NUR 163 Final Exam

Nursing Interventions for skin integrity - turn q2h, use draw sheet, heels on pillows, bladder training discharge instructions for cardiac patients - pace yourself rest periods conserve energy UAP and fall prevention - toilet q2h no loose socks physiological changes in older adults - decreased peristalsis decreased cardiac output Relocation Stress Syndrome - pt frequently irritable pt stays in room S/S of stress - muscle tension hyperventilation decreased HR dizziness Patients at greatest risk of stress related problems - Also have chronic illness loss of spouse relocated decreased income screenings for older adults to assess stress - BMI BP cognitive functional potential nutritional complications for older adults - limited income limited transportation neighborhood only has convenience stores external stressors - heat, cold, noise, light, physical trauma intrinsic motivation - internal motivation what do older adults fear the least - death Ostomies - change when 1/3 full chronic fatigue syndrome - lasts more than 6 months and is accompanied by muscle and joint pain, headaches, and sleep and memory problems priority to report to MD - obstructive sleep apnea diet for sacral ulcer - high protein if patient has stress - focus on emotion focus coping Vitamin D toxicity - liver is affected Flu vaccine - primary prevention Hearing aide care - keep dry, ear mold with mild soap and water and dry completely, check batteries(extras), lowest setting, Valsalva maneuver - Any forced expiratory effort against a closed airway such as when an individual holds his or her breath and tightens his or her muscles in a concerted, strenuous effort to move a heavy object or change positions in bed. Open mouth breathing decreased appetite - caused by decreased peristalsis if pt has low bone density - need to do weight bearing exercises fall risk - Morse Fall Scale (MFS) fluid volume deficit - hypovolemia, dehydration, diarrhea, DI. • S/s: ^HR, hypotension, dysrhythmias, ^RR, dyspnea, lethargic, weakness, decreased UO, tenting, constipation, hypernatremia • Rx: IVF, O2 fluid volume excess - hypervolemia: water intoxication d/t excessive Na intake • S/s: ^HR, ^BP, distended neck veins, dysrthymias, ^RR, altered LOC, ^UO, pitting edema, diarrhea, hyponatremia • Rx: diuretics, restrict fluid/Na, monitor I&O, monitor daily weight greatest risk for poly pharmacy - if pt has many doctors expressive aphasia - cannot express what they want to say best way to help relocation syndrome - same caregivers everyday patients with hip fractures are at greatest risk to - develop pneumonia ABC - airway, breathing, circulation when teaching oral hygiene - mention fluoride toothpaste when to get visual screenings - Every 12 months DVT (deep vein thrombosis) - blood clot in the extremities, swelling in legs or feet older adults at risk for hypothermia - dementia patients highest risk for suicide - patients who abuse alcohol low self esteem behaviors - infrequent eye contact sadness anger not motivatied says "don't waste your time on me" contributing factors to chronic fatigue - decreased sleep pain poor diet lack of exercise depression labs to confirm chronic fatigue - kidney function test electrolytes liver function hemoglobin nusing interventions for chronic fatigue - validate with pt that fatigue is real establish a therapeutic relationship encourage pt to avoid over exertion delegating to nursing assistant - snacks to patients empty colostomy lubricate lips older adults values and beliefs - their beliefs impact their perception of the world think their beliefs are normal nurse must be tolerant of all pt values different beliefs lead to miscommunication ineffective coping leads to.. - anxiety sleep disturbance altered bowel/bladder anger depression Benefits of exercise - control decreased bone loss increased well being increased balance problem-focused coping - the goal is to eliminate or reduce underlying cause emotion-focused coping - addresses the stressor but instead to control the emotional response meaning-focused coping - Individual draws on values, beliefs, and goals to modify the personal interpretation and response to a problem Reframing - a positive coping strategy characterized by purposeful cognitive thoughts whereby the individual identifies a positive aspect of the situation confrontational problem solving method - Continuing to face the stressor and live with the consequences Escape problem solving method - completely leaving the situation