ADULT CARE EXAM 3 (part 3)

legal/ethics + documentation + patient education + sensory system alterations

Terminology

• ____: taking positive actions to help others

• ____: avoidance of harm/hurt

• ____: agreement to keep promises 

• beneficence

• malifecence

• fidelity

Potential dilemmas 

• Autonomy issues

  • no informed consent was obtained

  • patient has the right to refuse!

• Beneficience

  • Ex: huge tornado effects entire community and we need to allocate resources. Injured patient with agonal breathing most likely isnt gonna be priority bc theyre about to die. See how its a dilemma?

• Pain management VS addiction risk

• Non-maleficence

  • Unintentional harm from therapy (CPR, chemo, medication adverse SE….)

• Justice

  • Resource allocation in crisis (ex: the tornado situation)

  • Treatment for un-insured patients 

• Fidelity

  • Confidentiality VS safety = is it gonna protect or violate HIPAA?

  • Broken promises 

Research

• uses scientific method to answer questions

• evidence from research used to generate answers for questions

• data source: participants

• conducted by: researchers

Evidence based practice

• uses information (from research or experience) to determine safe and effective care; goal is to improve patient care/outcomes/efficiency/costs

• focused on implementing evidence that has already been practiced from somewhere

• data source: multiple research studies, expert opinions, personal experiences of nurses and patients

• conducted by: healthcare team

Quality improvement

• improves local work process to improve patient outcomes and overall health systems

• focused looking at measures that affect our practice

• data source: EMR and patient record

• conducted by: healthcare team

7 steps of evidence based practice

1. Curiosity

2. Ask clinical question in PICOT format

3. Gather relevant/best evidence

4. Review the evidence

5. Integrate all evidence with clinical expertise and ur patient’s values/preferences

6. Evaluate outcomes

7. Share the outcomes with others

PICOT format

• Population associated with the certain disorder/problem

• Intervention or variable of interest

• Control group used for comparison

• Outcome

• Time

HEY!

next slide gonna be from patient education ppt

Types of prevention

1. Primary: promote health + reduce chance of getting disease

2. Secondary: screening for risk detection or early diagnosis

3. Tertiary: rehabilitation

OIder adult considerations

• private and quiet room

• proper lighting

• face patient while speaking

• visual aids (AVOID using colors green + blue)

• repetition

• only significant info

• offer breaks during the education session!

Teaching methods by domain

• Cognitive: discussion, lecture, Q/A

• Affective: roleplay and group discussion

• Psychomotor: physical demonstration

HEY!

next slide is gonna be from sensory alterations ppt

3 components of sensory experience

• reception: nerve impulse travels to either the brain or spinal cord

• perception: integration and interpretation of stimuli based on person’s past experience

• reaction: brain either discards or stores the sensory info

Senses

• ok yeah the basic ones we know

• gustatory (taste) **think: gus gus eating cheese in cinderella*

• kinesthetic (body movement/position in space)

• stereognosis (tactile object recognition)

Examples of sensory alterations

• visual (prebyopsia, glaucoma, cataracts, macular degen)

• hearing (prebycusis, cerumen, vertigo, tinnitus)

• touch (decreased sensitivity to temp/pressure)

• smell (decreased appetite, decreased alert to burning things, decreased alert to spoiled food)

• taste (xerostomia aka dry mouth, decreased appetite, improper nutrition)

• kinesthetic (gait imbalance, neuropathy, stroke)

Sensory function alterations that come with aging

Visual

• reading glasses

• astigmatism

• reduced peripheral vision

• poor night vision

• poor depth perception

Hearing

• decreased acuity

• speech intelligible

• pitch discrimination

Gustatory and Olfactory

• reduced taste discrimination

• sensitive to smells

Proprioceptive

• difficulty with balance, coordination, spatial awareness

Sensory function

• presence of meaningful stimuli influences a person’s alertness and ability to participate in care (ex: if patient cant stand the smell of alcohol wipes, its gonna be hard to do proper care)

• excess stimuli can cause sensory overload/overstimulation

• environmental and cultural factors

Environmental assessment

• person has reduced vision and cannot see hazards

  • appropriate lighting

  • clutter free room

  • clear path to the bathroom

• person has proprioceptive problems and loses balance easily

  • everything within reach

  • bathroom grab bars

• reduced sensation cant percieve hot/cold

  • label the sink faucets for hot VS cold

Communication deficits

Aphasia: varied degrees of inability to speak, interpret, or understand language

____: inability to name common objects or express simple ideas via writing or verbally

____: inability to understand written or verbal language BUT person can speak normally themselves

Artifical airways

• makes it hard to speak

• expressive aphasia

• receptive aphasia (aka sensory aphasia)

Communication methods

If Aphasia

• listen to them (even if unintelligable)

• patience

• dont speak loud/yell

• use simple short statements or questions

• offer communication boards

If artificial airway

• use pictures, word cards, objects

• offer a pad and pencil

• patience

If hearing impaired

• make sure you have the patient’s attention

• face ur patient

• DONT have anything in ur mouth while talking (ex: gum)

• DONT continue to talk if you turn away for a second (bc how r they gonna read ur lips)

• ensure quiet environment so they can clearly hear you

• clean eyeglasses + hearing aids are ON

• dont speak loudly/yell

• talk closer to the normal ear

• provide written material

If smell impaired

• smoke detectors in place

• check food/packages for expiration

Ambulating with guided sight

• offer assistance to visually impaired patients

• walk at relaxed pace one step AHEAD of patient

• describe the surroundings as you walk (ex: we are approaching some steps upward)

• remove obstacles

• never leave them standing alone in strange environment

Structures and functions of vision

• glaucoma = due to aqueous fluid issue

• cataracts = due to lens issue

• eye bleeding issues = due to vitreous humor issue

Refractive efforts

• ___: near-sightedness

• ___: far-sightedness

• ___: distorted vision caused by irregularity of cornea

• ___: loss of accommodation bc lens becomes rigid, losing its youthful flexibility and ability to change shape to bend light properly for near vision

• myopia

• hyperopia

• astigmatism

• prebyopsia

Effects of aging on vision

• decreased visual acuity

• dry irritated eyes

• yellowing of sclera

• cataracts (causes person to see halos of light)

• vision floaters

Exam of external eye structures

• irritation, inflammation, discharge

• pupils and pupillary response (best to be in a dark room while doing this)

• corneal light reflex

• 6 cardinal positions

• ___: droopy eyelid

• ___: oscillating movement of eyeball (“shaky eyes”)

• ptosis

• nystagmus

Conjunctivitis

• inflamed or infected conjunctiva

Types

___: aka pink eye; easily spread + easily avoided with handwashing

___: major cause of blindness worldwide

• treatment: antibiotics

___: due to allergens

• treatment: artificial tears (eyedrops), topical antihistamines, topical corticosteroids

• acute bacterial conjunctivitis

• chlamydia infections

• allergic conjunctivitis

Corneal disorders

• Corneal ulcer: eye tissue loss due to ____

• Corneal transplant: indicated for some corneal scarring that manifests as ____

• infection

• keratoconus

Caring for low vision and blind patients

• Support (coping strategies, grief process, acceptance)

• Adaption to environment

• Unchanged placement of items in room

• “Clock method” for food trays/plates

• Alternative communication strategies (ex: braille)

• Visual therapists

• Service animals

Age related macular degeneration (AMD)
Types

• dry/non-exudative (more common)

• wet/exudative (severe form of AMD)

Manifestations

• blurry vision or dark vision

• blind spots

• distortion

Treatment

• medication to slow down the progressive vision loss

  • SE: blurred vision, pain, irritation, photosensitivity

Glaucoma

• damaged optic nerve due to increased IOP

• risk increased with age

Types

• primary open angle

  • SX: gradual loss of peripheral vision (aka “tunnel vision”)

• primary closed angle:

  • SX: sudden acute horrible pain, halos around lights, blurry vision
    

Cataracts

Manifestations

• decreased vision

• abnormal color perception (basically color blindness)

• visual glare

Treatment

• surgical or non-surgical options available

Nursing process for eye operations

Pre-op

• dilating and non-steroidal anti-inflamm eyedrops

Intra-op

• small incision

• dissolve the lens and suction it out

• new lens is implanted behind iris

Post-op

• medications (antibiotics, steroid drops)

• no bending, lifting, stooping

• eye patch at night

Retinal disorders

____: microvascular damage usually seen in diabetes or hypertension

____: retina breaks or tears a hole

• painless

• person sees floaters, “cobwebs”, flashes/sparks/flickering lights

Care for retinal disorders

• bedrest and proper positioning

• medication

• education: incresed risk of detatchment in other eye + use protective eyewear

• retinopathy

• retinal detachment

Opthalamic meds

Eyedrops

• hold 1-2 cm above the conjuncitval sac > close eye > wait 5 mins between each different eyedrop med

Ointment

• apply thin line of ointment evenly from inner corner > outer corner > close eye > rub gent;y in circular motion

Intraocular disk

• place disk in conjuncitval sac on the sclera

Loss of hearing acuity

• Loss conduction ← interrupted sound wave transmission from outer to inner ear

  • caused by swollen auditory canal or torn tympanic membrane

• Loss sensorineural ability ← interrupted transmission of sound wave from middle ear to inner ear

• Mixed: combination of conduction and sensorineural loss

• Loss of central and functional hearing: inability to interpret sound AND speech

  • caused by CNS issue

Normal findings of ear physical assessment

• ears symmetric in location/shape

• auricles and tragus nontender

• canal clear, tympanic membrane intact, 4 o’clock and 7 o’clock light reflection is there

• can hear whisper 30cm away

• Weber test results have no lateralization

• Rinne test results AC > BC

Acute otitis media

• common in kids

Manifestations

• red, bulging, painful tympanic membrane

• fever

• possible tympanic membrane perforation (preventable if treated early)

Treatment

• antibiotics

Chronic otitis media

• result of recurrent acute otitis media

• preventable if you treat the acute otitis media!!!!

External otitis

• aka swimmers ear

• inflamed or infected auricle

Manifestations

• ear pain (*especially* when tragus is pulled)

• discomfort when chewing

• drainage

Malignant external otitis

• when the swimmer’s ear progresses to affect auditory canal

• Treatment: antibiotics, anti-inflammatory meds, ear drops

Otitis media with effusion

• inflamed with fluid collected inside

• often preceded by upper resp infection

Manifestations

• clogged and “fullness” feeling inside ear

• decreased hearing

Treatment

• NONE; resolves on its own

Otosclerosis

• most common cause of conductive hearing loss in YOUNG adults

Manifestations

• if any = dizzy, nausea

Treatment

• Na flouride

• Vitamin D and Ca carbonate

• Hearing aid

• surgery

Menieres disease

• Sx result from imbalanced inner ear fluid

Manifestations

• vertigo

• tinnitus

• fluctuations between hearing loss and fullness feeling

• “drop attacks”

Treatment

• during attack:

  • benzodiazepenes, antihistamines, bed rest, antiemetic, antivertigo drugs

  • position patient in a quiet darkened room

• between attacks: meds + LOW SODIUM DIET

Patient teaching

• avoid sudden head movements or position changes

• avoid flickering or flourescent lights

Presbycusis

Manifestations

• Early: tinnitus, increased inability to hear in crowds

• Later on: speech deterioration, fatigue, social isolation