Final Exam Review
Neurosensory
Confusion: What are the causes of acute confusion in the elderly?
Confusion- UTI, dehydration, medications, illness, stress, infection
Differentiate between dementia, delirium, and depression.
Delirium – acute reversible--- find the underline cause (HEAD TO TOE ASSESSMENT)
-r/t illness such as UTI or pneumonia (infection), dehydration or medications (anesthesia)
Dementia -Chronic, irreversible deterioration of brain
-Caused by stroke (vascular), AIDS, Parkinson’s (disease related), Alzheimer’s, tumors, past drug/
alcohol abuse (organic brain syndrome)
Depression - psychosocial changes from loss, experienced by older adults may cause physical changes
can result in losses of independence (SUICIDE ASSESSMENT RISK FORM)
What is important in the nursing care of dementia patients to control their S&S?
Care of the Patient
-Use clear simple directions/routine
-Use touch to calm the patient, keep environment calm and safe
-Walk agitated patients; Do not restrain patients or reorient them
What are the S&S of depression and what is the nurses responsibility if you recognize these S&S in a patient?
- hopelessness, helplessness, sadness, fatigue, diminished memory or concentration, sleep/appetite disturbances,
suicide
Monitor for suicide risk, provide cheerful environment but not large groups
Encourage brief /simple activities – reading, board games, limit choices.
What teaching would you provide regarding SSRI’s?
- SSRI Selective serotonin reuptake inhibitors: sertraline (Zoloft)
–do not drink Grapefruit juice!! -do not stop taking it -affects sexual performance elderly and adolescents
Restraints: What orders are required when applying restraints?
- Type of restraint, what will be restrained, reason, length of time applied, and MD ordering.(within 2
hours of putting on) chemical restraints meds
What nursing care is required when restraints are applied?
-Visually check pt Q30’-Q1h to prevent loss of circulation and strangulation (SAFETY CHECK)
-Release & Reposition Q2h; assess pulses, temp/ color/ sensation (NEUROVASCULAR CHECK)
-Ensure the patient is offered fluids frequently to prevent dehydration; DOCUMENT ALL CARE
-bathroom breaks -educate family why and parameters to remove restraints
Seizure: What are the signs and symptoms of generalized seizures?
• Generalized: involves the whole brain: S&S convulsions, loss of consciousness
What is the priority nursing care of patients having a seizure?
• Promote safety measures
• Pad the side rails, place oxygen & suction equipment at the bedside
• Instruct to avoid excessive alcohol, fatigue, and loss of sleep
• During a seizure
• Observe, treat, and document seizure
• Do not restrain patient or place any objects in their mouth
• Maintain patent airway; Turn patient to the side
• Support & Protect patient’s head; Raise side rails
• Loosen constrictive clothing
• Ease patient to floor; Provide privacy
, • After a seizure
• Reposition (to open and maintain the airway)
• Suctioning and oxygen prn
• Assess pt level of understanding, provide information about how and why the event occurred, and
provide a calm environment
• Implement patient and caregiver teaching, and psychosocial intervention.
Vision: What is the nursing care of patients newly diagnosed with glaucoma? (pressure in the eye foggy)
Limit strenuous activity NO SEX, BENING OVER, LIFT HEAVY OBJECTS
Assess perla squinting and tracking
glasses, magnifying
Safety -administer eye drops – lit environment reduce glare -proper eye care(clean
glass)
when presbyopia is and when does it usually first occur?
Farsightedness. Occurring typically in middle and old age.
What is the nursing care of patients newly diagnosed with vision loss
What patient teaching should you provide to patients with glaucoma regarding ALL medications?
• (Latanoprost)- Increases drainage of intraocular fluid decreasing IOP
• (Timolol)- Decreases production of intraocular fluid decreasing IOP
• (Alphagan)- Works to both decrease production of fluid and increase drainage.
Hearing: How can the nurse best communicate with a patient with a hearing impairment?
Use normal voice -Speak slowly and directly(FTF) at PT. Do not shout!
Reduce background noise and distractions
Speak into the less-impaired ear
Ensure hearing aids are working properly
what is the procedure for performing an ear irrigation? when is it contraindication
Neurosensory
Confusion: What are the causes of acute confusion in the elderly?
Confusion- UTI, dehydration, medications, illness, stress, infection
Differentiate between dementia, delirium, and depression.
Delirium – acute reversible--- find the underline cause (HEAD TO TOE ASSESSMENT)
-r/t illness such as UTI or pneumonia (infection), dehydration or medications (anesthesia)
Dementia -Chronic, irreversible deterioration of brain
-Caused by stroke (vascular), AIDS, Parkinson’s (disease related), Alzheimer’s, tumors, past drug/
alcohol abuse (organic brain syndrome)
Depression - psychosocial changes from loss, experienced by older adults may cause physical changes
can result in losses of independence (SUICIDE ASSESSMENT RISK FORM)
What is important in the nursing care of dementia patients to control their S&S?
Care of the Patient
-Use clear simple directions/routine
-Use touch to calm the patient, keep environment calm and safe
-Walk agitated patients; Do not restrain patients or reorient them
What are the S&S of depression and what is the nurses responsibility if you recognize these S&S in a patient?
- hopelessness, helplessness, sadness, fatigue, diminished memory or concentration, sleep/appetite disturbances,
suicide
Monitor for suicide risk, provide cheerful environment but not large groups
Encourage brief /simple activities – reading, board games, limit choices.
What teaching would you provide regarding SSRI’s?
- SSRI Selective serotonin reuptake inhibitors: sertraline (Zoloft)
–do not drink Grapefruit juice!! -do not stop taking it -affects sexual performance elderly and adolescents
Restraints: What orders are required when applying restraints?
- Type of restraint, what will be restrained, reason, length of time applied, and MD ordering.(within 2
hours of putting on) chemical restraints meds
What nursing care is required when restraints are applied?
-Visually check pt Q30’-Q1h to prevent loss of circulation and strangulation (SAFETY CHECK)
-Release & Reposition Q2h; assess pulses, temp/ color/ sensation (NEUROVASCULAR CHECK)
-Ensure the patient is offered fluids frequently to prevent dehydration; DOCUMENT ALL CARE
-bathroom breaks -educate family why and parameters to remove restraints
Seizure: What are the signs and symptoms of generalized seizures?
• Generalized: involves the whole brain: S&S convulsions, loss of consciousness
What is the priority nursing care of patients having a seizure?
• Promote safety measures
• Pad the side rails, place oxygen & suction equipment at the bedside
• Instruct to avoid excessive alcohol, fatigue, and loss of sleep
• During a seizure
• Observe, treat, and document seizure
• Do not restrain patient or place any objects in their mouth
• Maintain patent airway; Turn patient to the side
• Support & Protect patient’s head; Raise side rails
• Loosen constrictive clothing
• Ease patient to floor; Provide privacy
, • After a seizure
• Reposition (to open and maintain the airway)
• Suctioning and oxygen prn
• Assess pt level of understanding, provide information about how and why the event occurred, and
provide a calm environment
• Implement patient and caregiver teaching, and psychosocial intervention.
Vision: What is the nursing care of patients newly diagnosed with glaucoma? (pressure in the eye foggy)
Limit strenuous activity NO SEX, BENING OVER, LIFT HEAVY OBJECTS
Assess perla squinting and tracking
glasses, magnifying
Safety -administer eye drops – lit environment reduce glare -proper eye care(clean
glass)
when presbyopia is and when does it usually first occur?
Farsightedness. Occurring typically in middle and old age.
What is the nursing care of patients newly diagnosed with vision loss
What patient teaching should you provide to patients with glaucoma regarding ALL medications?
• (Latanoprost)- Increases drainage of intraocular fluid decreasing IOP
• (Timolol)- Decreases production of intraocular fluid decreasing IOP
• (Alphagan)- Works to both decrease production of fluid and increase drainage.
Hearing: How can the nurse best communicate with a patient with a hearing impairment?
Use normal voice -Speak slowly and directly(FTF) at PT. Do not shout!
Reduce background noise and distractions
Speak into the less-impaired ear
Ensure hearing aids are working properly
what is the procedure for performing an ear irrigation? when is it contraindication
