Exam 3 Fundamentals

A functional status assessment includes both,

Cognitive and mobility

a ADL is

fundamental tasks to take care of self

a IADL is

tasks needed to live independently

a AADL is

tasks needed to participate in society

Can someone be great with IADLSs but struggle with ADLs

Yes

Cognition is,

the process of acquiring and understanding knowlage

Mobility is the

ability to move feely and independently

What is essential for completion of ADLs and well being

mobility

What happens in the cardio system due to immobility

increased workload, orthostatic hypotension, DVT

What happens in the respatory system due to immobility

atelectasis, hypostatic pneumonia, decreased cough reflex

What happens in the metabolic system due to immobility

dec metabolic rate, negative nitrogen balance, hypercalcemia

What happens in the musculoskeletal system due to immobility

atrophy, dec strength, osteoperosis

What happens in the integumentary system due to immobility

pressure injuries

What happens in the GI system due to immobility

constipation, dec appetite

What happens in the UI system due to immobility

urinary stasis, kidney stones, UTI

In a nursing perspective, functional status is part of

inital assessment and ongoing evaluation

3 general reasons RN evaluate functional status

discharge planning, risk identification, care prioritization

Discharge planning with functional status is important to

determine where a patient goes, we want them out quick

Why do we want patients out quick

avoid nosicomial infections

Risk identification with functional status is important to

predict fall risks, hospital readmissions and poor outcomes

Care prioritization with functional status is important to

focus nursing interventions on what matters most, promote independence

What is a important in a functional status assesment

look for and document decline

Nursing considerations with functional status for daily care

can they and encourage participation

Nursing considerations with functional status for support of ADLs

ensure they have what is needed to ambulate

Nursing considerations with functional status for assessment and monitoring

assess cog and executive function, monitor for decline in IADLs

In-patient interventions for physical and safe mobility

early ambulation, range of motion, turn every 1-2 hrs, assistive devices

In-patient interventions for supportive and collaboritive care for mobility

hydration, nutrition, pain management, education and psyc support

Social work supports…

navigating complex life changes

Case management supports…

serves as a bridge between providers, patients and resources

PT supports…

Promoting physical function and mobility

OT supports…

developing skills for daily living and meaningful activites

Speech patho supports…

the ability to communicate and safely swallow

Palliative care supports…

improving quality of life, reliving pain, adressing needs, coordinating care across specialties

A mobility assessment is done…

every shift

The higher a mobility assessment the ?

better

Actual mobility on a mobility assessment is

What they actually do during the shift, what they did

Highest level observed on a mobility assessment is

goals and progression, what they can do

2 components of a mobility assessment

Actual and highest level observed

A AM-PAC is used for

admission assesement

The AM-PAC determines

how much help the patient will need, and works to predict discharge and recovery

The AM-PAC measures

basic mobility, daily activity, applied cognitive

What are the highest risk factors for fall

Vision impairment, hearing issue, arthritis, orthostatic hypotension, urinary incontince, pain, fraility

A 5 on the grading of muscle strength is

Good, can move through full ROM and full resistance

A goniometer is used by and measures

not a RN and measures ROM

Lordosis is common in

infants, children and pregnant females

Bone density, what with age

decreases

height of vertebral column, what with age

shortens

The spine moves to, what with age

kyphosis

Type 1 diabetes is a issue with

beta cell destruction, no insulin produces

type 2 diabetes main 2 issues are

insulin resistance and impaired secretion

Normal random glucose level

70-100

Worry is a random glucose is over …

200

Worry is a fasting glucose is over …

126

Worry is a oral glucose is over …

200

Oral glucose is found by

glucose tolerence test

Worry is a ALc glucose is over …

6.5%

What glucose measurement is preferred to diagnose diabetes

HbA1c

What does a HbA1c measure

average blood glucose levels over 2-3 months.

Prediabetic status HbA1c levels

5.7-6.4

What is a diabetic HbA1c

>6.5

What is a red flag test for glucose monitoring

ketones in urine

What is the primary goal for outpatient diabetes management

HgbA1c <7

3 Pillars for management of outpaitent diabetes

nutrition, exercise, medications

Blood glucose target ofr inpatient diabetes

140-180

Clinical protocols for inpatient management of diabetes

Schedule insulin, and align mealtimes with insulin admin

What are the 2 vital components for administering insulin

correct type and vial, with orange cap needle

Potential compliactions with insulin injection and how to avoid

local skin reactions and lipohypertrophy, avoid by moving spots each injection

How many grams of carbohydrate is dispoded by 1 unit of insulin?

10

What should happen for pople over 30 with 2 or more Heart risk factors before implamenting exercise for diabetes

stress test

Diabetes patient education: preventative care

good hygeine, eye care, health matience

Diabetes patient education: Key nursing consideration

want to maintain blood glucose

Diabetes patient education: before providing education a nurse should

asess readiness to learn, know target

Diabetes patient education: Basic skills

counting carbs, types of insulin, prepare for travel, what to do when sick

Diabetes patient education: What should diabetes patients do with feet

daily care, moistures, cut nails straight, avoid barefoot

Diabetes patient education: What should diabetes patients avoid with feet

Excess heat, self treatments, tight socks and shoes

A patient who is sick with diabetes and is not eating shoud ___ taking insulin

never stop

What should be reported from a diabetic patient who is sick to a provider

n/V, ketones, elevated blood glucose, s/s of dehyrdration

Hot and dry …

sugars high (hyperglycemic)

Cold and Clammy …

Need some candy (hypoglycemic)

Causes of new hyperglycemia in hosptial setting

new diagnosis, medications, IVF

Classic medication cause of hyperglycemia in the hopsital

steroids

What should be given to someone with hypoglycemia,

glucagon, fast acting carbs. juice, honey

Should oatmeal be given to someone with hypoglycemia

NO

Epistaxis is

a nose bleed

Rhinorrhea is

drainage of the nsoe

What sits infront of the ears and secretes salavia

Parotid gland

Conjunctiva should be

clear

Sclera should be

white

What nerves are tested with pupil reflex

2 and 3

What nerves are tested with extraoccular movemnts

3,4,6

A 1 of the tonsils is

hidden within the pillars

3,4 grading of the tonsils is

touching eachother or middle, emergency

What does the epidermis do

outer layer, 1st defense, vitamin d is activated by uv

Changes of skin with age

dec elasticity, turgor, epidermial thickenss, sebum

Goals of skin care

maintain pH correct flora balance

NC bathing guidlines

nonsoapy and non fracracy, lukewarm water, pat dry

Skin turgor shows the

level of hydration

If the skin is red a nurse should check for

blanching

4 types of open wounds

incision, laceration, abrasion, puncture

2 types of closed wounds

contusion, hematoma