Med Surge test 2

Signs and symptoms of a stroke

Signs and symptoms of a stroke

slurred speech, facial drooping, unable to hold left arm up for 10 seconds

Nurse planned memory training

dealing with gulp or short term memory improvement

short term change for the older adult

pneumonics, crossword puzzles

Person taking warfarin, what kind of stool GI bleed?

tar stool

Aging affects the nervous system

decrease in neurons, decreased neuron conduction speed

Definition of presbycusis

hard of hearing

Erikson, final stage if you dont meet your stage of ego and integrity

despair

highest priority geriatric nurse assessment on GI system

constipation

nurse fathering initial info, a pt losing 30 pounds since their spouse died

maslow’s physiological needs arent being met

self concept

someone that is a famous singer and they have thyroid cancer and they cant sing anymore

Maslow- self confidence

self actualization

pruritis

inflammation of skin loss of oils in the skin

what to do when there is pruritis

moisturizer, tempted bath

non modifiable

genetics, age, sex, history

modifiable

sun bathing, diet, exercise

nursing home bathing

maintaining independence, flexibility

incontinent nursing interventions

monitor, environment - uncluttering, urinal, bedside commode, gowns

What can cause fall risks

neurological disease that affects gait - parkinsons, drowsy medication, diuretic, urinary frequency, dizziness, low potassium

IV pt thats dehydrated output should be?

30 mls every hr

low fluid volume

high heart rate, low bp

urine specific gravity

1.025 above - the higher it is the lower the fluid volume

checking peripheral pulse and you can barely palpate it

blood volume is low or there is obstruction

negative body image - verse effect of negative body image

anorexia, depression, bulimia, anxiety

end of stage liver cancer - they dont believe that they only have a few months to live

denial

older adults that arent ill are still considered what?

High fall risk

admitting a new resident to nursing home and refuses to go out anywhere

depression

aging with liver

production of liver enzyme activity decreases

what should you do when dealing with meds for an aging liver?

check for the appropriate dose and watch for side effects of the medication

presbycusis - when dealing with someone with HOH

face them, quiet environment, slow and clear

alarm reaction - fight or flight

fast heartbeat, pupils dilate, sharper mentally

braden risk assessment

pressure sore scale, skin moisture, mobility, friction or shearing force, sensory perception, nutrition activity

spices assessment tool

an initial screening list of thing your looking for geriatric issues, sleep disorder, incontinence, confusion, evidence of fall, skin breakdown

special incident with resident

gather info, notify provider, before you do all that take their vital signs, incident report is not in their record

group therapy - for stress

humor, going to fav places and thinking of going to different places, progressive relaxation

patient asked reactin level check

tell them exactly what theyre getting tested for

fight or flight - what physical thing happens to your body?

sympathetic - bp/heart rate rises, pupils dilated, rapid pumping of oxygen

defense mechanism - you have a pt who forgets meds bc spouse isnt there what is that?

rationalization

nurse is teaching benefits of exercise

lower stress level, increases ability to relax, increases self confidence

stages of death and dying - terminal diagnosis

acceptance

caretaker is overwhelmed with all the work they have to do what type of self concept stressor would it be?

role performance overload

nurse immediate action

fever, respirations may be labored, difficulty swallowing

nursing pocess when dealing with a patient whos going through grief

assessment - collecting info first priority - signs of depression or suicidal

pt is still grieving for partner who died 3 years ago

prolonged grieving

nurse assessment - stress

psych eval, mental status exam

sources of stress

dont forget about physiological stressors

community clinic setting collecting info on someone whos elderly with bmi of 17.5

they are underweight

why shouldnt you do a skin turgor on an elderly patient?

skin tear because their skin is very thin

if dehydrated?

orthostatic meds, check their mucous membrane, check pulse, hypotension

med surge unit

before AMA inform them their leaving against medical advice and that it is not recommended

decreasing stress - a non pharmalogical thing you can do

meditation, exercise, yoga, acupuncture, biofeedback

UTI

confusion, painful urination, blood in urine

constipation

exercise, fluids 1500 ml or more, probiotics, hot liquids

constipation

exercise, fluids 1500 ml or more, probiotics, hot liquids

cardiovascular risk in the elderly

rigidity of heart, decrease cardiac output, prone to heart attack coronary blood flow increase

members of rehab team include who?

nurse, physical therapist, you, family, physician

what do you first check?

their level of consciousness

renal changes when you have an elderly person with urinary incontinence

reason for rehab is as much independence as possible

well being in overall health promotion

looks meds, diet and physical activity