vulnerability of the old-old; mid eighties and nineties
More chronic disabilities and function less independently
frail elderly
skeletal muscle mass decrease
sarcopenia
why does sarcopenia occur
due to Decreases physical activity and decreased protein intake
muscle mass decrease with excessive body fat
sarcopenia obesity
why are older people are usually cold, gain weight, and decreased glucose
decreased in metabolism
most common in older adults
pressure ulcers, incontinence, falls, functional decline, and delirium
what are signs of infection
incontinence and confusion
Activities necessary for well- being as an individual in society
katz ADLs
how is katz scoring ranked
6 points= independent
0 points= complete dependence
Scoring ranges 8-28, 8 being the best/independent and 28 being the worst
lawton scale for IADLs
common symptom of acute illness
sudden deterioration of cognition.
how to assess mental status
use SLUMS and CAM
t or f depression is more common in older adults
false
referred to as depression
pseudodementia
circulatory disorder affecting the peripheral blood vessels of the leg; symptoms are bilateral and progressive
Intermittent claudication
most common cause of infection-related deaths in older adults
pneumonia
weak or hoarse voice, pocketing of food, coughing after food or fluids to drooling
dysphagia
Disturbances in mental abilities resulting in confused thinking and is usually rapid progression
delirium
s/s of delirium
Hallucinations, restlessness, depression, mood swings
Interferes with daily life ; decline in mentality over a period of time
dementia
geriatric depression scale
Scoring 0-10 is within normal range ; 11 or higher indicates possible depression
short blessed test is used for what
rules out dementia disorder
how to score the short blessed test
0-4 normal cognition; 5-9 questionable impairment; 10 or more is impairment consistent with dementia
Involuntary loss of urine associated with an abrupt and strong desire to void. Impairs the ability of the bladder or urinary sphincter to contract and relax
urge incontinence
Involuntary loss of urine during coughing, sneezing, laughing, or other physical activities that increase abdominal pressure
stress incontinence
Involuntary loss of urine associated with overdistension of the bladder. BPH
overflow incontinence
Inability to get to the bathroom in time or to understand the cues to void due to problems with mobility or cognition
functional incontinence
round or irregularly shaped tan, scaly lesions that may bleed or be inflamed.
Actinic keratoses
sun exposed areas (basal cell carcinoma)
waxy or raised
squamous cell carcinoma, melanoma
Irregularly shaped lesions or scaly, elevated lesions
draining clear fluid or pustules atop an erythematous base following a clear, linear pattern and accompanied by pain
herpes zoster vesicles (shingles)
red-purple, nonblanchable petechiae (platelet deficiency)
pinpoint size
anticoagulant therapy, a fall, renal or liver failure, or elder abuse
larger bruises
extremely thin, fragile skin
friable skin
Sudden heat or cold intolerance could be signs of
thyroid dysfunction
foul smelling breath
periodontal disease
turning in of the lower eyelids
entropion
yellowish / brownish discoloration of the lens
cataracts
how to test for glaucoma
tonometry
difficulty seeing with one eye which turns into both
macular degeneration
speaking to someone slower and in lower frequency is better
prebycusis
aka the silent killer
pneumonia
male breast enlargement ; results from a decrease in testosterone
GYNECOMASTIA
get up and go test
People who take more than 30 seconds are dependent for their ADLs o 1=normal o 2=very slightly abnormal o 3= mildly abnormal o 4= moderately abnormal o 5=severely abnormal
when retinal detachment occurs
blindness will occur if not fixed in time
how long should you be outside to get vitamin d
at least 30 mins
pain unrelated to activity
venous insufficiency
correct technique to assess urinary incontinence
obtain a voiding diary
normal finding on the skin of an elderly client
senile purpura
The nurse utilizes the SLUMS mental status examination on a client who has recently shown some memory deficits. The total score is 12. What would this signify?
D. Dementia
In the _____________ belief system, the entire universe is seen to have supernatural forces at work.
Magicoreligious
In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?
Note-taking may make the client think the interview is unimportant
In which situation would it be best for the nurse to use open-ended questioning?
When taking the initial health history of a home care client
A client tells a nurse they want to try turmeric to lower their blood pressure. The nurse should take which action?
Encourage the client to discuss the use of turmeric with the provider
A patient tells the nurse that she has had a fever every day for the past two weeks. What would be the nurse’s best response?
“This pattern of elevated temperature may indicate a chronic infection.”
When documenting data, it is important to use sentences instead of phrases to record data?
False
A 80-year old man is at the outpatient clinic for an initial patient interview. The nurse is aware that the interview may take longer than an interview with a younger person. What is the reason for this?
he has a longer story to tell
The client scores a 4 on their PHQ-2. What would the nurse do next?
use the phq 9
The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows the physiologic changes can directly affect the nutritional status of the older adult and include:
Slow Gastrointestinal motility
During a nutritional assessment, why is it important for the nurse to ask the patient what medications he or she is taking?
Certain drugs can affect the metabolism of nutrients
A client with hypertension asks a nurse why a diet low in fat is recommended. The nurse explains to the client:
Diets high in fat increase the risk of cardiovascular disease
Waist to hip ratio is used as a marker of risk assessment for:
obesity related disease
During an assessment, the nurse uses the CAGE test. The patient’s answer is “yes” space to two of the questions. What could this be indicating?
The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment
A nurse works in a facility that uses charting by exception. What would the nurse expect to document?
Skin turgor greater than 7 seconds
It is important to document what the client tells you, what you observe, and what you interpret or infer from the presented data?
FALSE
A nurse knows when collecting and analyzing data that the first and most critical step of the nursing process is?
assessment
Pain from an abdominal surgery would be classified as:
visceral
A client has a body mass index (BMI) of 37, but has no other risk factors. The nurse should:
refer client to a dietician
Which of the following is true about axillary temperature?
The axillary route is 1 degree lower than oral temperature
The Confusion Assessment Method (CAM) test mood, feelings, expressions, and perceptions.
false
When performing a physical assessment, the first technique the nurse will always use is:
inspection
There are many sites in which arterial pressure can be taken, but there is one pulse in particular that gives a good overall picture of a client’s health status. This pulse is known as the?
radial pulse
In response to a question regarding the use of alcohol a patient asked the nurse why the nurse needs to know. What is the reason for needing this information?
Alcohol can interact with medications and can make some diseases worse
The nurse is assessing a client’s pain. The nurse knows that the most reliable indicator of pain would be the:
subjective
A client is brought in to the emergency department after being involved in a serious motor vehicle accident. The client is not alert and his injuries are severe. How would the nurse proceed with data collection?
Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit
Each step in the nursing process depends on the accuracy of the proceeding step.
true
Which situation is most appropriate during which the nurse performs a focused or problem-centered history?
Patient in an outpatient clinic has cold-like symptoms
A client is brought in to the emergency department after being found unresponsive. The client’s Glascow Coma Scale is 6, this score would be considered?
Considered to be in a coma
In addition to validation, what is another crucial part of the first step in the nursing process?
documentation
In addition to validation, what is another crucial part of the first step in the nursing process?
documentation
A patient has been in the intensive care unit for 15 days. The patient has just been moved to the medical surgical unit and the admitting nurse is planning to perform a mental status examination. During the test of cognitive function, the nurse would expect that the client:
Will be oriented to place and person, but the patient may not be certain of the date
Which situation is most appropriate during which the nurse performs a frequent or ongoing assessment?
patient has hypertension
A client being seen in the emergency room in acute pain, has not been feeling well lately. The client has had increased heart rate, increased blood pressure, and an increased respiratory rate. Which complaint should the nurse address first?
respiratory rate
The client asks the nurse what blood pressure means. Which statement correctly reflects the nurses understanding of blood pressure?
“Blood pressure is the measurement of the pressure of blood in the arteries when the ventricles are contracted and when the ventricles are relaxed.”
A client mentions that they are not as tall as they once were. Which would be the nurse’s appropriate response to the client’s statement?
“You are right, as you age the intervertebral discs become thinner.”
The nurse is using the Visual Analog Scale to assess a client’s pain. What data will the nurse prioritize?
The client’s rating on a 0 to 10 visual analog scale
The nurse teaches a client newly diagnosed with tachycardia about measuring their radial pulse. Which statement indicates to the nurse that the client understood the discharge teaching?
Palpate with pads of first and second fingers on lateral aspect of wrist
A nurse measures a client’s radial pulse and finds the pulse to be irregular. The nurse knows the best next step would be to?
count for a full minute
When assessing the quality of a client’s pain, the nurse should ask which question?`
what do your pain feel like
collecting subjective and objective data
assessment
ongoing and continuous throughout all phases of the nursing process
assessment
analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, referral)
diagnosis
determine outcome criteria and developing a plan
planning
carrying out the plan
implementation
assessing whether outcome criteria have been met and revising the plan as necessary
evaluation
collection of subjective data about the clients perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practice, as well as objective data gathered during a step be step physical examination
initial comprehensive assessment
client first enters a health care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared
initial
any problems that were initially detected in the clients body system or holistic health patterns are erased to determine any changes
ongoing or partial assessment
comprehensive database exists for a client who comes to the health care agency
center assessment
what does COLDSPA stand for
character; onset; location; duration; severity; pattern; associated factors
skin cancer that is the worst
melanoma
common problems in older adults warranting further investigation is SPICES
Skin impairment Poor nutrition Incontinence Cognitive impairment Evidence of falls or functional decline Sleep disturbances
examples of ADLs katz
bathing, dressing, toileting, transferring, continence, feeding
examples of IADLs lawton
ability to telephone shopping food prep housekeeping laundry transportation medication ability to handle finances
night sweats chronic fatigue weight loss dementia swollen lymph nodes
aids
symptoms of depression in older adults manifest as changes in
cognitive and physical symptoms
early signs of alz
irritability
aggression
suspiciousness
withdrawal
when an older adult complains of weakness and fatigue what must be ruled out
anemia
what are common causes of anemia
gi bleeding, low B12, folate, iron
cough fatigue weight loss SOB productive cough (sometimes bloody)
lung cancer
weight loss
night sweats
changes in respiratory status
TB
digoxin theophylline quinidine antibiotics accompanied with nausea and vomiting
drug toxicity
corticosteroid use can
thin the skin
shortening of neck from vertebral degeneration
buffalo hump
any drug with anticholinergic side effect may
promote dental caries and pneumonia
floaters are a symptom of
diabetic retinopathy
respiratory rates above 20-25
infections or CHF
resp rate when living independently
12-18
resp rate when living in long term care
16-25
old lady nips
are pendulus and retraction of the nips are normal but if only one retracts it could be cancer
tender and soft prostate
prostatitis
hard asymmetrical enlarged nodular prostate
cancer
tenderness
stiffness and pain in the shoulders and elbows and hips
aggravated by movement
polymyalgia rheumatica
poor judgment and decision making inability to manage a budget losing track of the date or season difficulty having conversation misplacing things and being unable to retrace steps to find them
alz disease
whats the AUDIT test used for
alc use. total score of 8 or more is an indicator of harmful alc use
what is SAD PERSONS used for
people are risk for suicide
glasgow coma scale
3-15 scoring. 3 is the worst; 15 is the best
10 or lower needs emergency attention ; 7 or lower is considered to be in a coma
what is SLUMS used for
mental status; made in st louis
tests LOC, memory, speech, and cognitive functions but not mood, feelings, expressions, thought processes or perceptions
SLUMS and CAM
PHQ-2 and PHQ-9
used to detect depression. score 3 or higher on phq-2 then you use phq-9. score of 10 or higher indicates major depression
use of SBAR
situation- what you need to communicated the clients data- why patient is here
background- events that led up to the current situation
assessment- subjective and objective data
recommendation- suggest what you believe needs to be done for the client
96.6-99.9
oral
95.6-98.5
axillary
97.4-100.3
rectal
98-100.9
tympanic
vital signs including the 5th one
temp respirations blood pressure heart rate pain
cultural expressions
p.148
circumstance when a person gives up the traits of his or her culture of origin as a result of context with another culture to variable degrees
acculturation
gradual adoption and incorporation of characteristics of the prevailing culture
assimilation
natural conscious and unconscious conditioning process of learning accepted culture norms, values, and roles in society and achieving competence in ones culture through socialization
enculturation
humans to think their ways of thinking, acting, and believing are the only right, proper, and natural ways
ethnocentrism
group of people with a culture that differentiates them from the larger culture of which they are a part of
subculture
bmi
bmi less than 18.5 is underweight. bmi between 25-29.9 is considered overweight. bmi at 30 is considered obese
type of body is better
pear shaped
The skin plays a vital role in?
Vitamin D synthesis and Excretion
The nurse is assessing the breasts of a Caucasian woman who has just been diagnosed with Paget disease. What would the nurse expect to find?
Red and scaling on the areola
If heard, this extra heart sound is heard early in diastole?
s3
The nurse uses which of the following techniques to assess dehydration?
elevation of skin turgor
The nurse is performing a respiratory assessment of a client who has congestive heart failure. What type of respiratory pattern should the nurse anticipate?
Cheyne-Stokes
A COPD client asks the nurse what is the difference between asthma and COPD. The nurse replies correctly.
“COPD is treatable and not fully reversible”
A client has large, pendulous breasts. What would be most appropriate to ensure better access while examining the client’s breasts for retraction and dimpling?
have the client sit then lead forward
A nurse is palpating the skin on the neck of a newly referred client. What would the nurse suspect if assessment reveals that the client has velvety darkening of the skin in the folds and creases?
Acanthosis nigricans
During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
When part of the lung is obstructed or collapsed
ask the client to repeat the phrase ninety nine while you auscultate the chest wall
bronchophony
ask the client to repeat the letter E while you listen over the chest wall
egophony
ask the client to whisper the phrase 1-2-3 while you auscultate
whispered pectoriloquy
what is abnormal in bronchophony
words easily understood and louder over increased density
what is abnormal in egophony
sounds like A
what is abnormal in whispered pectoriloquy
sound is transmitted clearly and distinctly ; sounds as if the client is whispering directly into the stethoscope.
The nurse should use the bell of the regular stethoscope to listen for:
Soft, low pitched sounds such as some heart murmurs
Most common skin cancer in Caucasians
basal cell
Most common skin cancer in African Americans
squamous
Most common on areas with very heavy sun exposure
squamous
Indoor tanning raises the risk of
melanoma
signs of skin cancer
ABCDE asymmetry irregular border color diameter evolving
present when fluid or solid tissue replaces air in the lung or occupies the pleural space
dullness
elicited in cases of trapped air such as emphysema or pneumothorax
hyperresonnace
percussion tone elicited over normal lung tissue
resonnance
What finding would a nurse expect to find in a client who has right-sided heart failure?
increased jugular venous pressure
While inspecting the skin of an older adult client, the nurse notes a localized collection of blood. The nurse should recognize the presence of which of the following?
cherry angioma
what does the allen test test
Document the lack of patency in the ulnar and/or radial arteries
slight pitting
1+
deeper than 1+
2+
noticeable deep pit; extremity looks larger
3+
very deep pit; gross edema in extremity
4+
usually unilateral
venous insuffiency
dry and shiny skin
arterial
toes and heels
arterial
very painful
arterial
pain is aching and cramping
venous
medial malleolus or anterior tibial area
venous
superficial ucler
venous