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What is Young Old, Middle Old, Old Old, Elite Old?
- Young Old is 65-74
- Middle Old is 75-84
- Old old is 85-99
- Elite Old is 100+
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SPICES measures:
- Sleep Disorders
- Problems with Eating/Feeding
- Incontinence
- Confusion
- Evidence of Falls
- Skin Breakdown
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Katz Measures?
- ADLS:
- Bathing
- Dressing
- Tolieting
- Transferring
- Continence
- Feeding
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Latrogenesis the adverse effect of medical care occurs due to:
Polypharmacy, invasive procedures, increased LOS (length of stay) Nosocomia infections
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Nursing Process
ADPIE. Assessment, Dx, Planning, Implemntation, Evaluation
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Assessment includes:
- Collection of data: both primary and secondary sources.
- Subjective and Objective data
- Analysis and Clustering of data
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Diagnosis includes
Clinical judgement about individual, family or community response to actual or potential problems that a nurse can treat.
Utilizes NANDA
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Planning includes:
- Establishes priorities from High, Intermediate to Low
- Individualizing patient care
- Evidence Based Practice
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Implementation includes
Indepedent: Nurse initiated
Depedendent: Physician Initatied
Interdependent: Collaborative
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Evaluation includes
- Discharge
- Modifying plan
- Contuing plan
Ongoing process
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Mobility is important because?
Mobility is equated with wellness and health among older adults.
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Safety Hazards for falls
- Old, rickety furniture and appliances
- Unsafe stairs (like w/o handrails)
- Throw Rugs, Frayed carpet
- Electric cords, objects on floor
- Poor lighting
- Poor height of either toilet, bed or chairs
- Clutter
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Strategies to prevent falls
- Encourage ambulation
- institute general safety precautions
- improve chair safety, comfort
- Improve ability to get out of bed easily
- Promote continence, comfort, reminders
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What should you assess if your patient is wandering and fall prone and you believe they are a harm to themselves?
Consider when, where and why this could be happening and eliminate the cause.
Use supervision/ companionship over restraints
Change lighting, add a bedside comode, keep bed rails down, reality orient.
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Causes of Delirium
- D: Drugs
- E: Elimination
- L: Liver/ Other organs
- I: Infection
- R: Respiratory
- I: Injury
- U: Unfamiliar environment
- M: Metabolic
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If you use restraints you must:
- Assess pt every 30 minutes for circulation and ROM.
- Every 4 hours, release.
- Do not keep on for longer than 24 hours.
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Immobilities effect on Metabolic and Intervention that can be used?
- E: Negative nitrogen balance
- Altered GI function
- Fluid and electrolyte imbalance
I: High protein diet with vitamin B and C
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Immobilities effect on cardiovascular and Intervention that can be used?
Thrombus formation, Orthostatic hypotension
- I: Bed to chair.
- SCDS & TEDS
- Leg exercises
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Immobilities effect on Musculoskeletal system and Intervention that can be used?
Loss of muscle mass. Decreases stability and balance.
I: Passive and Active ROM
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Immobilities effect on respiratory system and Intervention that can be used?
Atelectasis and Hypostatic pneumonia
- I: Cough & Deep breathe every 1 to 2 hours.
- Chest PT
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Immobilities effect on integumentary and Intervention that can be used?
Pressure uclers, ischemia
I: Reposition every 2 hours. Skin care.
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Immobilities effect on elimination and Intervention that can be used?
- Urinary stasis
- Renal Calculi
I: Adequate hydration. Diet rich in fiber, fluids.
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Risk factors for skin issues:
- Impaired sensory perception (diabetics)
- Imparied mobility
- Alteration in consciousness
- Shear and Friction
- Moisture
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Factors effecting pressure ulcer formation
- Nutrtion (Protein/Albumin)
- Tissue perfusion
- Infection
- Age
- Psychosoical impact
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Stage I is
Non blanchable, red
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Stage II
Blister, Partial skin loss. No slough
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Stage 3
Full thickness skin loss. May see fat, undermining, tunneling, slough. Will not see bone or muscle.
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Stage 4
Bone, Tendon, Muscle visible.
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Unstagable
Base of wound cannot be visualized due to slough.
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Deep Tissue Wound
Blood filled blister, purple, maroon, mushyness of skin.
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Debridement of wounds occurs in:
- Wet to Moist
- Whirlpool treatment
- Autolytic
- Surgical
- Chemical
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Braden # scale
- 15/16: At Risk
- 14/13: Moderate risk
- 12 or less: at high Risk
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Possible complications of wound healing
- Infection
- Dehiscense
- Evisceration
- Fistula
- Hematoma
- Hemorrhage and Interstital fluid loss
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Factors effecting Medication Absorption?
- The Route
- Dissolvability of medication
- Blood flow to site
- Lipid solubility of med
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Metabolism occurs where?
The liver. It is the only site where biotransformation occurs.
Medications are then excreted through the kidney, liver, bowels, lungs and exocrine glands.
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Idosyncratic reaction to a medication is?
and Over or under Reaction to a medication.
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Side Effect vs Adverse effect
Side effect is unintended second effect.
Adverse is a severe response to medication
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Med dose trough?
Minimum blood concentration before next scheduled dose.
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Med plateau?
Blood serum concentration is reached and maintained.
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How long do you have to administer a "now" medicaton?
up to 90 minutes. A STAT med is immeadiate.
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If given a medication scenario remember:
- Nurse role is for safe administration and pharmacology knowledge.
- Assess response and educate about med.
- Collaborate with others on healthcare team
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Med Errors occur beacause of
Wrong med, route, dose, patient time or poor documentation.
Also can occur due to wrong rate, or wrong preparation of medication
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Omission Medication error
Drugs not prescribed, administered or taken by pt.
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Reasons for med errors?
- Failed communciation both written and verbal
- Poor administration practice
- dose miscalculation
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Right drug
- Know both generic and brand name
- Do not administer without knowing its purpose
- double check order
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Right dose
- Double check therapuetic dose range
- Double check calculation
- Use only accepted abbreviations
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If there is an error
Fill out incident report
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Latent factors causing med errors in system
- Oraganization process: workload of healthcare workers. handwritten prescriptions
- Management decision: staffling levels and environment culture.
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# on Hendrich scale
5+ is high risk
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