Exam 5 ~ Master Topher
Nasogastric Tubes & Enteric Tubes
Used to decompress or drain stomach fluid or unwanted contents - Allows for rest p̄ surgery, & monitors for GI bleeding Can be used to DX GI d/o - Aspirate content for analysis - Administer RX & Feeding
In a report, the night nurse tells the incoming nurse that one client with dementia has sundowning syndrome. Which of the following nursing diagnoses would be most appropriate for this client? a. Social isolation b. Sleep deprivation c. Grieving d. Noncompliance
b. Sleep deprivation A common problem in clients with dementia is sundowning syndrome in which an older adult habitually becomes confused, restless, and agitated after dark and does not sleep. Implementing the nursing diagnosis of sleep deprivation will help the client obtain adequate sleep at night and awaken refreshed.
Constipation Risks & Diarrhea Care
Constipation Risks: Bedrest - Rx (Opioids) - Reduced fluid/fiber - Depression (R/T less activity) Diarrhea Care: Call lights - Reduce/Remove Rx - Observe anal region for S/S of skin breakdown - Avoid food poisoning (refrigeration, exp. dates, raw food care, odorous foods, proper temperatures) - May require education
Bisacodyl (Dulcolax)
Chemical stimulant laxative - OTC - Irritates lining of GI tract Indications: Constipation - Prevent straining - Evacuate bowels - Removal of Poisons Contraindications: Acute abdominal disorders - GI obstruction Adverse: N/V/D - Spasms - Cramping - HPoTN, Bradycardia - Weakness/Fatigue
Macular Degeneration
(AMD) Age-Related (54% of blindness in older adults) Types: - Dry (85-90%) - Slow breakdown of retinal layers - Wet - Abrupt - Damages vision faster - Abnormal BV's MGMT: Education - Support - Safety - Improve lighting - Provide magnifying devices
Maintaining Nutrition Balance & Tube Function
- Adhere to prescribed rate & method - Aspirate gastric (confirm adequate emptying) - Hydration (flushing) AC/p̄ - Rx & feeding separate - Room-Temp feedings Closed Systems: Prepackaged & sterile (req. pump) Open Systems: Syringe - Gravity/Pump - Fill bag
Suprapubic Catheter
A catheter that is inserted surgically through abdominal wall - drains urine into collection bag - UTI is associated - Often used for autonomic/neurogenic bladder PT r/t not wanting to self-cath so often
Factors affecting micturition
Age: Nocturia - ↑ Frequency (bladder Δ w/ time) - Retention (↑ w/ age & ↑ risk of UTI r/t stasis) - Control (intervene w/ Bladder training - q 4-5 hrs) Food & Fluid: ETOH/Caffeine (diuretic) - Nutrition/Hydration Psychological: Bladder training, allow privacy unless contraindicated Pathological: UTI's (painful & urged urination) - Renal calculi - HTN (destroys nephrons) RX: ABX/NSAID's (nephrotoxicity) - Anticoagulants (bleeding, emergency) - Rifampin/Pyridium (orange/red urine) - Diuretics (↑ frequency, pale/yellow urine)
Education & Assistance for Older Adults
Aging: Normal process & illness is pathological - can occur together Cost: Rx, Hospital, equipment, supplies are expensive - Provide referrals and gather resources to assist Pt. Family: Educate family on proper care & assist with adaptation to psychological stressors ~ r/t ambiguous loss
Physical Assessment (Abdomen & Rectum)
Abdomen: Inspect - Auscultate (quadrants, freq/clicks/flatus, hypo/hyperactive) - Palpation (tender/non-tender) Anus/Rectum: Inspection - Palpation - Assess lesions, ulcers, inflammation, hemorrhoids, skin irritation r/t incontinence/diarrhea
Large Intestine
Absorbs water, forms feces, & expels feces - increased water absorption (hard stool) - decreased (watery stools) Peristalsis: nervous system contracts small & large intestines q 3-12 min - Moves waste out of intestines
Ambulatory Care & Hospital Admission
Admission, Ambulatory: Day visit - Health HX - Same-day surgeries, screenings, teaching - Requires informed consent Admission, Hospital: Admission Form (demographics, personal information, date & time, AD & Code status, DX, Relative, Religion) - Nursing interview & Assessment - Financial agreement - Acceptable PT ID: Name, DOB, MRN, Account #
Loperamide (Imodium)
Antidiarrheal which slows peristalsis & ↑ time for absorption of fluid/electrolytes Indications: Diarrhea (A/C) - ↓ Discharge (ileostomy) Caution: HX (Obstruction, abdominal d/o) Adverse: Constipation - Ab Distention/Discomfort - Nausea - Dry Mouth - Megacolon - Fatigue/Weakness/Dizziness
Terminology R/T Urination
Anuria: < 50 mL/24 hr (hemodialysis) Oliguria: 60-400 mL/24 hr (peritoneal dialysis) Polyuria: excessive Pyuria: purulent drainage Dysuria: painful/difficulty Glycosuria: ↑ BG checks reduce - Glucose in urine Nocturia: Disruption to sleep Enuresis: Bed wetting
Elder Abuse
Around 10% of adults 60 or older are abused - Women more likely - Types: Physical, sexual, psychological/emotional, financial abuse - Exploitation, neglect Signs: Perineal excoriation (urine burns) - Poor skin integrity - Pressure injuries - Poor hygiene - Repeated hospital visits - Malnutrition - Acute fracture - Bilateral bruising - Bruises at different stages of healing - Nervousness around others - Sudden Δ BX
Nursing Process (Urine)
Assess and gather information regarding PT hx, deviations from normal - Novel conditions happening - I/O - Δ in habits DX: Knowledge deficit - Pain - Fear Goals: Understanding (procedures, tests) - Decreased pain/fear - Teach back description of tests, ect. - NSAIDs (nephrotoxic), educate PT Interventions: ↑ Fluids - Relaxation - Analgesics/Antispasmodics - Privacy (Bladder Training)
Assessing External Eye Structures
Assess: Eyelids, Sclera - Pupils & Response (PERRL) - Gaze & Position - Ptosis (drooping eyelid) - Nystagmus (oscillating movement, CNS toxicity r/t sleep deprivation/stroke)
Role of the Nurse (Abuse)
Assessment: Head-to-Toe (look for signs) - Be objective & investigate - Pay attention to how they interact with others Mandatory Reporting: Required to report (figure out policy) Build Trust: Develop rapport with Pt's - Avoid direct questions r/t abuse Provide education & resources: Social work, etc.
Hemianopsia
Blindness in half the visual field R/T stroke
Urine Specimens
Can measure Glucose, pH, SG, infectious agents, WBC destruction, drugs Routine Urinalysis: Not always sterile - Soap & water w/ aseptic on peri-area Clean-catch/Midstream: Sterile - Soap & water - aseptic on peri-area - PT stops urination, catches, continues into toilet - Minimum of 10 mL Urinary Diversion: Access port (clamp tube near hub & clean hub ~ 15 sec) - Screw syringe, draw sample 24-Hour: Not common - Set time & discard first sample - Catch urine from that point on - Place on ice in light resistant container - Must restart if urine dumped accidentally
Communication with an unconscious patient
Careful what you say (hearing last sense lost) - Assume they hear you - Speak before touch - Keep environmental noise low
External Ear Conditions
Cerumen Impaction (ear wax): Suction - Irrigation - Instrumentation - Glycerin - Mineral oil Foreign Bodies: Irrigation - Suction External Otitis: Inflammation (bacterial/fungal) - Pain/Tenderness, discharge, erythema, hearing loss - TX infection - Relieve pain - Reduce edema
Chronic Illness (Define, Characteristics)
Chronic Illness (>3 mo's) - Permanent Δ Characteristics: Alterations in Phys or Anatomy - Education required (modifiable RF's - smoking, drinking, diet) - Requires support & care
States of Awareness
Conscious: Delirium - Dementia - Confusion - Somnolence (drowsiness) - Locked-in Syndrome (quadriplegic, alert) Unconscious: Asleep - Stupor (arousal via extreme stimuli) - Coma (cannot be aroused) - Vegetative state
Cataracts
Cloudiness of lens - R/T aging - Traumatic/Congenital/Senile Manifestations: Blurry - Sensitivity to glare - Reduce acuity - Myopia/Astigmatism/Diplopia (double-vision) Interventions: Dilating eye drops - Education (verbal/written) - Advise to contact provider (flashing lights, vision change, pain ↑)
Nursing care for Pt's Across Settings
Community-based Nursing: Knowledge/Skilled - Independent - Accountable - Advocate for Pt. Continuity of Care: SBAR communication or Pt. transfers - Assist w/ info. collection & sharing Collaborative Practice: Teamwork to provide patient-centered care & safety Care Coordination: SBAR communication - Provide resources to enhance well-being - Information exchange - Reduce duplication of services (screening, labs, etc.)
Diabetic Retinopathy
Damage to the retina as a complication of uncontrolled diabetes (leading cause of blindness 20-74) - Damages microvascular vessels in eye DX: Acuity test - Pupil dilation TX: Laser surgery - Vitrectomy
In anticipation of discharge, a nurse is teaching the daughter of an older adult client how to change the dressing on the client's venous ulcer. Which teaching strategy would be effective? a. Demonstrate & explain the procedure and then have the daughter perform it b. Provide a passive multimedia resource that explains the procedure c. Explain the procedure with explicit detail d. Provide a brochure with written instructions
Demonstrate & explain the procedure and then have the daughter perform it. All steps of a procedure such as a dressing change should be demonstrated, practiced, and provided in writing. The client or caregiver should then perform the procedure or treatment in the presence of the nurse to demonstrate understanding and ability to carry out the procedure. This is more likely to facilitate success than providing a passive multimedia resource, explaining, or providing written instructions alone without reciprocal demonstration.
Micturition, urination, peeing
Detrusor muscles contract - sphincter relaxes - abdominal wall contracts - diaphragm lowers - urine passes - Muscles can be strengthened via "Kegel exercises"
Development, Tasks, & Causes of Death (Middle Adulthood)
Development: Physiologic (Δ's occur) - Cognitive (small Δ's from young) - Psychosocial (↑ Freedom, economic stability, social relationships) Tasks: Adjusting to physical Δ - Maintain occupation - Assist child Δ adult - Adjust to aging parents Causes of Death: Cancer - CVD - DM2 - Chronic lower respiratory disease (emph) - Cerebrovascular disease (stroke) Erikson's: Generativity vs. Stagnation
Development & Changes of the Older Adult
Development: Physiologic (↓ of body systems) - ↑ RXN Time - Psychosocial (self-concept stable through life) - Disengagement theory (substitute activities; continues socializing) Erikson's: Ego integrity vs. Despair/disgust Changes: Strength & Health (keep active, good diet) - Reduced income (social services) - Health of Spouse - Relating to age group - Social roles (Δ's w/ time - keep engaged) - Living arrangements & Family roles Sarcopenia: R/T ↓ activity/exercise, Pt. decreases muscle mass and exhibit w/ ↓ grip strength
Variables that affect bowel elimination
Developmental: Advanced age, slows motility - Diarrhea/incontinence possible Food & Fluid: Fiber (fruits, veggies, ETOH), hydration status - Constipating (cheese, meat, eggs) Activity & Lifestyle: Increased movement increases elimination Rx: Can inhibit or stimulate movement - Abx (green-gray & ↑ motility) - Aspirin (pink, red, black - emergencies) - Iron salts (black, normal) - Antacids (white stools, okay) Surgery/Anesthesia: Slows bowels & increases urinary retention
GI Stimulants (Dexpanthenol & Metoclopramide)
Dexpanthenol: ↑ ACh & Stims PSNS Metoclopramide: Blocks dopamine receptors & makes GI cells sensitive to ACh ↑ GI activity Action: ↑ Motility Indications: Gastroparesis Contraindications: GI Obstruction Adverse: N/V/D - Intestinal Spasms - Cramping - ↓BP&HR - Weakness/Fatigue Drug Interactions: Digoxin (R/T ↓BP&HR) - ETOH - Cyclosporine
Visualization Studies for GI System
Direct: Esophagogastroduodenoscopy (camera into esophagus down to duodenum) - Colonoscopy/Sigmoidoscopy (camera up rectum) Indirect: Abdominal ultrasound - Barium enema - MRI - CT scan Least Invasive to Most: Fecal occult test - Barium Studies - Endoscopic Exam Adequate hydration ā/p̄ surgery
Vulnerable Populations
Disabilities (mental, physical, social) - Co-morbidities - Mental illness/Substance abuse - Minorities - Poverty - Undocumented immigrants - Elderly/Children Provide access to resources to maintain health & address these issues upon admission
Components of Discharge Planning
Discharge planning begins upon admission Assess: Pt's Strengths & Limitations - Supports - Resources available & needed - Environment of which the patient will be returning too Provide: Goals - ID Healthcare needs - Referrals - Education Does the Pt. require OT, PT, rehabilitation services?
Colostomy
Diversion from bowel - Receiving bag for exiting stool Sigmoid: Bottom portion - Formed stool Descending: Slightly higher - Semi-formed Transverse: Horizonal area - Unformed Ascending: Fluid stool Ileostomy: Liquid stool Free odor & empty bag (burp) - Inspect stoma (pink, good; pale, anemia; dark, surgery) - Skin care - I/O - Educate PT on self-care, F/U Appt., Supply deliveries - Self-Image
Caring for Hearing-Impaired
Educate self-care (preserve hearing) - Orient pt. to your presence - Decrease background noise - Hearing aids - Position self in front - Talk directly to them - Pantomime when appropriate - Write messages - Avoid chewing gum
Caring for Visually Impaired
Educate self-care (prevent blindness) - Make your presence known - Normal tone of voice - Advise before touching pt. - Call-light - Orient pt. to environment
Emptying Colon of Feces
Enemas: Cleansing - Retention (Oil, Medicated, Antihelmintic) - Large/Small Volume - Retention enemas hold substance ~ 30 min - Lubricates stool - Medicated can have anti-parasite, ABX
Sensory Overload
Excessive stimuli over which patient feels no control - Brain cannot meaningfully respond or ignore stimuli Effects: Confusion/Agitation (elderly) - Cognitive disturbances - Emotional disturbances Interventions: Minimize lights, noise, TV/Radio - Rest - Educate on Stress Reduction - Offer simple explanations for procedures/tests - Assess what is stressful for the patient
Caring for Confused Patient
Face-Face Communication - Calm, simple, direct speaking - Orient & reorient - Foster independence - Explain care measures - Reinforce reality if delusional
Promoting Normal Urination
Fluid intake: Increases urine Maintain Habits: Respond to call lights (can delegate to CNA/UAP) - Provide comfort - Peri-care to prevent maceration Strengthening Muscle tone: Kegel exercises (contract to stop flow of urine for 3 sec., then continue) - 30/day Assisting with toileting: Normal routine - Assist - Provide comfort/privacy unless contraindicated - Bedpans/commodes - Appropriate hygiene - Schedule if necessary (q4, q6, etc.) Empty bedpans when you see them filled & sitting in the open
Hearing Loss
Increases w/ age - Excessive noise levels Types: Conductive (middle ear problem) - Sensorineural (damaged cochlea or vestibulocochlear nerve) - Functional (emotional problem) Manifestations: Tinnitus - Loss of hearing focus - Turning up TV - Insidious - Deteriorated speech - Fatigue - Social isolation - False Pride (not acknowledging decrease - look for confused expression/staring at mouth)
Urinary Tract Infections
Infection that occurs in the urethra and can travel to bladder. Factors: Most are bacterial - Ureterovesical Reflux (ureters - kidneys) bladder bag not draining by gravity - Women have shorter urethra (quicker travel to bladder) Risk Factors: Female - Neurologic D/O - Altered states r/t incomplete emptying of bladder S/S: Dysuria - Nocturia - ↑ Frequency - Low-Grade Fever Geriatric: Sludgy, dark, foul-smell urine - Possible mucous Asymptomatic not treated - W/ symptoms get culture & test for proper tx
A client is having an increasing amount of difficulty caring for oneself in the home alone. The client states to the nurse, "I need more help. What am I going to do?" Which action would be the most appropriate for the nurse to take? a. Provide resources for a physical therapist b. Provide resources for home health c. Have the social worker visit the client to discuss care options
Have the social worker visit the client to discuss care options Services to manage health care needs in the home can involve a team of interdisciplinary professionals, including social workers. The social worker is able to broadly identify resources to meet the client's needs. As no specific needs are indicated in this case, such as the need for rehabilitation, bathing, or adaptive devices, it would be more appropriate for the nurse to refer the client to the social worker than to a physical therapist, home health aide, or occupational therapist.
Assessment Questions R/T GI
Health HX: Abdominal pain - Dyspepsia (indigestion) - Gas - N/V - Constipation - Fecal incontinence - GI diseases - Gas, N/V, Dyspepsia often R/T foods we eat - Obtain dietary Hx & request allergies Pain: Character - Duration - Frequency - Location (Can be referred) - GI pain often referred - Must rule out heart problems
Health-Illness Continuum
Health constant Δing state between wellness & death
Bowel Training Programs
Help manipulate factors the PT controls & achieve normal BM - Food/Fluid intake - Exercise - Timing (respond to call light & help PT to toilet) Goal: Natural bowel movements w/o laxatives - W/ diarrhea, call-light response paramount - Clean peri-area
Mrs. Jimenez, age 79, became a widow earlier this year and now resides alone in the house that she and her husband shared for 30 years. Her children have encouraged her to move, but she expresses a desire to remain in her home, despite some slight mobility challenges. The nurse who provides occasional home healthcare for Mrs. Jimenez should first propose?
Home modification Older adults typically express a desire to maintain their existing living relationships and this should be facilitated as long as it is safe. Consequently, the nurse should prioritize Mrs. Jimenez's wishes. Home modification may allow her to maximize her independence and maintain her current living situation in spite of some mobility challenges.
Health Promotion Model
How a person incorporates themselves with the world to achieve health - Characteristics & Experiences considered to predict Pt's adherence to health-related bx's - Personal, Biologic, Psychologic, Sociocultural considered
Health Belief Model (HBM)
How beliefs influence bx's Perceived susceptibility to disease - Belief of capacity to contract - Afraid/Denial Perceived seriousness of disease - How much do they know - ↑ Knowledge of risks, ↓ BX's Perceived benefits of action - Beliefs r/t measures to prevent - Value in inhibiting smoking to prevent disease?
Leaving AMA (Against Medical Advice)
If patient is oriented & alert, they have a right to leave - Signature of form (assuming risk/consequences, negating right to sue, etc.) attempted - Document & sign if patient refuses Do not advise insurance will not pay - Insurance may drop client or sue client later on
Assessing Voiding & Urinary Function
Info: Habits - Patterns - Hx of problems Exam: - Assess bladder (ultrasound, palpate, percuss) - Distended/firm upon palpation is retention - Skin integrity (S/S infection, discharge, odor) - Hydration - Urine (color, odor, clarity, sediment) - Patient's response to problems Alleviating/aggravating factors for voiding issues. Want to acknowledge Δ from baseline. Sludge/sediment, odorous, darkened urine ~ r/t disease process
Sensory Deprivation
Insufficient sensory stimulation (impaired, unable to receive) - Monotonous, meaningless stimuli Effects: Perceptual disturbances - Cognitive disturbances - Emotional disturbances Interventions: Prevent via supporting senses (glasses, hearing aids) - Orient (calendar, view of outdoors) - Regular contact - TV/Radio - Pets - Smells
Agent-Host-Environment Model
Interaction between external agent, susceptible host, & environment - Considers factors that ↑ risk for infectious disease
Urinary System
Kidneys: Nephron's filter blood/lymph 60-150 mL/minute - Age-related damage < 60 mL - NSAIDs damage nephrons - Creatinine, BUN, GFR (watch trends) Ureters: Two - Flow downward (decrease risk of infection in bladder) - Contains waste products (urine) Bladder: Contains urine - Pain receptors - Can palpate - Innervated by ANS & Contains transitional cells (expansion) - Always residual urine (50 mL & Increases w/ Age) Urethra: Larger on men (↓ risk of UTI) - Shorter on women (↑ risk of UTI) - Ensure cleared when catheterizing - Urine from bladder to exterior
Low Vision, Blindness, Impaired (Define, Management)
Low: Requires corrective lenses Blindness: No light perception Impaired: Accompanied by functional impairment Management: Coping strategies - Item placement - Communication strategies - Low-Vision specialist - OT - Braille - Service animals
Docusate (Colace)
Lubricating Laxative that promotes passage of stool Indications: Constipation - Prevent straining - Evacuate bowels - Removal of Poisons Contraindications: Acute abdominal disorders - Obstruction Adverse: Diarrhea/Cramping/Nausea (GI) - Dizziness/Headache/Weakness (CNS) - Sweating/Palpitations/Flushing/Fainting (CV)
Bulk Laxatives
Magnesium (sulfate, citrate, hydroxide) - Lactulose - Polycarbophil - Psyllium - Increases bulk of fecal matter Indications: Constipation - Prevent straining - Evacuate bowels - Removal of Poisons Contraindications: Acute abdominal disorders - Obstruction Adverse: Diarrhea/Cramping/Nausea (GI) - Dizziness/Headache/Weakness (CNS) - Sweating/Palpitations/Flushing/Fainting (CV)
Inner Ear Conditions
Manifestations: Dizziness - Vertigo (motion/spinning) - Nystagmus (involuntary movement of eyes)
Information Included in Report
Name & Age - Admitting Dx & Physicians - Condition & Manifestations - Allergies, Rx, Tx - Labs & Special Equipment - Nursing Care Priorities - Advanced Directives
Stool Collection
Medical asepsis - Hand hygiene & gloves - Prevent contamination Collecting: Void urine - Use hat within bowel of toilet - No TP - Avoid contact with soaps, detergents
Discharging a Patient to Long-Term
Must Be Sent: Medical Records (copies) - Assessment & Care Plan - Property, prescriptions, appointment cards - SBAR conducted Once Pt. is transferred, new provider may dc or continue orders
Potential Problems R/T Enteral Tubes
N/V - Gas, bloating - Dumping syndrome (↑ gastric emptying) - Aspiration pneumonia (Fowler's position) - Displacement (aspirate) - Obstruction (flush AC/p̄) - Skin irritation (inspect & care) - Hyperglycemia (dietician) - Dehydration (↑ Flushing) Kidneys: BUN (10-20) & Creatinine (0.7 - 1.4)
Assessment of Vision
Ocular HX: Diminished acuity - Both eyes affected? - What is the problem? - Duration of problem? - Any discharge? Visual Acuity: Snellen (distance) - Rosenbaum (near)
Myths of Older Adults (Ageism)
Older begins 65 - Most in SNF - Sick & Mentally deteriorated - Not interested in sex - Do not care how they look - Are lonely - Bladder problems - Do not deserve Tx for illness - Cannot learn new things Older adults like to be involved socially - Keep them involved, active, provide holistic care
Glaucoma
Optic nerve DMG - ↑ IOP (aqueous humor congestion) - ↑'s w/ age - Mechanical & ischemic damage - "Silent Thief" RFs: HTN - CVD - Diabetes - Obesity Manifestations: Blurring - Halos - Difficulty focusing - Aching/Discomfort - Headache TX: Timolol (beta-blocker, reduces IOP - ↓'s aqueous humor production) Prevent: Trendelenburg - Valsalva maneuver - Bearing down
Community-Based Nurse
Qualities: Knowledgeable & Skilled - Independent (may need info. from community leaders; make decisions) - Accountable (have answers for community) - Trustworthy Roles: Pt. Advocate - Coordinator (home health, food, medication access) - Patient & Family Educator Communication: Continuity of care (communicate SBAR w/ Pt. transfers) - Smooth transitions
What is the biggest difference between the use of NG tubes and PEG tubes?
PEG tubes: long-term feedings/Rx administration NG tubes: short-term feedings/Rx administration Bolus feedings (certain volume given intermittently via gravity or pump) - Continuous - Cyclic feeding
Phases of Home Visit
Pre-Entry: Collect Pt. Data - Review & Schedule visit - Evaluate safety issues Entry: ID needs & interventions - Educate Pt. & caregivers - Documents care given Document: Patient condition - Care provided - Pt. response - Pt. progress - Plan for care - Plan for next visit
Motivational Interviewing - Phases
Precontemplation: No desire to make lifestyle Δ Contemplation: Pros v. Cons of Δ Determination: Planning to make Δ Action: Implementing change Recycling: Plan falls apart Stages gone through when confronted w/ change - Nurses can M. interview
Prior to the discharge of a client who is recovering from a stroke from an acute care facility, the nursing case manager has the nursing staff, client, client's family, physical therapist, and home health nurse meet. The most likely purpose of this meeting is to: a. Provide client education b. Prepare the client for home care c. To discuss hospital-based resources that the client may need
Prepare the client for home care Given that this client is being discharged from the acute care facility following a stroke, it is most likely that the nurse is calling a meeting of the entire health care team and the client and family to prepare the client for home care. Simply providing client education or evaluating the effectiveness of hospitalization could be done by the nurse alone and would not warrant calling a meeting with the entire health care team. As the client is being discharged, there is no reason to discuss hospital-based resources that the client might need.
Preventing & Improving Sensory Alterations
Prevent: Control Pt. discomfort - Provide rest - Use of sensory aids/devices - Increase social activity - Encourage activity/exercise - Stimulate as many senses as possible Improve Function: Educate on importance of stimulation - Educate self-care bx's - Therapeutic interactions
Health Promotion & Illness Prevention
Primary: Promote health & Prevent disease - Immunize - Diet Education - Accident-Prevention Secondary: Screening at risk populations - BP - Cancer screenings (mammograms, testicular) Tertiary: Reduce disability after DX - Rehabilitate Pt's - Diabetes education - PT for pt's post-stroke, spinal cord-injury - Support groups
Vision terms
Refractive Errors: Corrected w/ lenses that turn light away from retina Emmetropia: Normal Vision Myopia: Nearsightedness Hyperopia: Farsighted Astigmatism: Distortion r/t irregularity of cornea
Interventions for UTI's
Relieve pain - ABX, Analgesics, Antispasmodics - ↑ Fluids - Avoid coffee, tea, citrus, spices, cola, ETOH - Frequent voiding & Education (hand hygiene prior & after urination) Symptomatic PT - ABX, acetaminophen, analgesics
Patient Navigator
Removing obstacles pt's face in accessing & receiving TX Assistance w/ Scheduling - Financial Assistance - Psychosocial/Community support - Anticipate barriers to care Are patients able to f/u w/ appointments? What is stopping them?
Why do we catheterize patients?
Retention - Immobility - Anuria & require specimen - Measurement of UO for critically ill PT - Improve healing for sacral/perineal wounds in incontinent PT - Emptying bladder pre/post-op - Improved comfort for EoL External Cath: Use is facility-sensitive (some allow/disallow) - Requires Δ q 24 hr & peri-care Never done for convenience - Due to CAUTI risk, must have valid medical reason with daily provider charting
An assessment tool a nurse has for the older adult
SPICES S - sleep disorders P - Problem w/ eating/feeding I - Incontinence C - Confusion E - Evidence of falls S - Skin breakdown
Complications of UTI's
Sepsis: Systemic infection can cause organ damage Acute Kidney Injury: Ureterovesical reflux can damage kidneys - Can become Chronic if not treated - Immunocompromised, corticosteroids, ↑ risk
Diagnostic Tests R/T GI
Serum Labs Stool Specimens: Fecal Occult Breath: Carbohydrate levels Genetic: Predisposition to GI disease Ultrasound: Visualize abdominal cavity
Patients At Risk for UTIs
Sexually Active: Women (bacterial in urethra & can get into bladder) - Men (urethritis, inflammation of urethra) Enlarged Prostate: Inhibits complete voiding (urine stasis increases risk for infection) Diabetes Mellitus: Urine stays in bladder longer r/t stasis & nerve damage Indwelling Catheter: CAUTI is most common HAI If patient is asymptomatic, no TX - Research indicates risk for C. diff & resurgence of infection
A nurse is making a home visit to an older adult with multiple chronic health problems. The client is alert and oriented and cognition is intact. While talking with the client, the client reveals a belief that the adult child is stealing the client's social security checks to buy beer and eat out all the time. What action should the nurse first do regarding the possible elder abuse to keep the client safe? a. Report the abuse to the authorities b. Complete an elder abuse assessment c. Educate the adult child on elder abuse d. Educate the client on elder abuse
b. Complete an elder abuse assessment The client could be a victim of exploitation which involves illegally taking or misusing the funds, property, or assets of a vulnerable older adult. There are many elder abuse assessment tools available for healthcare providers. Many states require the nurse to report suspected elder abuse; however, the nurse should first assess the client using an elder abuse screening tool.
Stages of Illness Behavior
Stage 1: Experience symptoms Stage 2: Assuming sick role - Self-ID sick - Focused on body systems/functions Stage 3: Dependent role - Assistance ADL's, Emotional support - Foster independence Stage 4: Recovery & Rehabilitation
Receiving Data
Stimulus: Sound, taste, feeling, sight Receptor: Receives stimulus Nervous: Sends signal to brain Brain: Translates into sensation
Geriatric Considerations R/T Kidney Function
Susceptible to kidney injury & renal structural/functional changes - GFR Decreases w/ Age (Watch trends with Rx that affects kidneys) - Creatinine & BUN indicate kidney dysfunction if hyper Geriatric incomplete void - Urinary stasis - Decreased nerve innervations & have increased drug/drug interactions
A patient presents to the hospital with renal problems and a history of uncontrolled diabetes. Original diagnosis approximately 2 years ago. The patient asks how the diabetes and developing renal dysfunction are connected. An appropriate response by the nurse is: a. Diabetes targets the kidneys through the disease process, resulting in dysfunction b. Diabetes, if uncontrolled, increases the viscosity of the blood and pressure, damaging the nephrons c. Diabetes has nothing to do with the development of renal issues
b. Diabetes, if uncontrolled, increases the viscosity of the blood and pressure, damaging the nephrons The nephrons are the functional unit of the kidneys, responsible for filtering blood and lymph. The dynamics of the kidneys rely on a regulated pressure and when changed, as we see with increased blood glucose, the nephrons are damaged.
Diagnostic Studies (Urine)
Urinalysis/Culture: Midstream - Diversion - Routine - 24 Hour - Measures glucose, pH, sediment Ultrasound: Checks residual volume in bladder Osmolality: Indicates hydration status - Na x 2 (> 290, dehydrated - < 270, overhydrated)
Nursing Interventions (Promoting Bowel Habits)
Timing (know PT BM time) - Positioning - Privacy - Nutrition (increase fiber/fluid) - Exercise (increases motility)
Ophthalmic Medications
Topical Anesthetics: Mydriatics (dilate) - Cycloplegics (paralyze) - Increased BP & CNS symptoms Glaucoma-Timolol: ↓ Pressures in eye by controlling aqueous humor production - Constricts pupil and decreases focus of lens
Urinary Incontinence
Transient: Quick onset - Gone w/in 6 mo's (treatable) Overflow: Overdistention - Bladder releases urine Total: Unpredictable loss Functional: Not reach toilet in time - Nerve damage - Poor mobility & no help - R/T surgical procedure Reflex: "Autonomic or Neurogenic" - Loss of proper signaling for draining bladder - Requires straight/intermittent Cath (q 4-6 hrs ATC) Urge: ↑ Nerve Stim (normal ~ 300 mL of urine - Urge = 50, 100, 150 mL) - ↑ Frequency & STAT Stress: R/T emotions - Laughing, crying, sneezing - Kegel exercises (30/day) - (women often r/t ↓ pubic muscle & men w/ prostate surgery)
Education R/T Incontinence
Treatable (Hydration, Kegel, Rx) - Advise of Voiding log - Educate on Rx use - Toilet Training, find habits (q 4-6 hr., PT on toilet) & provide privacy unless contraindicated PT likely to be embarrassed - Incontinence is often treatable, give the PT time & encourage
Caring for a patient with enteral feeding
Tube Placement: X-Ray - Visualize aspiration (pH 1 - 5) Clearing Obstruction: Flushing (p̄ & AC) - Enzymes Nasal & Mouth: Ensure proper moisture - PT not eating Skin care: Tube placement sites (look for breakdown) I/O: Should be equal - BG LVL (Q6H) - Edema Weight: Avoid drastic loss - Proper nutrition Support: Self-Image - Δ of Habits
Measuring Urine Output (UO)
UO can be used to assess CO, hydration status - Can use bedpan/urinal/specimen container - Long-term residents, UO not measured - Common for unstable PT in hospital - Catheter bags not accurate
A nurse is teaching an elderly client's family about the causes of mental impairment. The nurse sees that the teaching has been effective when the family says which of the following? a. Sundowning is a common problem of dementia b. Dementia is acute and quickly resolving illness c. Alzheimer's is uncommon and reversible d. Delirium is a permanent illness
a. Sundowning is a common problem of dementia A common problem in patients with dementia is sundowning syndrome, in which an older adult habitually becomes confused, restless, and agitated after dark. Dementia is chronic and usually develops gradually. AD is the most common degenerative illness and is irreversible. Delirium, a temporary state of confusion, is an acute illness that can last from hours to weeks and resolves with treatment.
A nurse arrives at the home of an older adult client. The agency was called because a neighbor noticed that the client was home alone. The nurse finds the client alone in the living room. When asked about the client's daughter who lives there and has been caring for her, the client says, "She went on vacation for about a month. She'll be back soon." Further assessment reveals that there are no other family members or services currently involved. The nurse would identify this situation as: a. Neglect b. Exploitation c. Abandonment d. Emotional abuse
c. Abandonment The client is alone and without any support or caregivers. Therefore, abandonment, which is the desertion or a vulnerable older adult by anyone who has assumed responsibility for that adult's care, would apply. Exploitation involves illegally taking or misusing funds, property, or assets of a vulnerable older adult. Neglect involves refusal or failure by those responsible to provide food, shelter, protection, or health care for a vulnerable older adult. Emotional abuse involves verbally or nonverbally causing mental pain, anguish or distress on the older adult.
A patient is admitted to the hospital following a CVA and is experiencing dysphagia. The provider orders for enteral feeding due to the risk of aspiration related to the dysphagia secondary to CVA. The patient asks the nurse why the enteral feeding is necessary and the benefits of using them. The nurse's best response is: a. It is a highly expensive way to administer medications to prevent your bowels from having to work too hard b. It will decrease your endocrine system to allow for restoration of hormone levels following the stroke you just had c. It is a safe, cost-effective way to preserve GI integrity, allow for fat metabolism & lipoprotein synthesis, and will maintain your nutritional requirements until you are able to swallow normally d. I like kites
c. It is a safe, cost-effective way to preserve GI integrity, allow for fat metabolism & lipoprotein synthesis, and will maintain your nutritional requirements until you are able to swallow normally
The home care nurse is visiting an older adult client in the home to assess a leg wound and change the dressings. The nurse is aware that the client receives money monthly but there is no food in the house, no adequate heat, and the client states, "My sister takes my check and cashes it every month." What is the correct action by the nurse? a. Confront the sister and beat her ass b. Have the client confront the sister about the issue c. Take the client to the emergency department d. Report to social service the client does not have heat or food
d. Report to social services the client does not have heat or food The client is apparently a victim of financial abuse and is being left without resources in order to live comfortably and to have basic needs cared for. The nurse should not confront the sister or have the client confront her due to the potential for violence. The incident must be reported to social service to have them involved with obtaining immediate resources for the client. Taking the client to the Emergency department would be against regulations for home health nurses and the client is not in need of immediate medical attention.
Causes of accidental injuries in older adults
Δ's in vision & hearing - ↓ muscle mass & strength - ↓ reflex & rxn time - ↓ sensory - Combined effect of morbidities & Rx - Economic factors (Rx, hospital, supplies, etc.)
