NR 601 Midterm Study Guide

NR 601 Midterm Study Guide Developmental changes o Review Kennedy and Dunphy readings for age related changes: o Physiological: 1. Limited chest wall expansion 2. Cilia atrophy 3. Immune system alterations 4. Cardiac, respiratory and renal reduced physiological reserve 5. Reduced homeostatic mechanisms that fail to adjust regulatory systems such as temperature control and fluid and electrolyte balance. 6. Changes in the sympathetic response which contributes to orthostasis and falls, as well as lack of hypoglycemic response. 7. Impaired immunological function: infection risk is greater and auto-immune diseases are more prevalent. o Lab results- Dunphy Table 77.2- PAGE 1. Protein: rises slightly- kidney changes with age, UTI, renal pathology 2. Specific gravity: lower maximum in elderly- the decline in nephrons impairs the ability to concentrate urine. 3. ESR: significant increase- neither sensitive nor specific in aged. 4. Iron Binding: slight decrease 5. HGB: men slight decrease, women no change- anemia common in elderly. 6. HCT: slight decrease speculated: decline in hematopoiesis. 7. Leukocytes: slight decrease due to drugs or sepsis and should not be attributed immediately to age. 8. Lymphocytes: T-CELL AND B-CELL levels fall- therefore infection risk is higher and immunizations should be encouraged. 9. Platelets: no change 10. Albumin: decline- related to a decrease in liver size and enzymes: protein-energy malnutrition, infection, and liver disease. 11. BUN: increases significantly up to 69mg/100 ml.- decline in GFR; decreased cardiac output. 12. Creatinine: increases to 1.9 mg/100 ml- related to lean body mass decrease. 13. Creatinine clearance: decreases 10%/decade after 30 years of age- used for prescribing meds excreted by kidneys. 14. Glucose tolerance: slight increase of 10mg/DL per decade after 30 years of age- diabetes increasingly prevalent; drugs may cause glucose intolerance. o Atypical disease presentations- PG. 4 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 confusion, 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: confusion, agitation, new onset anorexia, weight loss, and arthralgias may occur. 5. Malignancy: new or worsening back pain secondary to metastasis from slow growing breast masses. Silent masses of the bowel. 6. Myocardial infarction: absence of chest pain. Vague symptoms of fatigue, nausea, and a decrease in functional and cognitive status. Classic presentations include dyspnea, epigastric discomfort, weakness, vomiting, history of previous cardiac failure. Higher prevalence in females versus males. Non-Q- WAVE MI. 7. Overall infectious disease processes: absence of fever or low-grade fever, malaise, sepsis without usual leukocytosis and fever. Falls, anorexia, new onset of confusion and/or alteration and change in mental status, decrease in usual functional status. 8. Peptic ulcer disease: absence of abdominal pain, dyspepsia, early satiety, painless, bloodless, new onset of confusion, unexplained tachycardia, and/or hypotension. 9. Pneumonia: absence of fever, mild coughing without copious sputum, especially in dehydrated patients, tachycardia and tachypnea, anorexia and malaise are common, alteration in cognition. 10. Pulmonary edema: lack of proximal nocturnal dyspnea or coughing, insidious onset with changes in function, food or fluid intake, or confusion. 11. Tuberculosis: hepatosplenomegaly, abnormalities in liver function test, and anemia. 12. UTI: absence of fever, worsening mental or functional status, dizziness, anorexia, fatigue, and weakness. o Geriatric syndromes: focus should be on maintaining function, dignity, and individual control to promote health and quality of life. Early detection and correction of problems such as sensory deficits, confusion, and gait and balance issues can increase independence and longevity among this group. 1. SPICES geriatric syndrome markers: S: sleep disturbances P: problems with eating or feeding. I: incontinence C: confusion- often caused by delirium and dementia. (PAGE 1291- • Delirium is a state of mental confusion that develops suddenly and can fluctuate over time. Symptoms include hallucinations, delusions, and a dream like state of incoherent and mental confusion. Common causes of delirium include infection often urinary tract infection, anticholinergic medications, sedatives, antidepressant drugs, steroids, dehydration and electrolyte in balance, metabolic and encephalopathy, vitamin deficiencies, or diabetes and thyroid disease. • Dementia has a gradual onset over months or even years. Evidence that regular physical exercise reduces the risk of dementia. This occurs when there is too much of a breakdown of acetylcholine. Defined as a chronic organic disorder of mental processes with symptoms of memory loss, personality changes, and impaired reasoning. The most common type of dementia is Alzheimer’s disease. A standard diagnosis requires two of the following impairments to be present; • A. memory impairment • B. communication and language impairment • C. inability to focus or pay attention • D. reasoning and judgment impairment • E. visual perception impairment. E: evidence of falls- identified as the leading cause of older adult injury related visits to the emergency department in the United States. One person every 11 seconds falls. Risk factors include previous falls, increasing age, medications, and cognitive deficits. The most common injury includes a head or hip fracture. RITUAL is the free falls risk assessment tool. The patient should be asked if they have fallen in the past year, if they feel unsteady when standing or walking, or if they worry about falling. Key interventions to reduce falls include patient education, enhancing strength and balance, modification of medications, management of hypotension, vitamin D and calcium supplement, addressing foot in footwear issues, assessment of vision, and implementing home safety precautions. S: skin breakdown. o Categories of aging- know age ranges for old, young old, old-old, etc. (page 1282) young-old: 65-74 old: 75-84 oldest- old: 85 and older. Exercise in older adults (Kennedy)- chapter 3 starts on page 19. Recommended amount of exercise 30 minutes per day for five days a week of moderate exercise. If weight management is part of this 60 minutes per day as advised. o Recommended exercises for sleep and flexibility: recommended activities include: tai chi, walking, aqua therapy, and biking. Provider should assess balance and risk for falls before beginning, and explain the importance of starting low intensity and going slow. o Exercise recommendations for specific diagnoses (Kennedy): a lot of the conditions include walking, aquatic activities, tai chi, cycling, stationary bike, and recreational activities. o Recommended testing prior to exercise initiation: clinician judgment should be exercised in assessing the patient and prescribing an exercise routine. • Adults who do not have symptoms and have no diagnosis chronic health conditions do not need to consult with a healthcare professional about increasing physical activity. • Patients with chronic conditions should consult a healthcare provider for physical activity goals that are realistic and safe. • Healthy adult men over 45 years old and healthy adult women over 55 years old who are considering a vigorous exercise program need healthcare provider screening and routine stress testing. • Sedentary older adults and all adults with cardiac disease or strong risk factors should undergo screening and stress test if they are undertaking a vigorous exercise program. o Barriers, facilitators and contraindications to exercise: • Patient barriers to exercise: lack of time, perceived need for equipment, perceived barrier to beginning exercise/physical activity, disability or functional limitation, unsafe neighborhood or weather conditions, no parks or walking trails, depression, high BMI, lack of motivation, interpersonal loss or significant life event, and ignorance of what to do. • Patient facilitators: social support, positive self-efficacy, motivation to engage in physical activity, good health with no functional limitations, frequent contact with prescriber, regular schedule and plan program, satisfaction with program, insurance incentive, improvement in mobility or health condition, staff of exercise facility support. • Medical contraindications for exercise therapy: unstable angina, uncompensated heart failure, severe anemia, uncontrolled blood glucose, unstable aortic aneurysm, uncontrolled hypertension or tachycardia, severe dehydration or heat stroke, and low oxygen saturation. Health promotion (Dunphy and Kennedy page 12) o Immunizations • Influenza: mended annually for all adults over 50 years old, unless contraindicated. Residence of long- term care facilities that house people with chronic medical conditions are at especially high risk for developing the flu. Healthcare workers should also receive the vaccine. Patients with a severe egg allergy or severe reaction to the influenza vaccine in the past and patience with a prior history of Guillain-Barre’ syndrome should talk with their healthcare provider before getting the vaccine. • Tetanus-diphtheria toxoids with acellular pertussis vaccine (Tdap): administered as a once in a lifetime booster to every adult, following this a TD booster is recommended every 10 years. • Pneumococcal: should be administered as a one-time dose to (PCV13) -naïve adults at age 65 years, followed by a dose of (PPSV2 3)12 months later. • Hepatitis B: recommended for high-risk person such as IV drug users, sexually active people with multiple partners, those living with someone that has hepatitis B, patients under 60 years old with diabetes, and all desiring protection from hepatitis B. The initial dose is given, followed one month later by the second dose, then the third dose is given 4 to 6 months after the second dose.