NR 601 Midterm Exam review (NR601)

Exam (elaborations) NR 601 Midterm Exam review (NR601) Week 1 Developmental changes o Review Kennedy readings for age related changes Physiological Age related Change Functional Change Implications Integumentary System Loss of dermal and epidermal thickness Loss of subcutaneous tissue and thin epidermis. Prone to skin breakdown and injury Decreased vascularity see • Atrophy of sweat glands resulting in decreased sweat production • Decreased body odor • Decreased heat loss • Dryness • Alteration in thermoregulatory response • Fluid requirements may change seasonally • Loss of skin water • Increased risk of heat stroke Respiratory System Decreased lung tissue elasticity Decreased vital capacity Reduced overall efficiency of ventilatory exchange Cilia atrophy Change in mucociliary transport Increased susceptibility to infection Decreased respiratory muscle strength • Reduced ability to handle secretions and reduced effectiveness against noxious foreign particles • Partial inflation of lungs at rest Increased risk of atelectasis NR 601 Midterm Exam review Cardiovascular System Heart valves thicken and become fibrotic Reduced stroke volume, cardiac output; may be altered Decreased responsiveness to stress Fibroelastic thickening of the sinoatrial node; decreased number of pacemaker cells Slower heart rate Increased prevalence of arrhythmias Decreased baroreceptor sensitivity (stretch receptors) Decreased sensitivity to changes in blood pressure Prone to loss of balance, which increases the risk for falls GI Liver becomes smaller Decreased storage capacity Decreased muscle tone Altered motility Increases risk of constipation, functional bowel syndrome, esophageal spasm, diverticular disease Decreased basal metabolic rate (rate at which fuel is converted into energy) May need fewer calories NE CONDE) Lab results Lab Test Normal Changes with age Comments UA Protein 0-5mg/100ml Rises slightly May be due to kidney changes with age, urinary tract infection, renal pathology Specific Gravity 1.005-1.020 Lower max in elderly 1.016-1.022 Decline in nephrons impairs ability to concentrate urine Hematology ESR Men: 0-20 Women: 0-30 Significant increase Neither sensitive nor specific in aged Iron Binding 50-160mcg/dl 230-410mcg/dl Slight decrease Decrease Hemoglobin Men: 13-18g/100ml Women: 12-16g Men: 10-17g Women: None noted Anemia common in the elderly Hematocrit Men: 45-52% Women 37-48% Slight decreased speculated Decline in hematopoiesis Leukocytes 4,300–10,800/mm3 Drop to 3,100– 9,000/mm3 Decrease may be due to drugs or sepsis and should not be attributed immediately to age Lymphocytes 00–2,400 T cells/mm3 50–200 B cells/mm3 T-cell and B-cell levels fall Infection risk higher; immunization encouraged Platelet 150,000–350,000/ No change in number Blood Chemistry Albumin 3.5–5.0 Decline Related to decrease in liver size and enzymes; protein-energy malnutrition common Globulin 2.3–3.5 Slight increase Total serum protein 6.0–8.4 g No change Decreases may indicate malnutrition, infection, liver disease Blood urea nitrogen Men: 10–25 Women: 8–20 mg Increases significantly up to 69 mg Increases significantly up to 69 mg Creatinine 0.6–1.5 mg Increases to 1.9 mg Related to lean body mass decrease Creatinine clearance 104–124 mL/min Decreases 10%/decade after age 40 years Used for prescribing medications for drugs excreted by kidney Glucose tolerance 62–110 mg/dL after fasting; 120 mg/dL after 2 hours postprandial Slight increase of 10 mg/dL/decade after 30 years of age Diabetes increasingly prevalent; drugs may cause glucose intolerance Alkaline phosphatase 13–39 IU/L Increase by 8–10 IU/L Elevations 20% usually due to disease; elevations may be found with bone abnormalities, drugs (e.g., narcotics), and eating a fatty meal o Atypical disease presentations 1. Acute abdomen Absence of symptoms or vague symptoms, acute confusion, mild discomfort and constipation, some tachypnea and possibly vague respiratory symptoms, appendicitis pain may begin in right lower quadrant and become diffuse 2. Depression Anorexia, vague abdominal complaints, new onset of constipation, insomnia hyperactivity, lack of sadness 3. Hyperthyroidism Hyperthyroidism presenting as “apathetic thyrotoxicosis,” i.e., fatigue and weakness; weight loss may result instead of weight gain; patients report palpitations, tachycardia, new onset of atrial fibrillation, and heart failure may occur with undiagnosed hyperthyroidism 4. Hypothyroidism Hypothyroidism often presents with confusion and agitation; new onset of anorexia, weight loss, and arthralgias may occur 5. Malignancy New or worsening back pain secondary to metastases from slow growing breast masses Silent masses of the bowel 6. Myocardial Absence of chest pain infarction (MI), vague symptoms of fatigue, nausea, and a decrease in functional and cognitive status; classic presentations: dyspnea, epigastric discomfort, weakness, vomiting; history of previous cardiac failure, higher prevalence in females versus males Non-Q-wave MI 7. Overall infectious diseases process Absence of fever or low-grade fever, malaise 8. Sepsis Without usual leukocytosis and fever, falls, anorexia, new onset of confusion and/or alteration in change in mental status, decrease in usual functional status 9. Peptic ulcer disease Absence of abdominal pain, dyspepsia, early satiety, painless, bloodless, new onset of confusion, unexplained, tachycardia, and/or hypotension 10. Pneumonia Absence of fever; mild coughing without copious sputum, especially in dehydrated patients; tachycardia and tachypnea; anorexia and malaise are common; alteration in cognition. 11. Pulmonary edema Lack of paroxysmal nocturnal dyspnea or coughing; insidious onset with changes in function, food or fluid intake, or confusion 12. Tuberculosis (TB) Atypical signs of TB in older adults include hepatosplenomegaly, abnormalities in liver function tests, and anemia 13. Urinary tract infection Absence of fever, worsening mental or functional status, dizziness, anorexia, fatigue, weakness o Geriatric syndromes refers to conditions that involve multiple organ systems. Most common are delirium, falls, dizziness and incontinence. risk factors include: older age, cognitive impairment, functional impairment, and impaired mobility. Bowel incontinence- involuntary passage of stool or the inability to control stool from expulsion. More prevalent in women than men. 3 types: urge incontinence, passive incontinence, and fecal seepage. urge- has desire to go but cannot make it to the toilet despite attempts to avoid defecating. Passive-involuntary loss of gas and stool without awareness. fecal seepage- leakage of stool after a normal bowel movement. etiology : a number of reasons including GI issues, cognitive or neurological diseases. Treatment: treat related etiology such as impaction of increasing fiber. Habit training is also recommended. Once clear evidence of no impaction, infection, or cause is determined. antidiarrheal medication like Imodium can be tried. For retrosphincter dysfunction biofeedback with strengthening exercises for the sphincter can be done. Constipation: presence of 2 or more symptoms: decreased stool frequency, straining, hard stools, sensation of incomplete emptying, blockage at anorectal site. constipation is most common digestive complaint. Cough: forceful expelling of air from the lungs involving the use of accessory muscles of the chest and constriction of the glottis. dehydration: caused by too little fluid intake, too much fluid lost or both. Chronic diseases like diabetes, cancer, cardiovascular diseases, and renal diseases make elderly sensitive to fluid shifts. Diarrhea: Passage of increased stool frequency, liquidity, or volume. Most episodes are caused by viral gastroenteritis. Chronic diarrhea is defined as lasting longer than 4 weeks. Dizziness: common clinical categories include vertigo, light-headedness, unsteadiness, or gait instability, and disequilibrium. Falls: WHO defines this as an event that results in a person coming to rest inadvertently on the ground, floor, or other lower level. can be witnessed or unwitnessed. due to intrinsic factors or extrinsic factors. Intrinsic factors include age, weakness, gait/balance, poor vision and postural hypotension. Extrinsic factors involve environment conditions like lack of handrails, poor lighting, obstacles, slippery surfaces, certain medication, and polypharmacy. Fatigue ● Description ○ Subjective state often described as a feeling of tiredness, weariness, lack of energy, or exhaustion that is unrelieved or only partially relieved by rest ○ Often results in an inability to initiate normal activity; a reduced capacity to maintain activity; and difficulty with concentration, memory, and emotional stability ○ Chronic fatigue syndrome occurs when fatigue lasts longer than 6 months and is not relieved with rest ○ Fatigue could also be a symptom of another illness and any older person with this complaint should obtain a medical evaluation and work-up. ● Etiology ○ Occurs normally with inadequate rest, excess exertion, or insufficient diet ○ Fatigue in older adults may be an early indicator of the aging process, as well as debility or another disorder ● Occurrence ○ 25% of the US population ● Age ○ Common among the elderly ● Gender ○ More common in women ● Ethnicity ○ Not significant ● Contributing Factors ○ Poor dietary habits, overexertion, alcohol abuse, smoking, stress, chronic illness, drug interactions, misuse of drugs, and sleep apnea ○ In the older adult individual, it is compounded by a decrease in muscle strength, loss of muscle neurons, muscle atrophy, a decrease in hormone levels, and lack of exercise. ● Signs and symptoms ○ Conduct a complete symptom assessment, including the onset; duration; severity; and precipitating, aggravating, and relieving factors. ○ Identify other indicators or associated symptoms of fatigue, which may include decreased energy expenditure, decreased endurance, sleep disturbance, attention deficits, somatic complaints (aching body, tired eyes), dyspnea, and weakness ○ Carefully review the adequacy of the diet, all medications (evaluating for potential medication side effects), activity level (including degree of independence of ADLs), and potential causes or contributing factors. Identify the impact fatigue is having on the person’s ADLs and quality of life and current stressors. ○ Distinguish between generalized fatigue and actual weakness by testing for muscle strength and presence of localized tenderness ○ A thorough physical examination will include a mental status examination to screen for dementia and rule out depression. ● Diagnostic tests ○ Diagnostic tests on all patients with persistent unresolved fatigue should include CMP, CBC with differential, erythrocyte sedimentation rate (ESR), and/or C-reactive protein, because these are low cost and offer significant screening capacity. ○ Thyroid function, urinalysis, and pulmonary function tests. ○ If symptoms and signs indicate cardiac decompensation, a B-type natriuretic peptide (BNP) may indicate degree of heart failure and an EKG may reveal cardiac arrhythmias, enlargement of the heart, myocardial infarction, or abnormalities in the conduction system ● Differential diagnosis ○ Psychiatric disorders, including depression and generalized anxiety disorder, account for 70% of cases of fatigue ○ Fatigue that cannot be relieved by rest or sleep is often a sign of disease. ● Treatment ○ Symptom management includes regular exercise, attention-restoring activities, psychosocial techniques, energy conservation measures, good sleep hygiene, improving diet, and possibly adding nutritional supplements ○ Psychostimulants may be considered for opioid-related somnolence, cognitive impairment, and depression ● Follow up ○ Monitor the patient periodically as indicated by diagnosis or symptoms, symptom persistence, and disability associated with the symptom ● Sequelae ○ The potential for complications relates to the cause of fatigue and the impact the symptom has on the person’s function ● Prevention/Prophylaxis ○ Optimal health maintenance, including maintaining a healthy diet, regular exercise, and good sleep hygiene, may prevent or enable early recognition of signs and symptoms of systemic or psychological illness ● Referral ○ May be indicated based on the results of the work-up ● Education ○ If the fatigue has a physiological cause, teaching should be related to the findings; psychological counseling, changes in the environment, behavior modification, and stress reduction may be needed Goal of fatigue management - provide the patient with self-help tools to eliminate or alleviate fatigue Headache: Hematuria: Description: Presence of RBCs in the urine, classified either gross or microscopic Gross hematuria: urine appears either red or brown in color to the naked eye