NURS 445 Test 2 – Questions With Fully Explained
Solutions
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Sherpath: Diabetes Mellitus Chapter 21 Test Case Study 4 (Short
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Terms in this set (139)
Comprehensive Geriatric Assessment - Cognitive Assessment
- Functional Assessment
- Physical Assessment
- Psychological Assessment
- Social Assessment
- Spiritual Assessment
Health History - Demographic information
- PMH
- Current medications and dietary supplements (prescribed,
OTC, home remedies, herbals)
- Social history
- Functional history
- Review of systems
Assessment of Older Adults - Complex
- Collaboration
- Special skills for older adult assessment (listen, pauses, ask
questions, minute details, use all available sources, normal
changes of aging from abnormal)
Physical Assessment - Technical competence (normal vs. abnormal changes with
aging; focused assessment of chronic conditions)
- Communication skills
- Body systems approach
Cognitive Assessment - Mini-Mental State Examination (MMSE)
- Mini-Cog
- Assessing the needs of adults with dementia
- Declines associated with Alzheimer's disease
,Ten Principles of Comprehensive 1. The cornerstone of an individualized POC for an older adult
Assessment is a comprehensive assessment
2. Comprehensive assessment considers age-related changes,
age-associated and other disease, heredity, and lifestyle
choices
3. Nurses are members of the healthcare team, contributing to
and drawing from the team to enhance the assessment
process
4. Comprehensive assessment is not a neutral process
5. Ideally, the older adult is the best source of information to
assess his or her health. When this is not possible, family
members or caregivers are secondary sources of information.
When the older adult cannot self-report, physical
performance measures may provide additional information
6. Comprehensive assessment should first emphasize ability
and then address disability. Appropriate interventions to
maintain and enhance ability and to improve or compensate
for disability should follow from a comprehensive assessment
7. Activity performance and activity capacity are two different
perspectives. Some assessment tools ask, "Do you dress
without help?" (performance), whereas others ask "Can you
dress without help?" (capacity). Asking about capacity will
result in answers that emphasize ability
8. Assessment of the everyday activities of older adults who
have cognitive limitations may require task segmentation, or
the breaking down of tasks into smaller steps
9. Some assessment tools or parts of assessment tools may be
more or less applicable depending on the setting: community,
acute care, or long-term care
10. It is important to explore the meaning and implications of
health status from older adult's perspective. For example, the
same changes in visual acuity for two older adults may have
different meanings and implications for everyday activities
ACE.S Essential Nursing Actions - Assess function and expectations
- Coordinate and manage care
- Use Evidence based knowledge
- Make Situational decisions
Cultural Considerations - Understanding culture helps the nurse to provide better
care
- If you aren't sure, ASK
- Alternative therapies/healers
- Lack of older adults in medica research
- Always use a medical interpreter
- Offer resources in native language, when possible
SPICES Assessment for Older Adults - Sleep disorders
- Problems with eating or feeding
- Incontinence
- Confusion
- Evidence of falls
- Skin breakdown
, Common Geriatric Syndromes - Falls and gait abnormalities
- Malnutrition
- Delirium
- Urinary incontinence
- Sleep disorders
- Pressure ulcers
Katz Assessment The most appropriate instrument to assess functional status as
a measurement of the client's ability to perform activities of
daily living independently
Activities of Daily Living (ADL) - Tasks to get going in the morning, get from place to place
and then close out the day. Involve caring for and moving the
body
- Walking, bathing, dressing, toileting, brushing teeth,
transferring
Instrumental Activities of Daily Living (IADL) - Activities that are more complex and look at how the older
adult interacts to environment and community
- Cooking, driving, telephone/computer use, shopping,
managing finances, managing meds, laundry/housekeeping,
meal preparation, yard work, home maintenance
Advanced Activities of Daily Living (AADL) - Societal, family and community roles as well as occupational
and recreational activities
- Hobbies and working
The Frailty Index for Elders (FIFE) See image
Chronic Illness in Older Adults - Higher risk of chronic illness
- Higher risk of hospitalization
- Prevention is key!
- Healthy people 2030 objectives
Cardiovascular System: Older Adults - Decline in cardiac reserve (Increased HR, dyspnea, muscle
fatigue)
- Mild systolic murmurs
- Arterial stiffness
- Reduced CO
- Increase LA size/LV thickness
- NURSING IMPLICATIONS: Listen for a full 60 seconds, put
stethoscope over the skin, identify extra heart sounds, get
accurate BP and RR, promote 30 minutes of exercise 3-5 days
per week, diets low in calories, fat, sodium, and cholesterol;
promote smoking cessation, normal weight, and remember
genetics play a role
Solutions
Save
Students also studied
Sherpath: Diabetes Mellitus Chapter 21 Test Case Study 4 (Short
30 terms 24 terms 22 terms
jesssbee Preview kenanderson2017 Preview Brittany182
Terms in this set (139)
Comprehensive Geriatric Assessment - Cognitive Assessment
- Functional Assessment
- Physical Assessment
- Psychological Assessment
- Social Assessment
- Spiritual Assessment
Health History - Demographic information
- PMH
- Current medications and dietary supplements (prescribed,
OTC, home remedies, herbals)
- Social history
- Functional history
- Review of systems
Assessment of Older Adults - Complex
- Collaboration
- Special skills for older adult assessment (listen, pauses, ask
questions, minute details, use all available sources, normal
changes of aging from abnormal)
Physical Assessment - Technical competence (normal vs. abnormal changes with
aging; focused assessment of chronic conditions)
- Communication skills
- Body systems approach
Cognitive Assessment - Mini-Mental State Examination (MMSE)
- Mini-Cog
- Assessing the needs of adults with dementia
- Declines associated with Alzheimer's disease
,Ten Principles of Comprehensive 1. The cornerstone of an individualized POC for an older adult
Assessment is a comprehensive assessment
2. Comprehensive assessment considers age-related changes,
age-associated and other disease, heredity, and lifestyle
choices
3. Nurses are members of the healthcare team, contributing to
and drawing from the team to enhance the assessment
process
4. Comprehensive assessment is not a neutral process
5. Ideally, the older adult is the best source of information to
assess his or her health. When this is not possible, family
members or caregivers are secondary sources of information.
When the older adult cannot self-report, physical
performance measures may provide additional information
6. Comprehensive assessment should first emphasize ability
and then address disability. Appropriate interventions to
maintain and enhance ability and to improve or compensate
for disability should follow from a comprehensive assessment
7. Activity performance and activity capacity are two different
perspectives. Some assessment tools ask, "Do you dress
without help?" (performance), whereas others ask "Can you
dress without help?" (capacity). Asking about capacity will
result in answers that emphasize ability
8. Assessment of the everyday activities of older adults who
have cognitive limitations may require task segmentation, or
the breaking down of tasks into smaller steps
9. Some assessment tools or parts of assessment tools may be
more or less applicable depending on the setting: community,
acute care, or long-term care
10. It is important to explore the meaning and implications of
health status from older adult's perspective. For example, the
same changes in visual acuity for two older adults may have
different meanings and implications for everyday activities
ACE.S Essential Nursing Actions - Assess function and expectations
- Coordinate and manage care
- Use Evidence based knowledge
- Make Situational decisions
Cultural Considerations - Understanding culture helps the nurse to provide better
care
- If you aren't sure, ASK
- Alternative therapies/healers
- Lack of older adults in medica research
- Always use a medical interpreter
- Offer resources in native language, when possible
SPICES Assessment for Older Adults - Sleep disorders
- Problems with eating or feeding
- Incontinence
- Confusion
- Evidence of falls
- Skin breakdown
, Common Geriatric Syndromes - Falls and gait abnormalities
- Malnutrition
- Delirium
- Urinary incontinence
- Sleep disorders
- Pressure ulcers
Katz Assessment The most appropriate instrument to assess functional status as
a measurement of the client's ability to perform activities of
daily living independently
Activities of Daily Living (ADL) - Tasks to get going in the morning, get from place to place
and then close out the day. Involve caring for and moving the
body
- Walking, bathing, dressing, toileting, brushing teeth,
transferring
Instrumental Activities of Daily Living (IADL) - Activities that are more complex and look at how the older
adult interacts to environment and community
- Cooking, driving, telephone/computer use, shopping,
managing finances, managing meds, laundry/housekeeping,
meal preparation, yard work, home maintenance
Advanced Activities of Daily Living (AADL) - Societal, family and community roles as well as occupational
and recreational activities
- Hobbies and working
The Frailty Index for Elders (FIFE) See image
Chronic Illness in Older Adults - Higher risk of chronic illness
- Higher risk of hospitalization
- Prevention is key!
- Healthy people 2030 objectives
Cardiovascular System: Older Adults - Decline in cardiac reserve (Increased HR, dyspnea, muscle
fatigue)
- Mild systolic murmurs
- Arterial stiffness
- Reduced CO
- Increase LA size/LV thickness
- NURSING IMPLICATIONS: Listen for a full 60 seconds, put
stethoscope over the skin, identify extra heart sounds, get
accurate BP and RR, promote 30 minutes of exercise 3-5 days
per week, diets low in calories, fat, sodium, and cholesterol;
promote smoking cessation, normal weight, and remember
genetics play a role
