adult/elder quiz one - study guide

components of a geriatric health history assessment

physical status, mood, mental status, ADLs, social/environmental factors, medications, functional ability, bathing, dressing, eating, toileting, transferring

why does a comprehensive geriatric assessment matter

a patient’s ability to function may be more than simply knowing their diagnoses

somatic pain

skin, muscle, joints, bones; sharp, aching, throbbing, can point to it

visceral pain

internal organs; deep, cramping, pressure; hard to locate

neuropathic

nerves/CNS; burning, shooting, electric, numb; nerve pain

stress involves the interation between

nervous system, endocrine system, immune system

interactions between the nervous, endocrine, and immune system can affect

cardiovascular system, respiratory system, gastrointestinal system, renal system, reproductive system

physiologic

what is happening inside the body

physiologic responses to stress

increased heart rate, increased respiratory rate, sweat, muscles tense, increased blood pressure

effects of stress on health

increased alertness, increased HR, BP, muscle tension, changes in breathing

long-term effects of stress of health

poor concentration, memory problems, sleep disturbances, impaired decision making, hypertension, cardiovascular disease, worsening of conditions such as asthma, diabetes, and anxiety

what are the 6 components of the braden scale

sensory perception, moisture, activity, mobility, nutrition, friction/shear

braden scale scoring: 15-16

mild risk

braden scale scoring: 12-14

moderate risk

braden scale scoring: <11

severe risk

1 layer of damage (epidermis); red skin that is nonblanchable and not broken

stage one

2 layers of damage (epidermis/dermis); open wound bed is red/pink and shiny or dry

stage 2

3 layers of damage (epidermis, dermis, subcutaneous); full thickness skin loss into the subcutaneous fat; wound may tunnel under the edges of the wound bed

stage 3

4 layers of damage; extends all the way down to the muscle, bone, or tendon

stage 4

eschar (black/brown necrotic tissue); slough (stringy yellow)

unstageable

the fatty tissue is injured below the skin (dark purple, and sometimes open wound

deep tissue

what is HIV

damages and destroys CD4+ T cells, weakening the immune system and making the patient vulnerable to opportunistic infections and cancers

what does antiretroviral therapy consist of

decreasing viral load, maintaining/increasing CD4 count, delaying disease progression

acute HIV

2-4 weeks after infection; may resemble the flu/mononucleosis

asymptomatic

may still have fatigue, headache, low-grade fever, or night sweats

symptomatic

CD4 decreases to about 200-500 cells/mcL; infections and other complications may occur

AIDS

CD4 <200 cells/mcL with severe immune suppression

HAI

healthcare-associated infections: acquired through exposure to microorganisms in a healthcare setting; 1/3 are preventable through appropriate healthcare precautions

HAI examples

hospital care, procedures, devices, healthcare exposure

CAUTI

catheter-associated urinary tract infection; tracks infections linked to urinary catheter insertion and maintenane, reflecting nursing adherence to sterile protocols and timely catheter removal

CLABSI

central line-associated bloodstream infection: measures central venous catheter infections, indicating the quality of line care, dressing changes, and maintenance hygiene

SSI

surgical site infection; evaluates post-operative infections and compliance with surgical prevention bundles

VAP

ventilator associated pneumonia; monitors respiratory infections in ventilated patients related to oral care and positioning protocols

HAI nursing intervention

review daily necessity of device!!! constantly assess