Card Set Information

2012-12-08 01:59:23

Show Answers:

  1. What is Young Old, Middle Old, Old Old, Elite Old?
    • Young Old is 65-74
    • Middle Old is 75-84
    • Old old is 85-99
    • Elite Old is 100+
  2. SPICES measures:
    • Sleep Disorders
    • Problems with Eating/Feeding
    • Incontinence
    • Confusion
    • Evidence of Falls
    • Skin Breakdown
  3. Katz Measures?
    • ADLS:
    • Bathing
    • Dressing
    • Tolieting
    • Transferring
    • Continence
    • Feeding
  4. Latrogenesis the adverse effect of medical care occurs due to:
    Polypharmacy, invasive procedures, increased LOS (length of stay) Nosocomia infections
  5. Nursing Process
    ADPIE. Assessment, Dx, Planning, Implemntation, Evaluation
  6. Assessment includes:
    • Collection of data: both primary and secondary sources.
    • Subjective and Objective data
    • Analysis and Clustering of data
  7. Diagnosis includes
    Clinical judgement about individual, family or community response to actual or potential problems that a nurse can treat.

    Utilizes NANDA
  8. Planning includes:
    • Establishes priorities from High, Intermediate to Low
    • Individualizing patient care
    • Evidence Based Practice
  9. Implementation includes
    Indepedent: Nurse initiated

    Depedendent: Physician Initatied

    Interdependent: Collaborative
  10. Evaluation includes
    • Discharge
    • Modifying plan
    • Contuing plan

    Ongoing process
  11. Mobility is important because?
    Mobility is equated with wellness and health among older adults.
  12. Safety Hazards for falls
    • Old, rickety furniture and appliances
    • Unsafe stairs (like w/o handrails)
    • Throw Rugs, Frayed carpet
    • Electric cords, objects on floor
    • Poor lighting
    • Poor height of either toilet, bed or chairs
    • Clutter
  13. Strategies to prevent falls
    • Encourage ambulation
    • institute general safety precautions
    • improve chair safety, comfort
    • Improve ability to get out of bed easily
    • Promote continence, comfort, reminders
  14. What should you assess if your patient is wandering and fall prone and you believe they are a harm to themselves?
    Consider when, where and why this could be happening and eliminate the cause.

    Use supervision/ companionship over restraints

    Change lighting, add a bedside comode, keep bed rails down, reality orient.
  15. Causes of Delirium
    • D: Drugs
    • E: Elimination
    • L: Liver/ Other organs
    • I: Infection
    • R: Respiratory
    • I: Injury
    • U: Unfamiliar environment
    • M: Metabolic
  16. If you use restraints you must:
    • Assess pt every 30 minutes for circulation and ROM.
    • Every 4 hours, release.
    • Do not keep on for longer than 24 hours.
  17. Immobilities effect on Metabolic and Intervention that can be used?
    • E: Negative nitrogen balance
    • Altered GI function
    • Fluid and electrolyte imbalance

    I: High protein diet with vitamin B and C
  18. Immobilities effect on cardiovascular and Intervention that can be used?
    Thrombus formation, Orthostatic hypotension

    • I: Bed to chair.
    • SCDS & TEDS
    • Leg exercises
  19. Immobilities effect on Musculoskeletal system and Intervention that can be used?
    Loss of muscle mass. Decreases stability and balance.

    I: Passive and Active ROM
  20. Immobilities effect on respiratory system and Intervention that can be used?
    Atelectasis and Hypostatic pneumonia

    • I: Cough & Deep breathe every 1 to 2 hours.
    • Chest PT
  21. Immobilities effect on integumentary and Intervention that can be used?
    Pressure uclers, ischemia

    I: Reposition every 2 hours. Skin care.
  22. Immobilities effect on elimination and Intervention that can be used?
    • Urinary stasis
    • Renal Calculi

    I: Adequate hydration. Diet rich in fiber, fluids.
  23. Risk factors for skin issues:
    • Impaired sensory perception (diabetics)
    • Imparied mobility
    • Alteration in consciousness
    • Shear and Friction
    • Moisture
  24. Factors effecting pressure ulcer formation
    • Nutrtion (Protein/Albumin)
    • Tissue perfusion
    • Infection
    • Age
    • Psychosoical impact
  25. Stage I is
    Non blanchable, red
  26. Stage II
    Blister, Partial skin loss. No slough
  27. Stage 3
    Full thickness skin loss. May see fat, undermining, tunneling, slough. Will not see bone or muscle.
  28. Stage 4
    Bone, Tendon, Muscle visible.
  29. Unstagable
    Base of wound cannot be visualized due to slough.
  30. Deep Tissue Wound
    Blood filled blister, purple, maroon, mushyness of skin.
  31. Debridement of wounds occurs in:
    • Wet to Moist
    • Whirlpool treatment
    • Autolytic
    • Surgical
    • Chemical
  32. Braden # scale
    • 15/16: At Risk
    • 14/13: Moderate risk
    • 12 or less: at high Risk
  33. Possible complications of wound healing
    • Infection
    • Dehiscense
    • Evisceration
    • Fistula
    • Hematoma
    • Hemorrhage and Interstital fluid loss
  34. Factors effecting Medication Absorption?
    • The Route
    • Dissolvability of medication
    • Blood flow to site
    • Lipid solubility of med
  35. Metabolism occurs where?
    The liver. It is the only site where biotransformation occurs.

    Medications are then excreted through the kidney, liver, bowels, lungs and exocrine glands.
  36. Idosyncratic reaction to a medication is?
    and Over or under Reaction to a medication.
  37. Side Effect vs Adverse effect
    Side effect is unintended second effect.

    Adverse is a severe response to medication
  38. Med dose trough?
    Minimum blood concentration before next scheduled dose.
  39. Med plateau?
    Blood serum concentration is reached and maintained.
  40. How long do you have to administer a "now" medicaton?
    up to 90 minutes. A STAT med is immeadiate.
  41. If given a medication scenario remember:
    • Nurse role is for safe administration and pharmacology knowledge.
    • Assess response and educate about med.
    • Collaborate with others on healthcare team
  42. Med Errors occur beacause of
    Wrong med, route, dose, patient time or poor documentation.

    Also can occur due to wrong rate, or wrong preparation of medication
  43. Omission Medication error
    Drugs not prescribed, administered or taken by pt.
  44. Reasons for med errors?
    • Failed communciation both written and verbal
    • Poor administration practice
    • dose miscalculation
  45. Right drug
    • Know both generic and brand name
    • Do not administer without knowing its purpose
    • double check order
  46. Right dose
    • Double check therapuetic dose range
    • Double check calculation
    • Use only accepted abbreviations
  47. If there is an error
    Fill out incident report
  48. Latent factors causing med errors in system
    • Oraganization process: workload of healthcare workers. handwritten prescriptions
    • Management decision: staffling levels and environment culture.
  49. # on Hendrich scale
    5+ is high risk