. Delirium in older adults sometimes accompanies systemic infections and is often the presenting symptom for pneumonia or urinary tract infection. Delirium is also sometimes due to environmental factors such as sensory deprivation or unfamiliar surroundings or psychosocial factors such as emotional distress or pain.

Front 6

Define/Describe depression

Back 6

Older adults sometimes experience late-life depression, but it is not a normal part of aging. In fact, it is a treatable medical illness. Various estimates of its prevalence range from 10% to 15% in community-dwelling older adults; 11% to 45% among those requiring inpatient medical care; and up to 50% of nursing home residents. Older adults with dementia also experience depression. When dementia and depression occur together, the distress of the older adult and the family increases.

Front 7

Discuss issues related to psychological changes of aging

Back 7

The psychosocial changes occurring during aging involve life transitions and loss. The longer people live, the more transitions they have to cope with and the more losses they experience. Life transitions, for which loss is a major component, include retirement and the associated financial changes, changes in roles and relationships, alterations in health and functional ability, changes in one’s social network, and relocation. But the universal loss for older adults usually revolves around the loss of relationships through death.

Front 8

Describe the structure and function of the CP system

Back 8

The right ventricle pumps blood through the pulmonary circulation. The left ventricle pumps blood through the systemic circulation. The circulatory system exchanges respiratory gases, nutrients, and waste products between the blood and the tissues.

Myocardial Pump. The pumping action of the heart is essential to oxygen delivery. The four cardiac chambers, two atria and two ventricles, fill with blood during diastole and empty during systole.

Myocardial Blood Flow. To maintain adequate blood flow to the pulmonary and systemic circulation, myocardial blood flow must supply sufficient oxygen and nutrients to the myocardium itself. Blood flow through the heart is unidirectional. The four heart valves ensure this forward blood flow. During ventricular diastole the atrioventricular (mitral and tricuspid) valves open, and blood flows from the higher-pressure atria into the relaxed ventricles. This represents S1, or the first heart sound. After ventricular filling, the systolic phase begins.

During the systolic phase semilunar (aortic and pulmonic) valves open, and blood flows from the ventricles into the aorta and pulmonary artery. Closure of aortic and pulmonic valves represents S2, or the second heart sound. Some clients with valvular disease have backflow or regurgitation of blood through the incompetent valve, causing a murmur that you can hear on auscultation

Front 9

List physiological processes of ventilation, perfusion, and exchange of respiratory gases

Back 9

Cardiopulmonary physiology involves delivery of deoxygenated blood (blood high in carbon dioxide and low in oxygen) to the right side of the heart and to the pulmonary circulation and oxy-genated blood (blood high in oxygen and low in carbon dioxide) from the lungs to the left side of the heart and the tissues. The cardiac system delivers oxygen, nutrients, and other substances to the tissues and removes the waste products of cellular metabolism through the vascular and other body systems (e.g., respiratory, digestive, and renal)

Front 10

Discuss ways to maintain a safe environment for clients with sensory deficits.

Back 10

When sensory function becomes impaired, individuals become less secure within their home and workplace. Security is necessary for a person to feel independent. Make recommendations for improving safety within a client’s living environment without restricting his or her independence. During a home visit or while completing an examination in the clinic, offer several useful suggestions for home safety. The nature of the actual or potential sensory loss determines the safety precautions taken. Interventions may include (but are not limited to):
Adaptions for visual loss such as limiting or preventing driving, ensure appropriate safety measures are in place in the home such as proper lighting, clutter free, furniture arrangment, safe floors free from rugs or needed repairs, railing for stairs, sturdy stairs, large print on medications or potentially hazardous materials and so forth.
Adaptions for hearing loss; amplified door bells, or telephones, TCDs
Adaptions for olfactory loss; install smoke detectors, education regarding checking of food package dates, proper maintenance of gas pilots and so forth
Adaptation to reduced tactile sensation (loss of feeling in extremeties); educate pt regarding proper temperature settings for hot water heater and heating pads, label faucets clearly with "hot" or "cold"

Front 11

List interventions for preventing sensory deprivation and controlling sensory overload.

Back 11

Reduce sensory overload for the pt in the acute care setting by organizing plan of care to minimize excessive activities. Combine things such as bathing, dressing, VS. Allow sufficient time for rest and quite. This will require coordination with the pt's family or other visitors as well as interdisciplinary coordination.

Quiet time should include dimming lights, closing doors and drapes and limiting amt of visitors. Allow repositioning, back massage and other therapeutic influences. Control extraneous noise

Front 12

Identify factors to assess in determining a client’s sensory status.

Back 12

• Client’s health promotion practices
• Nursing history regarding extent of risks for and existing sensory deficits
• Review of potential factors that may affect the client’s sensory function
• Extent of lifestyle and self-care alterations
• Determine the client’s expectations regarding sensory alterations

Front 13

Evaluate the nursing plan for maintaining body alignment and mobility.

Back 13

To evaluate outcomes and response to nursing care, compare the client’s actual outcomes with the outcomes selected during planning, such as the client’s ability to maintain or improve body alignment, joint mobility, walking, moving, or transferring. Evaluate the effectiveness of specific interventions designed to pro-mote body alignment, improve mobility, and protect the client from the hazards of immobility. Evaluate the client’s and family’s understanding of all teaching provided as well. The continuous nature of evaluation allows you to determine whether new or revised therapies are required and if new nursing diagnoses have developed.

Front 14

Describe nursing interventions needed for safe client handling and movement.

Back 14

Assess every situation that involves client handling and movement to minimize risk of injury you the algorithm: can patient assist:
fully able-caregiver assistance not needed
partially able-encourage pt to assist using a positioning aid or cues; <200lb use a friciton reducing device and two or three caregivers; >200lb use a friction reducing device and at least 3 caregivers
No assistance-use a full body sling lift and two or more caregivers
Steps include- ask pt is they can assist; determine wheather the client comprehends what is expected; determine the comfort level of the client; evaluate your personal strength and knowledge of the procedure; finally determine wheather the client is too heavy or immobile for you to move the pt alone.

Front 15

Compare and contrast active and passive range-of-motion exercises.

Back 15

To ensure adequate joint motibility, teach the client about ROM exercises. ROM exercise are active, passive, or somewhere in between. Clients with restricted mobility are unable to perform some or all ROM exercises independently. Some clients are able to move some joints actively, whereas the nurse passively moves others. In general, exercises need to be as active as HEALTH AND MOBILITY ALLOW. Passive ROM exercises begin as soon as the client's ability to move the extremity or joint is lost. Carry out movements slowly and smoothly, just to the point of resistance; should not cause pain. Perform passive ROM using a head-to-toe sequence and moving from larger to smaller joints. Support the joint by holding the adjacent distal and proximal areas, or support the joint with one hand and cradle the distal portion of the extremity with the remaining arm. Appropriate ROM exercises are based on the client and the affected joint.

Front 16

Assess for correct and impaired body alignment and mobility.

Back 16

Assessment of client mobility focuse on ROM, gait, exercise and activity tolerance, and body alignment.
ROM-is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, frontal or transverse. (we know these)
Gait-describes a particular manner or style of walking (begins with heel strike of one leg ends with heel strike of the other leg) allows you to draw conclusions about balance, posture, safety, and ability to wak without assistance.
Exercise and activity tolerance- exercise is physical activity for conditioning the body, improving health, and maintaining fitness. used to correct a deformity or restore the overall body to a maximal state of health. Activity tolerance is the type and amount of exercise or work that a person is able to perform, necessary when planing activity such as walking, ROM exercise, or ADLs. Assessment includes data from physiological, emotional, and developmental domains.
Body alignment-perform assessment with the client standing, sitting, or lying down, first step is to put client as ease so they do not assume unnatural or rigid postions. particular to assess when sitting is pt has muscle weakness, mucsle paralysis, or nerve damage. Pt who are conscious have voluntary muscle control and normal perception of pressure

Front 17

Identify changes in physiological and psychosocial function associated with mobility and immobility

Back 17

Psychosocial effects on immobility-leads to emotional and behavioral responses, sensory alterations, and changes in coping. sensory deprivation: altered sleep patterns and significant increases in anxiety, hostillity, and depression. behavioral changes include hostility, giddiness, fear, and anxieyt. affects coping and creates sleep-wake alterations. depression due to changes in role and self concept.
Physiological effects on immobility- Systemic effects-all body systems work more efficiently with some form of movement. Immobility has effects of metabolic changes-alter endocrine metabolism, calcium resorption, and functioning of the GI system; Respiratory changes- higher risk of pulmonary complications such as atelectasis and hypostatic pneumonia; Cardiovasuclar changes-3 major changes are orthostatic hypotension, increased cardiac workload, and thrombus formation; Musculoskeletal changes-loss of endurange, strength, and muscle mass and decreased stability and balance; Muscle effects- because of protein breakdown, the client loses lean body mass; Skeletal effects- causes two skeletal changes: impaired calsium metabolism and joint abnormalities; Urinary elimination changes-urinary stasis and renal calculi; Integumentary changes-pressure ulcers.

Front 18

Discuss physiological and pathological influences on body alignment and joint mobility

Back 18

Body alignment is the condition of joints, tendons, ligaments, and muscles in various body positions. Developmental stages influence body alignment and mobility; the greatest impact of physiological changes on the musculoskeletal system is observed in children and older adults.
Pathological influences include: postural abnormalities-which affect the efficiency of the musculoskeletal system, as well as body alignment, balance, and appearance.; impaired muscle development-injury and disease lead to numerous alterations in musculoskeletal function; Damage to the Central nervous stystem-regulates voluntary movement results in impaired body alignment, balance, and mobility; Direct trauma to the Musculoskeletal system- results in bruises, contusions, sprains, and fractures.

Front 19

Describe nursing care interventions to promote oxygenation in the primary care, acute care, and restorative and continuing care settings

Back 19

Interventions for promoting and maintaining adequate oxygenation include health promotion and prevention behaviors, positioning, and coughing techniques. Other interventions include oxygen therapy, lung inflation techniques, hydration, medication administration, and chest physiotherapy

Interventions in the primary care setting include: vaccinations, educating and encouraging healthy lifestyle behaviors (e.g. smoking cessation, healthy diet and excersise, sufficient hydration)

Interventions in acute care settings include: dyspnea management, airway mgmt, mobilization of pulmonary secretions, humidification, nebulization, chest physiotherapy (CPT), suctioning techniques, incentive spirometry, chest tubes, oxygen therapy, and more

Interventions in restorative and continuing care facilities include oxygen therapy, hydration, coughing techniques, breathing exercises, respiratory muscle training

Front 20

Identify the clinical outcomes occurring as a result of hyperventilation, hypoventilation, and hypoxemia.

Back 20

Hyperventilation can result in loss of consciousness as result of excess CO2 exhalation

Hypoventilation will cause pts rapidly decline, leading to convulsions, unconsciousness, and death

Hypoxia is inadequate tissue oxygenation at the cellular level. This results from a deficiency in oxygen delivery or oxygen utilization at the cellular level. Hypoxia is a life-threatening condition. Untreated, it produces cardiac dysrhythmias that will possibly result in death

Hypoxemia may be mild to severe and leads to shortness of breath.

Front 21

Identify the clinical outcomes occurring as a result of disturbances in conduction, altered cardiac output, impaired valvular function, myocardial ischemia, and impaired tissue perfusion.

Back 21

Disturbances in conduction result in dysrhythmia as a response to ischemia, valvular, abnormalty, anxiety, and so forth

Altered cardiac output can result ultimately in heart failure. Left sided failure is decreased functioning of the left ventricle. Sx include fatigue, breathlessness, dizziness, and confusion as a result of hypoxia, and pulmonary edema

Right sided heart failure results from impaired functioning of right ventricle. Sx include elevated pulmonary vascular resistance (PVR), jugular venous distention (JVD), blood back up in systemic system showing in hepatomegaly, splenomegaly and dependent peripheral edema

Impaired valvular function can result in stenosis or regurgitation of blood and flow of blood through valves is obstructed. Ultimately resulting in hypertrophy of ventricle and leads to heart failure

Myocardial ischemia results due to insufficient supply of blood to myocardium (lack of oxygen) and manifests in Angina pectoris and myocardial infarction

Front 22

Describe the components of self-concept as related to psychosocial and cognitive developmental stages.

Back 22

Trust Versus Mistrust (Birth to 1 Year)-Develops trust following consistency in caregiving and nurturing interactions, Distinguishes self from environment
Autonomy Versus Shame and Doubt (1 to 3 Years)Begins to communicate likes and dislikes, Increasingly independent in thoughts and actions, Appreciates body appearance and function (including dressing, feeding, talking, and walking)
Initiative Versus Guilt (3 to 6 Years)-Identifies with a gender, Enhances self-awareness, Increases language skills, including identification of feelings
Industry Versus Inferiority (6 to 12 Years)-Incorporates feedback from peers and teachers, Increases self-esteem with new skill mastery (e.g., reading, math, sports, music), Aware of strengths and limitations
Identity Versus Role Confusion (12 to 20 Years)Accepts body changes/maturation, Examines attitudes, values, and beliefs; establishes goals for the future, Feels positive about expanded sense of self
Intimacy Versus Isolation (Mid-20s to Mid-40s)-Has stable, positive feelings about self, Experiences successful role transitions and increased responsibilities
Generativity Versus Self-Absorption (Mid-40s to Mid-60s)-Able to accept changes in appearance and physical endurance, Reassesses life goals, Shows contentment with aging
Ego Integrity Versus Despair (Late 60s to Death)-Feels positive about life and its meaning, Interested in providing a legacy for the next generation

Front 23

Identify stressors that affect self-concept and self-esteem.

Back 23

A self-concept stressor is any real or perceived change that threatens identity, body image, or role performance. The individual’s perception of the stressor is the most important factor in determining his or her response. Stressors include: any change in health, a physical change in the body, adjustment to loss, Identity stressors are particularly vulnerable during adolesence. Identity confusion results when people do not maintain a clear, consistent, and continuous consciousness of personal identity, It occurs at any stage of life if a person is unable to adapt to identity stressors. Body image stressors-changes in the appearance, structure, or function of a body part requires an adjustment in body image. Amputation, facial disfigurement, or scars from burns are bobious stressors affecting body image. also includes pregnancy. Role Performance stressors-Situational transitions occure when partents, spouses, children, or clsoe frinds die or people move, marry, divorce, or change jobs. Any of these transitions may lead to role conflict, role ambiguity, role strain, or role overload.

Self-esteem stressors very with developmental stages, Perceived inability to meet parental expectations, harsh criticism, inconsistent discipline, and unresolved sibling rivalry reduce the level of self-worth of children. Stressors affecting the self-esteem of an adult include failure in work and unsuccessful relationships. Stressors in older adults include health problems, declining socioeconomic status, spousal loss or bereavement. loss of social support, and decline in achievement experiences following retirement.

Front 24

Discuss factors that influence the following components of self-concept: identity, body image, and role performance.

Back 24

Identity-involves the internal sense of individuality, wholeness, and consistency of a person over time and in different situations, influenced by factors such as: self-observations, parenting figures, role models, relationships, sexuality, gender, socialization, identification with traditions, customs and rituals within ones race ethinic group, social groups.
Body image-involves attitudes related to the body, including physical appearance, structure, or function. influenced by factors such as: cognitive growth, physical development, puberty, aging, hormonal changes, secondary sex characteristics, changes in body fat distribution, cultural and societal attitudes and values, racial and ethnic background.
Role performance-the way in which individuals perceive their ability to carry out significant roles. Influenced by factors such as: socialization to expectations or standards of behavior Processes include:
• Reinforcement-extinction: Certain behaviors become common or are avoided, depending on whether they are approved and reinforced or discouraged and punished.
• Inhibition: An individual learns to refrain from behaviors, even when tempted to engage in them.
• Substitution: An individual replaces one behavior with an-other, which provides the same personal gratifi cation.
• Imitation: An individual acquires knowledge, skills, or behav-iors from members of the social or cultural group.
• Identifi cation: An individual internalizes the beliefs, behavior, and values of role models into a personal, unique expression of self.

Front 25

Identify the role of the nurse in client education

Back 25

Nurses have an ethical responsibility to teach their clients. The nurses responsibility is to teach the imformation that clients and their families need. Identification of the need for theaching is easy when clients request information. To be an effective educator, the nurse has to do more than just pass on the facts. Carefully determine what clients need to know and find the time when they are ready to learn.

Front 26

Identify the purposes of client education

Back 26

The goal of educating others about their health is to assist individuals, families, or communities in achieving optimal levels of health
Maintenance and Promotion of Health and illness prevention-the nurse is a visible, competent resource for clients who want to improve their physical and psychological well-being, in the school, home, clinic, or workplace the nurse provides information and skills that allows clients to assume healtheir behaviors.
Restoration of Health-Injured or ill clients need information and skills to help them regain or maintain their levels of health.
Coping with impaired functions-Not all clients fully recover from illness or injury, many have to learn to cope with permanent health alterations.

Front 27

Compare and contrast the nursing and teaching processes

Back 27

A relationship exist between the nursing and teaching process. The nursing and teaching process are not the same. The nursing process requires assessment of all sources of data to determine a clients total health care needs. The teaching process focuses on the clients learning needs and willingness and capability to learn.
At times assessment reveals a clients need for health care information. When education becomes a part of the care plan, the teaching process begins, the teaching process requires assessment, in this case, analyzing the clients needs, motivation, and ability to learn.

Front 28

Identify basic learning principles

Back 28

To teach effectively and effi ciently, the nurse fi rst needs to under-stand how people learn. Motivation addresses a person’s desire or willingness to learn. The client’s willingness to become involved in learning infl uences a nurse’s teaching approach. Previous knowledge, attitudes, and sociocultural factors infl uence motivation. The ability to learn depends on physical and cognitive attributes, developmental level, physical wellness, and intellectual thought processes. An ideal learning environment allows a person to attend to instruction.

A mild level of anxient motivates learning however a high level of anxiety prevents learning from occurring. Determine the clients level of comfort before beginning a teaching plan, and ensure that the pt is able to focus on the info.
Motivation is a force that acts on or witin a person that causes the person to behave in a particular way.
Compliance is a clients adherence to the prescribed course of therapy.
Active participation occurs when the client is actively involved in the educational session.
Cognitive development influences the clients ability to learn, you need to know the clients level of knowledge and intellectual skills before begining a teaching plan. learning occurs more readily when new information complements existing knowledge.
Factors in the physical environment where teaching takes place makes learnng either a plasant or a difficult experience.

Front 29

Include patient teaching while performing routine nursing care

Back 29

Many nurses find they are able to teach more effectively while delivering nursing care. This becomes easier as nurses gain confidence in their own clinical skills. For example, while hanging blood, the nurse explains why the blood is necessary and the symptoms indicated with transfusion reactions that need to be reported immediately. Another example is the nurse who explains a medication’s side effects while administering the medication. An informal, unstructured style relies on the positive therapeutic relationship between nurse and client, which fosters spontaneity in the teaching-learning process. Teaching during routine care is effi cient and cost-effective.

Front 30

 Use appropriate methods to evaluate learning.

Back 30

Client education is not complete until the nurse evaluates out-comes of the teaching-learning process. The nurse determines whether clients have learned the material. Evaluation reinforces correct behavior, helps learners realize how to change incorrect behavior, and helps the teacher determine adequacy of teaching.
The nurse is legally responsible for providing accurate, timely client information that promotes continuity of care; therefore it is essential to document the outcomes of teaching. Documentation of client teaching also supports quality improvement efforts, meets TJC standards, and promotes third-party reimbursement. The nurse evaluates success by observing the client’s perfor-mance of each expected behavior. Success depends on the client’s ability to meet the established outcome and goals. The nurse care-fully phrases questions to ensure that the learner understands them and that objectives are truly measured. Questions to ask when evaluating client education include the following:• Were the client’s goals or outcomes realistic and observable?• Did the client value the information provided?• Was the client willing to change an existing or adopt a new behavior?• What barriers prevented learning or change in behaviors?• Is the client able to perform the behavior or skill in the natural setting (e.g., home)?etc....

Front 31

Trust Versus Mistrust (Birth to 1 Year).

Back 31

Establishment of a basic sense of trust is essential for the development of a healthy personality. The infant ‘s successful resolution of this stage requires a consistent caregiver who is available to meet his needs. From this basic trust in parents, the infant is able to trust in himself, in oth-ers, and in the world (Hockenberry and Wilson, 2008). The for-mation of trust results in faith and optimism. A nurse’s use of an-ticipatory guidance will help parents cope with the hospitalization of an infant and the infant’s behaviors when discharged to home. The child’s sense of trust may be challenged during hospitalization and may need support from parents when returning home.

Front 32

Autonomy Versus Sense of Shame and Doubt (1 to 3 Years).

Back 32

By this stage a growing child is more accomplished in some basic self-care activities, including walking, feeding, and toileting. This newfound independence is the result of maturation and imitation. The toddler develops his or her autonomy by making choices. Choices typical for the toddler age-group include activities related to relationships, desires, and playthings. There is also opportunity to learn that parents and society have expectations about these choices. Limiting choices and or harsh punishment lead to feelings of shame and doubt. The toddler who successfully masters this stage achieves self-control and willpower. The nurse is able to model empathetic guidance that offers support for and understanding of the challenges of this stage.

Front 33

Initiative Versus Guilt (3 to 6 Years).

Back 33

Children like to pretend and try out new roles. Fantasy and imagination allow children to further explore their environment. Also at this time children are developing their superego, or conscience. Conflicts often occur between the child’s desire to explore and the limits placed on his or her behavior. These conflicts sometimes lead to feelings of frustration and guilt. Guilt also occurs if the caregiver’s responses are too harsh. Preschoolers are learning to maintain a sense of initiative without imposing on the freedoms of others. Successful resolution of this stage results in direction and purpose. Teaching impulse control and cooperative behaviors to the child help the family avoid the risks of altered growth and development.

Front 34

Industry Versus Inferiority (6 to 11 Years).

Back 34

School-age children are eager to apply themselves to learning socially produc-tive skills and tools. They learn to work and play with their peers. School-age children thrive on their accomplishments and praise. Without proper support for learning of new skills or if skills are too diffi cult, children then develop a sense of inadequacy and inferiority. Children at this age need to be able to experience real achievement to develop a sense of competency. Erikson believed that the adult’s attitudes toward work are traced to successful achievement of this task (Erikson, 1963).

Front 35

Identity Versus Role Confusion (Puberty).

Back 35

Dramatic physiological changes associated with sexual maturation mark this stage. There is a marked preoccupation with appearance and body image. This stage in which identity development begins with the goal of achieving some perspective or direction answers the question, “Who am I?” Acquiring a sense of identity is essential for making adult decisions such as choice of vocation or marriage partner. Each adolescent moves in his or her unique way into society as an interdependent member. There are also new social demands, opportunities, and conflicts that relate to the emergent identity and separation from family. Erikson held that successful mastery of this stage resulted in devotion and fidelity to others and to their own ideals. The nurse provides education and anticipatory guidance for the parent about the changes and challenges to the adolescent. Nurses also assist hospitalized adolescents in dealing with their illness by giving them enough information to allow them to make decisions about their treatment plan.

Front 36

Intimacy Versus Isolation (Young Adult).

Back 36

Young adults, having developed a sense of identity, deepen their capacity to love others and care for them. They search for meaningful friendships and an intimate relationship with another. Erikson portrayed in-timacy as fi nding the self and then losing the self in another (Santrock, 2007). If the young adult is not able to establish com-panionship and intimacy, isolation will result because they fear rejection and disappointment (Berger, 2005). You need to under-stand that during hospitalization young adults will benefi t from the support of their partner or signifi cant other because this strengthens their need for intimacy.

Front 37

Generativity Versus Self-Absorption and Stagnation (Middle Age).

Back 37

Following the development of an intimate rela-tionship, the adult focuses on supporting future generations. The ability to expand one’s personal and social involvement is critical to this stage of development. Middle-age adults achieve success in this stage by contributing to future generations through parent-hood, teaching, and community involvement. Achievement of generativity results in care as a basic strength. Inability to play a role in the development of the next generation results in stagna-tion (Santrock, 2007). Nurses assist physically ill adults in choos-ing creative ways to foster social development. Middle-age persons often fi nd a sense of fulfi llment by volunteering some time in a local school, hospital, or church.

Front 38

Integrity Versus Despair (Old Age).

Back 38

As the aging process creates physical and social losses, some adults also suffer loss of status and function, such as through retirement or illness. These external struggles are also met with internal struggles, such as the search for meaning in life. Meeting these challenges creates the potential for growth and the basic strength of wisdom. Many older adults review their lives with a sense of satis-faction even with their inevitable mistakes, whereas others see themselves as failures with their lives marked by despair and regret. Older adults often engage in a retrospective appraisal of their lives and see it as a meaningful whole or experience regret at goals not achieved. Box 11-1 presents research pertaining to the losses experienced by older adults.

Front 39

Describe common physiological changes of aging (Sensory)

Back 39

Sensory
Eyes: Decreased accommodation to near/far (presbyopia), diffculty adjusting to changes from light to dark, yellowing of the lens, altered color perception, increased sensitivity to glare, smaller pupils
Ears: Loss of acuity for high-frequency tones (presbycusis), thickening of tympanic membrane, sclerosis of inner ear, buildup of earwax (cerumen)
Taste: Often diminished, often have fewer taste buds
Smell: Often diminished
Touch: Decreased skin receptors
Proprioception: Decreased awareness of body positioning in space
Genitourinary: Fewer nephrons, 50% decrease in renal blood flow by age 80, decreased bladder capacity
Male: Enlargement of prostate
Female: Reduced sphincter tone
Reproductive Male Sperm count diminishes, smaller testes, erections less firm and slow to develop
Female: Decreased estrogen production, degeneration of ovaries, atrophy of vagina, uterus, breasts
Endocrine:
General: Alteration in hormone production with decreased ability to respond to stress
Thyroid: Decreased secretion
Thymus: Involution of thymus gland Cortisol, glucocorticoidsIncreased anti-infl ammatory hormone
Pancreas: Increased fibrosis, decreased secretion of enzymes and hormones

Front 40

Describe the structure and function of the CP system (cont.)

Back 40

Coronary Artery Circulation. The coronary circulation is the branch of the systemic circulation that supplies the myocardium with oxygen and nutrients and removes waste.

Systemic Circulation. The arteries and veins of the systemic circulation deliver nutrients and oxygen to and remove waste from the tissues. Oxygenated blood flows from the left ventricle through the aorta and into large systemic arteries. These arteries branch into smaller arteries, into arterioles, and finally into the smallest vessels, the capillaries. At the capillary level the exchange of respiratory gases, nutrients, and wastes occurs, and the tissues are oxygenated. The waste products exit the capillary network through the venules that join to form veins. These veins form larger veins, which carry deoxygenated blood to the right side of the heart, where it then returns to the pulmonary circulation.

Blood Flow Regulation. The amount of blood ejected from the left ventricle each minute is the cardiac output. The normal cardiac output is 4 to 6 L/min in the healthy 150-pound (68-kg) adult at rest. The circulating volume of blood changes according to the oxygen and metabolic needs of the body.

Stroke volume (SV) * Heart rate (HR) = Cardiac output (CO)

Front 41

Define: Stroke Volume

Back 41

amount of blood ejected from the left ventricle with each contraction. The amount of blood in the left ventricle at the end of diastole (preload), the resistance to left ventricular ejection (afterload), and myocardial contractility all affect stroke volume.

Front 42

Define Preload

Back 42

AKA: End Diastolic Volume:

The ventricles stretch when filling with blood. The more stretch on the ventricular muscle, the greater the contraction and the greater the stroke volume

Front 43

Define Afterload

Back 43

Resistance to left ventricular ejection. The heart must work to overcome this resistance to fully eject blood from the left ventricle. The diastolic aortic pressure is a good clinical measure of afterload. In hypertension, afterload increases, which makes cardiac workload increase. In hypertension, afterload is manipulated by reducing systemic blood pressure.

Front 44

Biologic process: influence on growth and development

Back 44

Biologic processes produce changes in an individual’s physical growth and development. These changes are a result of genetic inheritance that interacts with external influences such as nutrition, exercise, stress, culture, and even climate. Height and weight, development of gross and fine motor skills, and sexual maturation resulting from hormonal changes during puberty are examples of changes resulting from biologic processes.

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Cognitive process: influence on growth and development

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Cognitive processes comprise changes in intelligence, ability to understand and use language, and the development of thinking that shapes an individual’s attitudes, beliefs, and behaviors. Genes inherited from parents, life experiences, and environmental infl uences contribute to the changes in cognitive processes. Learning how to take turns during a conversation, playing a board game, and studying for a test all involve cognitive processes.

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Socioeemotional process: influence on growth and development

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Socioemotional processes consist of the variations that occur in an individual’s personality, emotions, and relationships with others during the individual’s lifetime. Genetic endowment and an individual’s environmental context play a part in these changes. Temperament or behavioral style can be defined as the biological base of personality development. Most parents realize that their infant has a distinct personality and reacts in a consistent way to changes in routine. Knowledge of infant temperament will help you provide health promotion teaching so that parents are able to better understand their child’s behavior

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Respiratory Gas Exchange

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Diffusion is the process for the exchange of respiratory gases in the alveoli and the capillaries of the body tissues. Oxygen is transferred from the lungs to the blood, and carbon dioxide is transferred from the blood to the alveoli and exhaled. At the tissue level, oxygen is transferred from the blood to tissues, and carbon dioxide is transferred from tissues to the blood to return to the alveoli and be exhaled.

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Oxygen Transport

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The oxygen transport system consists of the lungs and cardiovascular system. Delivery depends on the amount of oxygen entering the lungs (ventilation), blood fl ow to the lungs and tissues (perfusion), rate of diffusion, and oxygen-carrying capacity. Three things infl uence the capacity of the blood to carry oxygen: the amount of dissolved oxygen in the plasma, the amount of hemoglobin, and the tendency of hemoglobin to bind with oxygen. Hemoglobin, which is a carrier for oxygen and carbon dioxide, transports most oxygen (approximately 97%). The hemoglobin molecule combines with oxygen to form oxyhemoglobin. The formation of oxyhemoglobin is easily reversible, allowing hemoglobin and oxygen to dissociate, which frees oxygen to enter tissues.

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Carbon Dioxide Transport

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Carbon dioxide diffuses into red blood cells and is rapidly hydrated into carbonic acid (H2CO3). The carbonic acid then dissociates into hydrogen (H) and bicarbonate (HCO3  ) ions. Hemoglobin buffers the hydrogen ion, and the HCO3  diffuses into the plasma (see Chapter 41). Some of the carbon dioxide in red blood cells reacts with amino acid groups, forming carbamino compounds. This reaction occurs rapidly. Reduced hemoglobin (deoxyhemoglobin) combines with carbon dioxide, and the venous blood transports the majority of carbon dioxide.

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Discuss the effect of a pts nutrition on oxygenation

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Severe obesity decreases lung expansion, and increased body weight increases tissue oxygen demands. The malnourished client experiences respiratory muscle wasting, resulting in decreased muscle strength and respiratory excursion. Cough efficiency is reduced secondary to respiratory muscle weakness, putting the client at risk for retention of pulmonary secretions.Clients who are morbidly obese and/or malnourished are at risk for anemia. Diets high in carbohydrates play a role in increasing the carbon dioxide load for clients with carbon dioxide retention. As carbohydrates are metabolized, an increased load of carbon dioxide is created and excreted via the lungs

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Discuss the effect of a pts level of health on oxygenation

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Factors that can affect a pts oxygenation include:
Conditions affecting chest wall movement such as pregnancy, obesity, musculoskeletal abnormalties, trauma, neuromuscular diseases, CNS alterations, and chronic disease.
As the fetus grows during pregnancy, the enlarging uterus pushes abdominal contents upward against the diaphragm.
Clients who are morbidly obese have reduced lung volumes from the heavy lower thorax and abdomen, particularly when in the recumbent and supine positions. Morbidly obese clients have a reduction in compliance as a result of encroachment of the abdomen into the chest, increased work of breathing, and decreased lung volumes
Musculoskeletal impair-ments in the thoracic region reduce oxygenation
Multiple rib fractures develop into a flail chest, a condition in which fractures cause instability in part of the chest wall. The unstable chest wall allows the lung underlying the injured area to contract on inspiration and bulge on expiration, resulting in hypoxia. Chest wall or upper abdominal incisions also decrease chest wall movement as the client uses shallow respirations to minimize chest wall movement to avoid pain. Excessive or high doses of opioids depress the respiratory center, further decreasing respiratory rate and chest wall expansion
Neuromuscular diseases affect tissue oxygenation by decreasing the client’s ability to expand and contract the chest wall.
Diseases or trauma involving the medulla oblongata and spinal cord result in impaired respiration.
Oxygenation decreases as a direct consequence of chronic disease. It also decreases as a secondary effect, as with anemia. The physiological response to chronic hypoxemia is the development of increased red blood cells (polycythemia)

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Discuss the effect of a pts age on oxygenation

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The cardiac and respiratory systems undergo changes throughout the aging process. The changes are associated with calcification of the heart valves, SA node, and costal cartilages. The arterial system develops atherosclerotic plaques. Osteoporosis leads to changes in the size and shape of the thorax.

The trachea and large bronchi become enlarged from calcification of the airways. The alveoli enlarge, decreasing the surface area available for gas exchange. The number of functional cilia is reduced, causing a decrease in the effectiveness of the cough mechanism, putting the older adult at increased risk for respiratory infections

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Discuss the effect of a pts environment on oxygenation

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Incidences of pulmonary disease is higher in smoggy, urban areas than in rural areas.

In addition, the client's workplace sometimes increases the risk for pulmonary disease. Occupational pollutants include asbestos, talcum powder, dust and airborne fibers.

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Discuss the effect of smoking, substance abuse, and stress on oxygenation

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Smoking worsens peripheral vascular and coronary artery diseases. Inhaled nicotine causes vasoconstriction or peripheral and coronary blood vessels, increasing BP and decreasing blood flow to peripheral blood vessels

Excessive drug or alcohol can affect oxygenation in two ways: 1) those who use drugs often have poor nutritional intake which can affect hemoglobin production and decreasing O2 carrying capacity

A continuous state of stress or severy anxiety increases the body's metabolic rate and increases need for O2

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"A resh look at assessing the elderly"
What are the physiological changes of aging and theri implications?

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Heart and lungs work less efficiently- older pt are prone to fatigue, dizziness, and falls in part because the older heart cant respond quickly to sudden movements, exertion, or changes in postion.
Digestive and urinary functions slow down-saliva secretion decreases, salivary ptyalin is reduced, tooth loss and gum disease, inhibited intake of solids, decrease in intestinal motility, inadequate fluid intake, poor diet, lack of dietary bulk or exercise, vasopressin (a hormone with an antidiuretic effect), glomerular filtration rate declines by as much as half by age 90.
Physical changes are more apparent-wrinkling and loss of resiliency of an older persons skin, subcutaneous fat diminishes, capillary blood flow decreases as well, slowing wound healing, height decreases as intervertebral disk and vertebrae thin, strength and endurance decline.
Senses are less acute, reaction time slows-all senses become less acute, loss of appetite as the sensitivity of taste buds and olfactory receptors declines, sweet and salt tastes are especially dulled, ability to distinguish by touch diminishes, lens of the eyes yellows and become cloudy, which may cause problems with color vision, blues and greens may be hard to distinguish, it is hard to see in dim light, Hearing difficulties may be natural or mechanical with inability to hear high-frequency sounds often results from degeneration in the cochlea (presbyeusis), cerumen is harder because of a greater amount of keratin. neurotransmitter levels change(MAO and serotonin increase with age while norepinephrine decreases)
Glandular activity -its complex effects--lowered resistance to disease and infection can be traced to the thymus gland which regulates the development of T-lymphocytes (normally shirinks by 90%), By about age 60, thymic hormones are completely absent, reduction in capacity in multiple systems

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What types of loss are associated with Alzheimers disease?

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Cognitive or intellectual losses
Affective or personality losses
Conative (planning) losses
Progressively lowered stress threshold

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What are the four stages of Alzheimer's?

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forgetful
confused
ambulatory dementia
terninal

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What is validation therapy?

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the nurse enters the patient's reality to provide comfort
eg. provide the comfort, nurturing, and protection associated with "mama"

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What is reality orientation?

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a useful and necessary intervention in pt who are acutely confused (delirious) rather than permanently confused and intellectually impaired as in AD. Useful in pts who are expected to recover but not in pt with AD.

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How do you communicate with a pt with AD?

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The way you communicate with the pt can mean the difference between a successful and a catastrophic interaction.
Begin each interaction with the pt by identifying yourself and calling the pt by name.
modify your speaking style, speak slowly and clearly, simplify your message, use positive statements, limit the types of questions to yes or no answers, ask only one question at a time.
Pt with AD respond more readily to your tone of voice and gestures than to the content of your message

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What is dehydration?

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a fluid imbalance caused by too little fluid taken in or too much fluid lost or both
Maintaining adequate fluid balance is an essential component of health at every stage of life. Age-related changes make older adults more vulnerableto shifts in water balance that can result in overhydration or, more frequently, dehydration.

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Why does hydration matter?

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Fluid balance, the state in which fluid intake equals output, is essential to health, regradless of a person's age. Potential consequences of dehydration incllude constipation, falls, medicaiton toxicity, urinary track and respiratory infections, delirium, renal failure, seizure, electrolyte imbalance, hyperthermia, and longer time to wound healing.
Increased amouts of fluid are needed during exercise, in hot weather, and during illness
Approximately 1,500 to 2,000 mL per day, is indicated to maintain hydration.

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What are causes and risk factors of dehydration?

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diarrhea, excessive sweating, blood loss, fluid accumulation, inadequate fluid intake, fever, illnesses that entail excessive urination, such as diabetes and hypercalcemia,
Risk factors: older age and black race, dementia, delirium, medications including diuretics, laxatives and angiotensin-converting enzyme inhibitors. and polypharmacy

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Waht are the clinical markers of dehydration?

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urine specific gravity
serum osmolality
hemotocrit
serum sodium
hemoglobin levels

Indicators of hydration status include:
Urine color chart-eight standardized colors, ranging from pale straw (#1 normal hydration status) to greenish brown (#8)
Serum markers- most reliable indicatiors of dehydration include elevated serum sodium, elevated serum osmolality, and the ratio of blood urea nitrogen-creatinine.
Clinical assessments-dry oral mucosa, a furrowed tongue, decreased salivation, sunken eyes, decreased urine output, upper-body weakness, and a rapid pulse may indicate dehydration.

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What are age-related changes that promote dehydration?

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The thirst respose becomes blunted with age
Total body fluid decreases
Decline in kidney function: kidneys are less able to concentrate urine