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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+
- Sleep Disorders
- Problems with Eating/Feeding
- Evidence of Falls
- Skin Breakdown
Latrogenesis the adverse effect of medical care occurs due to:
Polypharmacy, invasive procedures, increased LOS (length of stay) Nosocomia infections
ADPIE. Assessment, Dx, Planning, Implemntation, Evaluation
- Collection of data: both primary and secondary sources.
- Subjective and Objective data
- Analysis and Clustering of data
Clinical judgement about individual, family or community response to actual or potential problems that a nurse can treat.
- Establishes priorities from High, Intermediate to Low
- Individualizing patient care
- Evidence Based Practice
Indepedent: Nurse initiated
Depedendent: Physician Initatied
- Modifying plan
- Contuing plan
Mobility is important because?
Mobility is equated with wellness and health among older adults.
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
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
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.
Causes of Delirium
- D: Drugs
- E: Elimination
- L: Liver/ Other organs
- I: Infection
- R: Respiratory
- I: Injury
- U: Unfamiliar environment
- M: Metabolic
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.
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
Immobilities effect on cardiovascular and Intervention that can be used?
Thrombus formation, Orthostatic hypotension
- I: Bed to chair.
- SCDS & TEDS
- Leg exercises
Immobilities effect on Musculoskeletal system and Intervention that can be used?
Loss of muscle mass. Decreases stability and balance.
I: Passive and Active ROM
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
Immobilities effect on integumentary and Intervention that can be used?
Pressure uclers, ischemia
I: Reposition every 2 hours. Skin care.
Immobilities effect on elimination and Intervention that can be used?
- Urinary stasis
- Renal Calculi
I: Adequate hydration. Diet rich in fiber, fluids.
Risk factors for skin issues:
- Impaired sensory perception (diabetics)
- Imparied mobility
- Alteration in consciousness
- Shear and Friction
Factors effecting pressure ulcer formation
- Nutrtion (Protein/Albumin)
- Tissue perfusion
- Psychosoical impact
Stage I is
Non blanchable, red
Blister, Partial skin loss. No slough
Full thickness skin loss. May see fat, undermining, tunneling, slough. Will not see bone or muscle.
Bone, Tendon, Muscle visible.
Base of wound cannot be visualized due to slough.
Deep Tissue Wound
Blood filled blister, purple, maroon, mushyness of skin.
Debridement of wounds occurs in:
- Wet to Moist
- Whirlpool treatment
Braden # scale
- 15/16: At Risk
- 14/13: Moderate risk
- 12 or less: at high Risk
Possible complications of wound healing
- Hemorrhage and Interstital fluid loss
Factors effecting Medication Absorption?
- The Route
- Dissolvability of medication
- Blood flow to site
- Lipid solubility of med
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.
Idosyncratic reaction to a medication is?
and Over or under Reaction to a medication.
Side Effect vs Adverse effect
Side effect is unintended second effect.
Adverse is a severe response to medication
Med dose trough?
Minimum blood concentration before next scheduled dose.
Blood serum concentration is reached and maintained.
How long do you have to administer a "now" medicaton?
up to 90 minutes. A STAT med is immeadiate.
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
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
Omission Medication error
Drugs not prescribed, administered or taken by pt.
Reasons for med errors?
- Failed communciation both written and verbal
- Poor administration practice
- dose miscalculation
- Know both generic and brand name
- Do not administer without knowing its purpose
- double check order
- Double check therapuetic dose range
- Double check calculation
- Use only accepted abbreviations
If there is an error
Fill out incident report
Latent factors causing med errors in system
- Oraganization process: workload of healthcare workers. handwritten prescriptions
- Management decision: staffling levels and environment culture.
# on Hendrich scale
5+ is high risk