NUR 242 Exam 1
ADPIE - Nursing Process - ANS Assessment, Diagnosis, Plan, Intervention, Evaluation
World Health Organization definition of health - ANS Health is a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity.
Framework of Healthy People 2030 - ANS Principles
Overarching Goals
Plan of Action
History & Context
Level of Prevention - ANS Primary- Prevention
Secondary- Screening
Tertiary-Rehab
Risk Factors - ANS Modifiable
Non-modifiable
Prevent Constipation in Older Adults - ANS Increase Fiber (35 to 50g) & Fluid Intake (2L),
Exercise Regularly
Common Adverse Drug Events in older Adults - ANS Edema, N/V, Anorexia, constipation,
dehydration, dizziness, syncope, acute confusion, dysrhythmias, urinary retention, and
hypotension
Major predictor of morbidity & morality - ANS Delirium
Confusion Assessment Method (CAM) - ANS Acute onset and fluctuating course
Inattention
Disorganized thinking
Altered level of consciousness
Monitor Older Adults receiving Antipsychotics ADEs - ANS Anticholingeric Effects
ORTHOSTATIC Hypotension
Parkinsonism
Restlessness
Hyperglycemia & DM
When do you assess skin on pt that is reddened? - ANS Every 8 hours
Immobility - ANS Long periods of immobility
,Musculoskeletal Immobility - ANS Wasting, Osteoporosis
Integumentary Immobility - ANS Pressure Injuries
GI Immonility - ANS Constipation
Cardiovascular Immobility - ANS orthostatic hypotension, thrombus formation (DVT)
Neurological Immobility - ANS depression, forgetfulness, anxiety, confusion
-pressure on skin will cause nerve pain/damage
Renal/Urinary Immobility - ANS Stones
Incontinence
Respiratory Immobility - ANS atelectasis -> pneumonia
Metabolic Fluid & Electrolyte Imbalance-Immobility - ANS Dehydration or Fluid Overload
Orthostatic Hypotension - ANS A drop of more than 10 mmHg in systolic or 10 mmHg in
diastolic pressure between positions
Walker Procedure - ANS Lift Walker
Move walker about 2 feet forward
Small Steps
Check Balance Repeat
Proper body Mechanics - ANS Maintain a wide, stable base with your feet
Place the bed at the correct height----waist level while providing direct care and hip level when
moving patients
Keep the patient or work directly in front of you to prevent your spine from rotating
Keep the patient as close to your body as possible to prevent reaching
Use appropriate safe patient -handling equipment
Cane Procedure - ANS Cane in strong hand- use unaffected side
Well Balanced
Cane, Weak Leg, then strong leg
Physiological Effects Immobility - ANS Changes in Sleep/Wake Cycle
Impaired Coping
Changes in Body Image
Anxiety
Depression
Behavioral Changes
, Assessment of skin - ANS Once per shift, upon admission, or nursing instinct
Access individuals with any devices assess skin every 2 hours for skin breakdown
Inspect skin - ANS -Beneath and around compression stockings
•Bony prominences
•Skin to skin areas
•Any areas where the client lacks sensation
•Special attention if the client is getting pain epidural /spinal pain medications
- epidural or spinal caths (monitor and ensure infection free, access toe sensation)
• assess perinuem
Functions of Skin - ANS Protection, Homeostatis (Water Balance), Temperature Regulation,
Sensory, Vitamin Synthesis, Psychosocial
Skin Cultural Assessment - ANS Detective subtle color changes
Assess: Mucous Membranes, Nail Beds & Skin tones
Skin Assessment Process - ANS Skin temperature, tugor (back of hand, head, clavicle), color
(blanchable to nonblanchable), texture, moisture (incontinence, wounds, ostomy, ilesotosmy),
integrity, capillary relief (hypoperfusion), edema
Skin Alterations - ANS White- decreased Hgb & blood flow
Yellow-orange- Jaundice, Cartoenemia, Urochrome level
Red- Vasodilation
Blue- Cyanosis
Reddish Blue- decreased peripheral circulation
Brown- Melanin Production
Assessing skin changes on darker skin tones - ANS Cyanosis- lips or tongue are gray, nail beds
are blue, conjunctiva is white
Inflammation- increased warmth, shiny or pitting, assessment of both extremities
Jaundice- yellow oral mucous membrane or sclera
Bleeding- swelling, petechiae
Dryness - ANS -scaling
-flaking
-lanolin, antipruritic agents, topical/ oral antihistamines
Pruritus - ANS - Itching
-scabies, lice
-iodine medications
-antipruritic agents
- topical corticosteroids
ADPIE - Nursing Process - ANS Assessment, Diagnosis, Plan, Intervention, Evaluation
World Health Organization definition of health - ANS Health is a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity.
Framework of Healthy People 2030 - ANS Principles
Overarching Goals
Plan of Action
History & Context
Level of Prevention - ANS Primary- Prevention
Secondary- Screening
Tertiary-Rehab
Risk Factors - ANS Modifiable
Non-modifiable
Prevent Constipation in Older Adults - ANS Increase Fiber (35 to 50g) & Fluid Intake (2L),
Exercise Regularly
Common Adverse Drug Events in older Adults - ANS Edema, N/V, Anorexia, constipation,
dehydration, dizziness, syncope, acute confusion, dysrhythmias, urinary retention, and
hypotension
Major predictor of morbidity & morality - ANS Delirium
Confusion Assessment Method (CAM) - ANS Acute onset and fluctuating course
Inattention
Disorganized thinking
Altered level of consciousness
Monitor Older Adults receiving Antipsychotics ADEs - ANS Anticholingeric Effects
ORTHOSTATIC Hypotension
Parkinsonism
Restlessness
Hyperglycemia & DM
When do you assess skin on pt that is reddened? - ANS Every 8 hours
Immobility - ANS Long periods of immobility
,Musculoskeletal Immobility - ANS Wasting, Osteoporosis
Integumentary Immobility - ANS Pressure Injuries
GI Immonility - ANS Constipation
Cardiovascular Immobility - ANS orthostatic hypotension, thrombus formation (DVT)
Neurological Immobility - ANS depression, forgetfulness, anxiety, confusion
-pressure on skin will cause nerve pain/damage
Renal/Urinary Immobility - ANS Stones
Incontinence
Respiratory Immobility - ANS atelectasis -> pneumonia
Metabolic Fluid & Electrolyte Imbalance-Immobility - ANS Dehydration or Fluid Overload
Orthostatic Hypotension - ANS A drop of more than 10 mmHg in systolic or 10 mmHg in
diastolic pressure between positions
Walker Procedure - ANS Lift Walker
Move walker about 2 feet forward
Small Steps
Check Balance Repeat
Proper body Mechanics - ANS Maintain a wide, stable base with your feet
Place the bed at the correct height----waist level while providing direct care and hip level when
moving patients
Keep the patient or work directly in front of you to prevent your spine from rotating
Keep the patient as close to your body as possible to prevent reaching
Use appropriate safe patient -handling equipment
Cane Procedure - ANS Cane in strong hand- use unaffected side
Well Balanced
Cane, Weak Leg, then strong leg
Physiological Effects Immobility - ANS Changes in Sleep/Wake Cycle
Impaired Coping
Changes in Body Image
Anxiety
Depression
Behavioral Changes
, Assessment of skin - ANS Once per shift, upon admission, or nursing instinct
Access individuals with any devices assess skin every 2 hours for skin breakdown
Inspect skin - ANS -Beneath and around compression stockings
•Bony prominences
•Skin to skin areas
•Any areas where the client lacks sensation
•Special attention if the client is getting pain epidural /spinal pain medications
- epidural or spinal caths (monitor and ensure infection free, access toe sensation)
• assess perinuem
Functions of Skin - ANS Protection, Homeostatis (Water Balance), Temperature Regulation,
Sensory, Vitamin Synthesis, Psychosocial
Skin Cultural Assessment - ANS Detective subtle color changes
Assess: Mucous Membranes, Nail Beds & Skin tones
Skin Assessment Process - ANS Skin temperature, tugor (back of hand, head, clavicle), color
(blanchable to nonblanchable), texture, moisture (incontinence, wounds, ostomy, ilesotosmy),
integrity, capillary relief (hypoperfusion), edema
Skin Alterations - ANS White- decreased Hgb & blood flow
Yellow-orange- Jaundice, Cartoenemia, Urochrome level
Red- Vasodilation
Blue- Cyanosis
Reddish Blue- decreased peripheral circulation
Brown- Melanin Production
Assessing skin changes on darker skin tones - ANS Cyanosis- lips or tongue are gray, nail beds
are blue, conjunctiva is white
Inflammation- increased warmth, shiny or pitting, assessment of both extremities
Jaundice- yellow oral mucous membrane or sclera
Bleeding- swelling, petechiae
Dryness - ANS -scaling
-flaking
-lanolin, antipruritic agents, topical/ oral antihistamines
Pruritus - ANS - Itching
-scabies, lice
-iodine medications
-antipruritic agents
- topical corticosteroids
