Hans Bowder Nur 323 Older Adult

Front 1

Evidence-based practice is the utilization of

Back 1

-research evidence in combination with
-clinical expertise and
-patient preferences

Front 2

PICO format for asking clinical questions =

Back 2

P= patient population of interest
I = Intervention of interest
C = Comparison of interventions or groups of patients
O = Outcome of interest

Front 3

Evidence Based Practice

Back 3

Is the use of some or many results of clinical trials on a topic to improve quality and outcomes for patients.

Front 4

The five steps of the nursing process:

Back 4

Assessment
Nursing Diagnosis
Planning
Implementing the plan
Evaluating

Front 5

Example of a properly written Nursing Diagnosis

Back 5

Activity intolerance
related to insufficient oxygenation secondary to decreased cardiac output and pulmonary congestion,
as manifested by weakness, fatigue, shortness of breath upon minimal exertion and patient’s statement ‘I feel too weak to do anything.’”

Front 6

Clinical Pathways

Back 6

Are over-arching plans that direct the whole healthcare team on what to do in patients with similar needs/diagnoses

Front 7

Older Adults

Back 7

Young-old 55-75
Old-old 75 and up.

Front 8

Ageism:

Back 8

This is a term that means discrimination against old people like “racism”.

Front 9

Erikson’s stages
Intimacy vs. Isolation: 18 - 34.

Back 9

Love relationships: The young adult must develop intimate relationships or suffer feelings of isolation

Front 10

Erikson’s stages
Generativity vs. Stagnation: 35 - 60

Back 10

Parenting: Each adult must find some way to satisfy and support the next generation. Not meeting this goal makes people become pre-occupied with their own aging.

Front 11

Erikson’s stages
Ego Integrity vs. Despair: 60 - death

Back 11

Reflection on and acceptance of one's life: This goal comprises a life review which arrives at acceptance of oneself as-one-is, and feeling fulfilled. Not meeting this goal leaves those persons in despair. This can mean the difference of meeting death with anxiety or acceptance

Front 12

Elder Abuse
Typical abuser profile:

Back 12

Is a family member 9/10ths of time
Usually is an adult child of the victim
Is still dependent on the victim
Usually has a history of violence
Often unemployed
May be abusing substances or mentally ill

Front 13

6 stages of change as theorized by Dr. James Prochaska

Back 13

Precontemplation
Contemplation
Preparation
Action
Maintenance
Termination

Front 14

Stress
General Adaptation Syndrome (GAS)

Back 14

There are 3 stages to this syndrome
1. Alarm: sympathetic NS is is activated. This upsets the body’s homeostasis
2. Resistance: This is where the person makes some effort to adapt by taking action.
3. Exhaustion: Results when adaptation doesn’t occur. The person has used all resources and may become sick or die. –This occurs only with severe stressors.

Front 15

Stress
Lazarus transaction theory:

Back 15

says that the amount of stress is relative to the perceived threat. Emotions heavily influence idea of stress

Front 16

Stress certainly will happen?

Back 16

Hypothalamus responds to pain, blood pressure changes and input from the Limbic system from emotions.

Front 17

Stress the Hypothalamus will have what effect (NS)

Back 17

It is the primary player in the stress response because it can modulate

Front 18

Stress chemicals released by the body

Back 18

Cortisol increases glucose (fuel) in the blood and inhibits inflammation from injuries.
Endorphins blunt pain response and can elevate/stabilize the mood.
ADH reabsorbs water from the urine keeping blood volume and pressure up.
Epinephrine increases heart rate and respiratory rate, dilates airways, and increases reaction times.

Front 19

Stress, Bad effects of

Back 19

Chronic stress can suppress the immune system causing susceptibility to illness (effect of cortisol).
It can cause atrophy of the hippocampus resulting in memory impairment (cortisol).
It is a factor in heart disease and heart attacks (effects of cortisol, epinephrine and ADH).
It can cause osteoporosis and abdominal obesity (effect of cortisol).

Front 20

Stress, Pain can make you sicker

Back 20

Pain is stressful and can prolong the stress response.
The more pain a patient has, the more likely that person is to become sicker or heal more slowly.
Morale: Adequate pain control is important in all patients.

Front 21

Kidneys

Back 21

1.2 liters of blood flows through the kidneys per minute

Front 22

Kidney
The glomerulus is like a tiny coffee filter

Back 22

It allows the liquid part of the blood to pass through without letting the large particles out (like blood cells and protein)
Normal GFR is around 125 ml per minute.

Front 23

GFR

Back 23

A GFR of less than 60 is generally the magic number below which you need to question what drug dosing is occurring
Creatinine is a useful indicator of kidney function If the creatinine is above 1.5 you need to ask yourself if the doses of drugs you are giving are correct.

Front 24

Chronic Renal Failure

Back 24

presence of kidney damage of a GFR of less than 60ml per minute for 3 months or more.

Front 25

end stage Renal Failure

Back 25

End stage renal disease (requiring dialysis) occurs when the GFR drops to below 15 ml/min.

Front 26

Other things the kidney does

Back 26

It regulates body fluid balance by responding to antidiuretic hormone.
ADH makes the reabsorption part of the kidney (distal convoluted tubules) open up and let water back into the blood, increasing blood volume and pressure.
Aldosterone causes the distal tubule to reabsorb sodium and water and get rid of potassium in trade.
The distal tubule is the part of the nephron that conserves bicarbonate and secretes hydrogen ions to maintain appropriate pH.

Front 27

Other things the kidney does

Back 27

It makes erythropoietin, the stuff that causes the bone marrow to make red blood cells.
It activates vitamin D to make it useful to you.
It secretes renin which causes a Rube Goldberg like cascade that makes you retain water and sodium, increasing the ECF and raising the blood pressure

Front 28

Normal adult urine output

Back 28

Urine output should be 1500 milliliters a day.
Urine goes into the bladder via the ureters where it is dispatched.
200 – 250mls of urine in the bladder causes the urge to urinate.
Discomfort starts at around 500mls.
The average bladder holds between 600 and 1000 mls.

Front 29

Urinary tract infections (UTIs)

Back 29

1/3rd of deaths from gram-negative sepsis occurred from urinary tract infections
E. Coli is the most common bacteria to cause UTIs.
In addition to E. Coli, Pseudomonas is a common infecting organism.
Pseudomonas has been found colonizing and corroding airplane fuel tanks. It is a tough and very dangerous organism.
Urinary catheter caused infections are the single most common hospital infection

Front 30

Azotemia

Back 30

–buildup of nitrogenous wastes due to inability of damaged kidneys to excrete it

Front 31

Uremia

Back 31

-describes the multiple symptoms resulting from the buildup of urea and other wastes in the blood

Front 32

Oliguria

Back 32

–the decrease of urinary output to less than 400ml per day (or about 15ml per hour –the number at which to worry)

Front 33

There are 3 main regions from which kidney failure precipitates

Back 33

Prerenal –means a damagingly-low blood supply to kidneys has occurred
Intrarenal –describes processes happening within the kidney itself that creates damage
Postrenal is basically a urine outlet problem/obstruction that damages kidneys

Front 34

kidney Waste excretion problems

Back 34

Patient develops uremia -headaches, nausea, vomiting lethargy and even seizures as nitrogenous wastes increase (Blood Urea Nitrogen or BUN)

Front 35

kidney Waste excretion problems

Back 35

Insulin resistance occurs or worsens in the case of those with DM. the cause is unclear as yet. High blood sugars can result (hyperglycemia)

Front 36

kidney Waste excretion problems

Back 36

Uremia can make insulin last longer in the body, creating problems with low blood sugar as well

Front 37

kidney Electrolyte imbalances

Back 37

Hyperkalemia results as kidneys can’t excrete it. Fatal heart arrhythmias can occur (remember capital punishment?) potassium consumption may be restricted.
Sodium can be low but this is deceptive. As as the person can’t excrete excess sodium it holds onto water at a great rate and produces actually a dilutional hyponatremia.
Sodium must be restricted
Hypermagnesemia can occur if person takes laxatives like MOM. The kidney can’t excrete excess.

Front 38

kidney Metabolic Acidosis

Back 38

Inability to excrete ammonia (in form of urea) can cause acidosis
Kidney also can’t reabsorb bicarbonate and combined with the destruction of bicarbonate from normal buffering it falls to a low state between 16-20 meq/L.
Bone demineralization takes over some of the buffering capacity

Front 39

kidney Blood disorders

Back 39

Anemia -The kidney no longer makes adequate amounts of erythropoietin to stimulate red blood cell production.
Bleeding –impaired platelet function and clotting factor release can increase the incidence of bleeding in uremia
Infection -White blood cells become impaired and can’t respond to infections as well. Chemicals that mediate the inflammatory response are diminished as well due to dysfunctional neutrophils and monocytes.

Front 40

kidney Cardiovascular

Back 40

Hypertension occurs due to frequent volume overload and is aggravated by sodium retention.
The kidneys can’t excrete sodium or water and large amounts of fluid consumed is retained.
Stroke from increased atherosclerosis
Heart attacks and dysrhythmias occur from electrolyte imbalances and atherosclerosis

Front 41

Kidneys

Back 41

1.2 liters of blood flows through the kidneys per minute

Front 42

Kidney
The glomerulus is like a tiny coffee filter

Back 42

It allows the liquid part of the blood to pass through without letting the large particles out (like blood cells and protein)
Normal GFR is around 125 ml per minute.

Front 43

GFR

Back 43

A GFR of less than 60 is generally the magic number below which you need to question what drug dosing is occurring
Creatinine is a useful indicator of kidney function If the creatinine is above 1.5 you need to ask yourself if the doses of drugs you are giving are correct.

Front 44

Chronic Renal Failure

Back 44

presence of kidney damage of a GFR of less than 60ml per minute for 3 months or more.

Front 45

end stage Renal Failure

Back 45

End stage renal disease (requiring dialysis) occurs when the GFR drops to below 15 ml/min.

Front 46

Other things the kidney does

Back 46

It regulates body fluid balance by responding to antidiuretic hormone.
ADH makes the reabsorption part of the kidney (distal convoluted tubules) open up and let water back into the blood, increasing blood volume and pressure.
Aldosterone causes the distal tubule to reabsorb sodium and water and get rid of potassium in trade.
The distal tubule is the part of the nephron that conserves bicarbonate and secretes hydrogen ions to maintain appropriate pH.

Front 47

Other things the kidney does

Back 47

It makes erythropoietin, the stuff that causes the bone marrow to make red blood cells.
It activates vitamin D to make it useful to you.
It secretes renin which causes a Rube Goldberg like cascade that makes you retain water and sodium, increasing the ECF and raising the blood pressure

Front 48

Normal adult urine output

Back 48

Urine output should be 1500 milliliters a day.
Urine goes into the bladder via the ureters where it is dispatched.
200 – 250mls of urine in the bladder causes the urge to urinate.
Discomfort starts at around 500mls.
The average bladder holds between 600 and 1000 mls.

Front 49

Urinary tract infections (UTIs)

Back 49

1/3rd of deaths from gram-negative sepsis occurred from urinary tract infections
E. Coli is the most common bacteria to cause UTIs.
In addition to E. Coli, Pseudomonas is a common infecting organism.
Pseudomonas has been found colonizing and corroding airplane fuel tanks. It is a tough and very dangerous organism.
Urinary catheter caused infections are the single most common hospital infection

Front 50

Azotemia

Back 50

–buildup of nitrogenous wastes due to inability of damaged kidneys to excrete it

Front 51

kidney Cardiovascular

Back 51

Hypertension occurs due to frequent volume overload and is aggravated by sodium retention.
The kidneys can’t excrete sodium or water and large amounts of fluid consumed is retained.
Stroke from increased atherosclerosis
Heart attacks and dysrhythmias occur from electrolyte imbalances and atherosclerosis

Front 52

kidney GI ttract

Back 52

Ulcerations along the mucosa in the GI tract can occur from excess ammonia in the blood.
Patients can have GI bleeds from these ulcerations.
Nausea vomiting and anorexia occur from built up toxins.
Breath can smell like urine as these products are not excreted

Front 53

kidney Nervous system

Back 53

Nerves become demyelinated from urea and the various other imbalances.
General depression of the CNS occurs resulting in lethargy, poor concentration, and irritability
Seizures can occur.
Coma can ensue from hypertensive encephalopathy
Paresthesias –restless legs, burning sensation in the feet, “bugs crawling in skin”

Front 54

kidney Skin & Musculoskeletal system

Back 54

Osteomalacia from bone demineralization using calcium to buffer acids occurs
Holes in bone can fill in with fibrous tissue resulting in osteitis fibrosa cystica
Skin becomes yellow-gray from urinary pigments.
Itching is common

Front 55

kidney Management

Back 55

Restrict high potassium foods, limit potassium to 2-4 grams per day (cut out bananas, tomatoes ,yellow vegetables, oranges)
Limit sodium to between 2-4 grams per day (cut out canned soups, cured meats, pickled foods)
Manage hypertension but avoid ACE inhibitors due to worsening the GFR
Reduce phosphate by dietary modifications and by taking tums or other phosphate binders (limit ice-cream, and other dairy products)

Front 56

kidney Peritoneal dialysis

Back 56

Infuses a dialysate into the peritoneal space.
The capillaries of the peritoneal cavity are used as the dialysis membrane
A catheter is placed into the peritoneum
A bag of 2 liters of dialysate is warmed and instilled
The fluid is allowed to sit and absorb excess metabolic products and electrolytes
It then is drained off and disposed of.
Because dialysate has glucose to increase the osmotic gradient and pull out excess fluid, sometimes the glucose can get into the blood and cause hyperglycemia

Front 57

kidney Peritoneal dialysis

Back 57

Drawbacks
Abdominal pain during infusions
Protein loss
Bacterial peritonitis
Hyperglycemia
Catheter infections
Benefits
Can do at home
Can do at any hospital
Less cardiovascular stress due to slower fluid
shifts

Front 58

Hemodialysis -Removes the blood and runs it through a dialysis machine

Back 58

Usually a fistula is placed in the arm connecting a vein and an artery
Blood is taken from the arterial side to dialysis machine and returned to the venous side of the fistula.
Fistulas are usually made of synthetic material.
They produce a vibration or “thrill” when working properly to agitate the blood and prevent thrombus formation.

Front 59

Intracellular fluid or 1st space:

Back 59

is the sum of the fluid contained in each individual cell. 42% of body weight.
“First spacing” is nothing but normal fluid distribution.

Front 60

Extracellular fluid or 2nd space:

Back 60

is what lies between the cells and what is in the blood stream. 17% of body weight.
“Second spacing” refers to interstitial edema usually of the type that makes the legs swell up. Fluid that goes here can be reabsorbed if correction of the underlying abnormality is corrected

Front 61

Transcellular space or 3rd space:

Back 61

is the combination of the spinal fluid, GI tract, Pleural fluid, Joint fluid and Peritoneal fluid. 1L per person.
Vomiting and diarrhea can deplete the transcellular fluid in the GI tract resulting in replacement from fluid from the extracellular space.

Front 62

Third spacing

Back 62

is a term you will hear commonly when fluid is pulled in to the peritoneal or pleural cavities from oncotic or hydrostatic pressure problems. This is body fluid that becomes unavailable for use.

Front 63

Types of pressure

Back 63

Osmotic: the pull a solute has for pure water will cause that fluid to expand and apply pressure to a cell or vessel wall.
Oncotic: the pull protein has for pure water will similarly cause the fluid volume to expand and apply pressure on cell or vessel walls.
Hydrostatic: the pressure exerted by actual mechanical force such as from the heart pumping or lungs expanding.

Front 64

when the blood pressure is low or the osmolality is high

Back 64

The hypothalamus is responsible for causing the pituitary to release Anti Diuretic Hormone to affect water conservation.
ADH does this by causing the renal tubules to reabsorb water (from the urine in the kidney)
It also makes you thirsty.

Front 65

Regulation of fluid balance -Aldosterone

Back 65

Aldosterone increases vascular volume.
It is regulated by the kidneys in response to blood flow.
Aldosterone is the major mineralcorticoid made in the adrenal glands (sitting just above the kidneys) .
Aldosterone is released when the blood pressure is low or the sodium is low.

Front 66

Selected normal limit is for electrolytes
Sodium

Back 66

135-145 mEq/L

Front 67

Selected normal limit is for electrolytes
Potassium

Back 67

3.5-5.5 mEq/L

Front 68

Selected normal limit is for electrolytes
Calcium

Back 68

8.5-10.5 mEq/L

Front 69

Selected normal limit is for electrolytes
Magnesium

Back 69

1.5-2.5 mEq/L

Front 70

Selected normal limit is for electrolytes
Phosphorus

Back 70

2.5-4.5 mEq/L

Front 71

Selected normal limit is for electrolytes
Chloride

Back 71

96-106 mEq/L

Front 72

Water deficit /Hypernatremia
the concept of “too much sodium” and “water deficit” are nearly synonymous.

Back 72

Symptoms
Acute weight loss, oliguria, concentrated urine, weak rapid pulse, Low BP, dizziness especially upon standing, weakness, thirst,
Contributing factors
Vomiting, diarrhea, fever, excessive sweating without fluid replacement, Diabetes insipidus (insensitivity to vasopressin), careless hypertonic IV saline administration.
GIVE 5% dextrose = isotonic

Front 73

Water excess /Hyponatremia

Back 73

Symptoms
Acute weight gain, edema especially in the lower legs, JVD, crackles in the lungs, shortness of breath, high blood pressure, bounding pulse.
Contributing factors
Congestive heart failure, hypotonic IV fluid excess, SIADH (too much ADH), primary polydipsia (rare) Burns, Diarrhea, vomiting, Nasogastric suction, Diuretics.
GIVE 3% Saline

Front 74

5% Dextrose in 0.225 saline =

give?

Back 74

isotonic
provides Na , Cl +free water
replace hypotonic losses + treat hypernatremia

Front 75

5% dextrose in 4.5 or 9% Saline=

Give?

Back 75

hypertonic

Front 76

0.45% Saline =

give?

Back 76

hypotonic
provides free water + na , Cl
use as maintenance solution
no calories

Front 77

0.9% saline =

give?

Back 77

isotonic used to expand intravascular volume and replaces extracellular fluid losses. contains na + cl
(carefull may causeintravascular overload + hyperchloremic acidosis

Front 78

3.0% saline =

give?

Back 78

hypertonic
to treat hypoatremia
give slowly may cause dangerous intravascular volume +pulmonary edema

Front 79

Lactated ringer =


give

Back 79

Isotonic HAs no mgs
used for losses of burns + GI
can be used for metabolic acidosis
DONOT USE IN LACTiC ACIDOSIS

Front 80

Potassium regulates

Back 80

intra-cellular osmolality by being exchanged for sodium (which water likes to follow)
Abnormal levels can cause heart arrhythmias

Front 81

Low Potassium = HYPOKALEMIA

Back 81

Fatigue, anorexia, N&V, muscle weakness, hypoactive reflexes, paresthesias, leg cramps, polyuria, ileus, abdominal distension, Ventricular-fibrillation, Low BP
ECG: flattened T waves
(low K+ means low T waves

Front 82

High Potassium = HYPERKALEMIA

Back 82

Vague muscle weakness, Heart arrhythmias, flaccid paralysis, paresthesias, intestinal colic, Muscle cramps, irritability, anxiety
ECG: tall tented T waves
(High potassium means high T waves)

Front 83

maximum rate that potassium should be given IV is no more than

Back 83

20meq/hour

Front 84

Emergency treatment for hyperkalemia is

Back 84

administration of insulin and dextrose to force potassium back into cells. After this, a binding agent (Kayexelate) can be given orally to absorb it in the gut

Front 85

HYPERCALCEMIA

Back 85

Muscle weakness, constipation, anorexia, N&V, polyuria, polydipsia, hypoactive reflexes, lethargy, deep bone pain, pathological bone fractures, flank pain, calcium stones,
Emergency treatment is by rapid dilution of the blood by giving IV normal saline, and by special drugs

Front 86

HYPOCALCEMIA

Back 86

Symptoms:
Numbness and tingling of the toes, fingers, circumoral region (aka paresthesias)
Positive Trousseau’s and Chvostek’s signs, seizures, hyperactive reflexes

Front 87

lungs Pleural effusion

Back 87

Is a buildup of the pleural fluid in the chest cavity around the outside of the lung.
It can happen from blocked lymph outflow from cancer
From leakage of fluid from the blood in congestive heart failure
Infection and inflammation

Front 88

lungs When to suspect Pneumonia

Back 88

Sudden onset of:
Fever, chills, cough with purulent sputum and sharp pain with breathing (pleuritic pain)
Dullness to percussion in an area
Crackles on auscultation
Increased fremitus (vibration with speech)

Front 89

lungs Pleurisy

Back 89

Inflammation of the pleura
Hurts to breathe in.
The pain is Sharp.
Person breathes shallowly to avoid pain.

Front 90

lungs Asthma meds

Back 90

albuterol inhaler reduces bronchospasm, with onset of wheezes
Corticosteroids reduce inflam
Rinse mouth after inhaled steroids to prevent yeast infection (thrush)


other drugs like cromolyn (Stabilizes mast cells) and Montelukast [singulair)
(inhibits leukotrienes)

Front 91

lungs Drugs for treating TB

Back 91

Four drugs at once are now being used to treat TB due to drug resistance.
Isoniazid
Rifampin
Pyrazinamide
Ethambutol
There are a number of combinations…
Treatment may continue for 9 months