NR 226- Exam 2 Study Guide Case NR226 / NR 226- Exam 1 Study Guide

Older Adults 1. Principles for promoting older adult learning Make sure they are ready to learn; are they well enough to learn; sit in front of pt so they can watch your lips move & facial expression; speak slowly & in normal tone; say one idea at a time straight & to the point; give them enough time to answer; minimal distractions w/ proper lighting & comfortable settings; if tired or distracted stop teaching; invite another family to talk; audio, visual & tactile cues to help w/ learning & memory; ask for feedback to know they understand; using past experiences to connect to new learning. 2. Presentation of illness in older adults; acute care, restorative care Presentation of illness – confusion, occurrence & reasons for fall, dehydration, decreased appetite, loss of function, dizziness, incontinence Acute care – (short term hospital stay) risk for delirium, dehydration, malnutrition, nosocomial infections, urinary incontinence & falls. Restorative care - (recovering from acute illness or surgery & support of chronic conditions that effect day-to-day) stabilize chronic conditions, promote health and promote independence w/ ADL’s & IADL’s; prevent, improve, reduce or eliminate problems 3. Comparison of clinical presentation of delirium, dementia and depression; nursing implications Delirium – sudden onset; short fluctuations, worse by night & waking; abrupt progression; last hours to less than month (longer if untreated); consciousness is reduced; alertness fluctuates (lethargic or hypervigilant); attention fluctuates; orientation impaired (severity varies); forgetful; disorganized thinking (speech slow or fast); delusions & hallucinations; psychomotor movements varies; disturbed sleep (reverse). medical emergency & prompt assessment. Bedside 24/7 and ready to recognize development to report. Cognitive impairment reversed once doc identify and treat cause Dementia – slow onset & often unrecognized; long & progressively stable; slow but even progression; last moths to years; consciousness is clear; generally normal alertness; generally normal attention; orientation is normal to person but not place or time; memory impaired; thinking is impaired; misperceptions; normal psychomotor movements (may have apraxia, which is inability to perform purposeful actions); fragmented sleep. Always consider safety, physical & psychosocial needs. Enhance quality of life & maximize functional performance (cognition, mood &behavior) Depression – major life changes, can be sudden or gradual; during day, worse in morning, fluctuations w/ situation; varied progression; last at least 6 weeks or several months to years; consciousness is clear; normal alertness; attention is easily distracted; selective disorientation; sections of intact memory; thinking intact but w/ hopelessness & helplessness; intact perception(delusions & hallucinations in severe cases); varied psychomotor; disturbed sleep (wakes up early). 4. Sexuality in the older adult Changes in reproductive structure & function does not affect libido; still have desires, thoughts & actions for decades. Less activity because illness, death of partner & decreased socialization. Involves love, warmth, sharing and touching. Important role to help maintain self-esteem. understand physical changes in sexual response, provide privacy for discussion of sexuality, be nonjudgmental, ask open-ended questions. Talk about prevention of STI. Touch has many meaning and is an alternative sexual expression. 5. Health concerns; health promotion and maintenance, stroke, smoking, alcohol abuse, safety; nursing implications Health promotion & maintenance – (genetics, good health habits & preventative measures) participate in screenings; exercise regularly; within weight limits; eat low-fat & well balanced diet; low use of alcohol; dental visits; stop smoking; have immunizations. Give info on nutrition, exercise, meds, safety, some med conditions & self-care. Stroke – 3rd leading cause of death; brain ischemia (not enough blood to brain because arterial blockage) or brain hemorrhage; risk factor: hypertension, hyperlipidemia, diabetes, history of ischemic attacks & history of CVA. Impairs functional abilities; inability to be independent. Teach about risk-reduction, to look for early warning signs, ways to support pt inn recovery & rehab. smoking – 4th leading cause of death; preventable; if stopped can stabilize COPD & coronary artery disease; stopping after 65 can add 2-3 more yrs of life; within 1 yr coronary heart disease reduced by 50%; if rejects stopping then at least ask to reduce Alcohol abuse – there are two patterns: lifelong heavy drinking or new pattern heavy drinking late in life; causes from depression, loneliness, & lack of social support; suspicion if history of repeated falls & accidents, social isolation, recurring memory loss & confusion, failure to meet obligations, skipping meals or meds, and unable to manage finances. Encourage to be involved in activities of interest & increase self-worth. Safety - drink water when exercising, good support shoes, avoid outdoor exercise if weather is too hot or cold, exercise w/ partner, stop if feeling bad. Teach about different meds, combining& managing. Assess environment for risks at home (temp on water heater, throw rugs, slippery floor) 6. Therapeutic communication; reality orientation, validation therapy, reminiscence Therapeutic communication – respect them, their uniqueness & health expectations Reality orientation – communication technique to make them aware of time, place & person; improving awareness & orientation. Validation therapy – used w/ confused older adults; accepting the time & place the confused pt states it is. Reminiscence – remembering the past; using it to give meaning & understanding to present or resolve current conflicts 7. Older adults in the acute care setting vs restorative care Acute care setting is short term as in hospital stay, they need help adjusting to environment. Risks of delirium, dehydration, malnutrition, health care associated infections, urinary incontinence & falls. Restorative care has two types of on-going care: continued recovery from acute illness or surgery that started in acute care setting and support of chronic conditions that affect day-to-day functions. Can be in private home or long-term care setting. (this is basically a rehab) The Grief Response 1. Types of loss Necessary loss – a part of life; needs to happen & be replaced w/ something different or better Maturation loss – form of necessary loss; happens throughout life span as normally expected (mother sad because kid goes to college) Situational loss – sudden & unpredictable external event (car accident, injured so cant work ) Actual loss – no longer see, hear, feel or know person or object. (death in family, loss of body part, loss of job, loss of home) Perceived loss – defined uniquely by the person that experienced the loss & less obvious to others. (how intensely you feel about the loss) Death is ultimate loss and part of the continuation of life 2. Grief; stages of grief, mourning, bereavement; therapeutic communication, nursing implications Stages of grief – (dying) denial, anger, bargaining, depression & acceptance Grief – emotional response to loss; unique experience per individual; based on personal experience, cultural and spiritual belief. Mourning – outward expression and behavior to the loss; adapting to loss Bereavement – includes both mourning and grief Nursing implications – taking extensive nursing CEU’s to improve end-of-life care and help pt’s and families experiencing loss, grief death & bereavement. One can use research, practice evidence, experience. Show support and give space when needed Therapeutic communication - open heartedness; open-ended questions; active listening (go on, tell me more); learn to be comfortable in silence; empathize; be there for them; intentional &meaningful touch; make sure they know you are available to talk whenever; respectful of privacy; avoid barriers (false reassurance, denying pt’s grief); help family access other resources (spiritual care) 3. Normal grief vs Complicated grief; symptoms, nursing implications Normal grief – normal universal reactions; feelings of acceptance, disbelief, yearning, anger & depression. Complicated grief – prolonged or difficult time moving forward; chronic yearning, trouble accepting death & others, feel excessively bitter, emotionally numb or anxious about future. 4. Grief considerations in the older adults No different because of age, response is related to nature of loss experience; increased age means increased loss in life; they recover quickly (others can learn to from their courage); can have complicated grief from multiple losses (depression, loneliness, functional decline); physical decline because of illness leads to grief over health, functions & roles; pain is undertreated (mostly w/ dementia pt’s); benefit from same therapeutic techniques as other age groups; goals for grieving relieving depression & maintaining physical function. 5. Coping strategies, client education life experiences shape the persons way to deal w/ loss; emotional disclosure (talking about feelings, venting); always positive & optimistic emotions to better cope; writing letters or in a journal leads to accomplishment. 6. Palliative care vs Hospice care Palliative care – prevention, relief, reduction or soothing of symptoms of disease or disorder throughout entire time; include care of the dying & bereavement follow-ups for family; achieve best possible quality of life; advanced or chronic illness, any age, any diagnosis, any time, any setting Hospice care – care for the terminally ill; managing pain & symptoms; comfort; attention to all needs; less than 6-12 months to live; home, hospital, extended care or nursing home 7. End of life care; Promoting comfort in the terminally ill client Pain - Skin & mucous membrane discomfort – skin care as needed, lotion on skin, dry clean linens Mucous membrane discomfort – oral care every 2-4 hrs w/ soft toothbrush or swab and nonabrasive toothpaste or water, light lip balm, topical analgesics to oral lesions Corneal irritation – eye drops or optic lubes, warm water to remove crust Fatigue – balance activity & rest periods according to pt’s priorities & preferred time of day, conserve pt’s energy Anxiety – address cause, provide calm & supportive environment, active listening, use benzodiazepines for acute anxiety. Nausea – give antiemetic or promotility agents, stop meds or foods that cause it, oral care atleast 2-4 hrs, liquid diet & ice chips, no liquids that increase stomach acidity Constipation – laxatives w/ opioids, change diet as tolerated, increase fluid if tolerated Diarrhea – fecal impaction?, ask doc to change meds if that the cause, moisture barrier on skin Urinary incontinence – dry clothes and linens, foley or condom cath for comfort & skin protection Altered nutrition – smaller portions of pt-preferred foods, do not force food, treat anorexia if pt wants to eat Dehydration – mouth care as least every 2-4 hrs, ice chips or moist cloth to lips. Keep lips & tongue moist Ineffective breathing patterns – treat or control cause, position for comfort & maximal breathing, supplemental oxygen, reduce anxiety or fever, pain management, fan for air movement, stimulate 5th nerve on cheek to decrease dyspneic sensation; give anxiolytics, bronchodilators, inhaled steroids or opioids to suppress cough & ease breathing Noisy breathing (death rattle) – elevate head for postural drainage, turn side to side to mobilize & drain, stop oral intake, avoid suction (discomfort & ineffectiveness), anticholinergic meds sometimes helpful 8. Care of the body after death; cultural considerations Fed & state laws require to have policies for requesting organ or tissue donation, performing autopsy, certifying and documenting how death happened, providing safe and postmortem care. Each culture is different in how they handle their dead. Give compassion, maintain privacy & dignanity and respect for pt and pt’s family members cultural beliefs & practices. African American – large extended family and church family there at time of death, mourning period short, memorial service & public viewing (wake) before burial. Organ donation & autopsy allowed. Chinese –Same respect as living. Buried w/ food & stuff. Extended family stays w/ body for up to 8 hrs. oldest son or daughter bathes body under direction of older relative or temple priest. Organ donation & autopsy are uncommon. Hispanic – special objects like amulets or rosary beads, alternative healing practices & prayer. Grief expressed openly. Religious rituals are essential in end of life. Death is gods will. Native American – Navajos do not touch body after death. Cleansing body, painting the face, dressing in clothing and attaching an eagle feather to symbolize a return home. mourners cleanse their bodies. Dead buried in deceased homeland. Islamic – body ritualistically washed, wrapped, cried over, prayed for and buried as soon as possible. Eyes & mouth closed and face turned toward mecca. Same gender prepare the body. Body is burned not cremated. Autopsies interfere w/ quick burial so ask w/ sensitivity. Soul stays w/ body until It is buried. Organ donation is permissible by some quran interpretations. Buddhist – believe in afterlife, death preferred at home & state at time of death in important. Minimal emotion expression & maintain peaceful compassionate atmosphere. Male family members prepare the body. Recommend not touch body after death so they can transition smoothly into afterlife. Prayer and standing & touching by head of dead. Body not left alone after death. Respects after death & before cremation. Hindu: body placed on floor w/ head facing north. Same gender handles body. Yes to autopsy, bodies cremated Jewish – a member stays w/ body until burial. Burial w/in 24 hrs but not on the Sabbath. Some avoid cremation, autopsy, embalming.