adult/elder quiz 1

Comprehensive Geriatric Assessment 

Health History – physical status, mood, mental status, ADLs, social/environmental status, meds, functional ability, bathing, dressing, eating, toileting, transferring

• Patient's ability to function is more important than knowing diagnosis

Somatic Pain

skin, muscle, bone, joints – EASY to point too

Somatic Pain Symptoms

sharp, aching, throbbing

Visceral Pain

 internal organs – HARD to locate

Visceral Pain Symptoms

deep, cramping, pressure

Neuropathic Pain

nerves/CNS – NERVE pain

Neuropathic Pain Symptoms

burning, shooting, electric, numb

Physiologic Responses to Stress

• Affects: cardiovascular, respiratory, gastrointestinal, renal, reproductive 

• HR increase, BP increase, alertness increased, tachypnea, sweating, muscle tension

Long-Term Stress

• Poor concentration, memory problems, sleep disturbances impaired decision making, HTN, cardiovascular disease

  • Worsening Conditions: asthma, diabetes, anxiety

mild risk

15-16

moderate risk

12-14

severe risk

<11

Pressure Injuries

Damage to skin and/or underlying tissue over a bony prominence

• Common with bedridden patients who are not turned adequately or from a medical device (oxy therapy)

• Common Areas:

  • lower back & bottocks

  • heels, ankles

  • hip bones

  • shoulders/elbows

Pressure Injuries Intervention/Management

assess → relieve pressure → care for wound → promote nutrition → manage pain

Stage 1 Pressure Injuries

1 layer of damage (epidermis)

• red skin, NON blanchable, NOT broken

Stage 2 Pressure Injuries

2 layers of damage (epidermis, dermis)

• open wound = wound bed red/pink, shiny, dry

Stage 3 Pressure Injuries

3 layers of damage (epidermis, dermis, subcutaneous)

• full-thickness skin loss into subcutaneous fat

• wound may tunnel under edges of wound bed

Stage 4 Pressure Injuries

4 layers of damage

• extends all the way into muscle, bone, tendon

eschar

dead necrotic tissue

• black//brown

slough

yellow stringy

• wound needs to be debrided before a stage is made

deep tissue

fatty tissue is injured below skin

• dark purple, sometime open wound

HIV

damages and destroys CD4+ T cells – weakens immune system – immune function decreases, patient becomes vulnerable to opportunistic infections and cancers

• CD4 count below 200 cells/mm^3

• Transmission: sexual contact (most common)

• Contact with Infected: blood, semen, vaginal secretions, breast milk

HIV Treatment

Antiretroviral therapy (ART)

• Decrease viral load, maintain / increase CD4 count, delay disease progression

Acute Stage

 2-4 weeks after infection – may resemble flu/mononucleosis

Asymptomatic Stage

fatigue, headache, low-grade fever, night sweats

Symptomatic Stage

CD4 decreases to 200-500 cells/uL – infections + complications may occur

AIDS

CD4 < 200 cells/uL w/ severe immune suppression

Healthcare-Associated Infections (HAIs)

infection acquired through exposure to microorganisms in healthcare setting 

• Hospital care, procedures, devices, healthcare exposure 

• ⅓ HAIs preventable through appropriate precautions 

Catheter-Associated Urinary Tract Infections (CAUTIs)

infection linked to urinary catheter insertion and maintenance – reflects nursing adherence to sterile protocols and timely removal 

Central Line-Associated Bloodstream Infection (CLABSI)

central venous catheter infections – indicates quality of line care, dressing change, maintenance hygiene

Surgical Site Infections (SSI)

post-operative infections – compliance w/ surgical prevention bundles

Ventilator-Associated Pneumonia (VAP/VAE)

respiratory infections in ventilated patients – related to oral care and positioning protocols

HAI Nursing Intervention

!!!REVIEW NECESSITY OF DEVICE!!!

sodium range

135-145

hypernatremia causes

1. Low ADH → DI = Diabetes Insipidus (dry inside)

2. Rapid respirations

3. Watery diarrhea

4. Loss of thirst

hypernatremia manifestations

Body = BIG + BLOATED

• Edema (swollen body)

• Increased muscle tone

• Swollen dry tongue

• N/V

hyponatremia causes

1. Sweating

2. Excess water intake (running in extreme heat)

3. Vomiting/Diarrhea

4. Diuretics, diuresis

5. Low salt diet

6. Low aldosterone

hyponatremia manifestations

Brain, Muscular, Respiratory = LOW + SLOW

• Headache = cerebral edema

• Mental status changes

• Seizures, comas

• Fatigue, muscle cramps

• Respiratory arrest

potassium range

3.5-5.0

hyperkalemia causes

1. Renal failure

2. Low aldosterone

hyperkalemia manifestations

Heart, Neuromuscular, GI = HIGH

• Peaked T waves & ST elevation

• Severe Vfib & cardiac arrest

• Increased DTR

• Paralysis, paresthesia

• Muscle weakness

• Diarrhea

• Hyperactive bowel sounds

hypokalemia causes

1. Fluid/electrolyte loss

2. Diarrhea

3. Diuretics

4. Diet

5. DKA

6. Aldosterone

hypokalemia manifestations

Heart, Neuromuscular, GI = LOW + SLOW

• Flat T waves, ST depression, Uwave

• Shallow respirations = DEADLY

• Decreased DTR

• Muscle cramping, flaccid paralysis

• Constipation

• Hypoactive bowel sounds

• Paralytic ileus

chloride

KINDA SAME AS SODIUM

magnesium range

1.3-2.1

hypermagnesemia causes

1. Renal failure

2. Alcoholism

3. Malnourishment

hypermagnesemia manifestations

Heart, DTR, Lungs & GI = High MELLOW

• Heart block

• Hypotension, bradycardia

• Hyporeflexia (decreased DTR)

• Depressed respirations

• Hypoactive bowel sounds

hypomagnesemia causes

1. Crohn’s disease

2. Celiac disease

hypomagnesemia manifestations

Heart, DTR, Lungs & GI = low MELLOW → EXCITED!!!!!!!

• Torsades de Pointes

• Vfib

• Hyperreflexia (increased DTR)

• Diarrhea

• Hyperactive bowel sounds

calcium range

9.0-10.5

hypercalcemia causes

1. Hyperparathyroidism → high PTH = high calcium

2. Cancer

3. Immobility

hypercalcemia manifestations

HIGH calm

• Kidney stones

• Constipation

• Bone pain

• Severe muscle weakness

hypocalcemia causes

1. Hypoparathyroidism → low PTH = low calcium

2. Renal failure → CKD

hypocalcemia manifestations

LOW calm =. EXCITED!!!!!!!

• Trousseaus sign

• Chvostsk’s sign

• Diarrhea

• WEAK B’s

  • bones - fractures

  • blood - clotting

  • beats - cardiac dysrhythmias

ABG

acid bases imbalances affecting pH (maintaining homeostasis)

normal pH

7.35-7.45

full compensation

FULLY normal pH

partial compensation

pH is NOT normal

acidosis

respiratory → low + slow RR, sleep apnea, pneumonia, COPD, asthma attack

metabolic → diarrhea, renal failure, DKA

alkalosis

respiratory → panic attack, fast RR

metabolic → vomitting, hypokalemia

PaCO2 (respiratory) range

35-45

HCO3 (metabolic)

22-26