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OA Exam 1 > OA: Nursing Process > Flashcards

OA: Nursing Process Flashcards

(78 cards)

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1
Q

Each person ages..

A

at a different rate and adapts to the aging process individually

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2
Q

Knowledge of the aging process enables the nurse to…

A

accurately differentiate between normal and abnormal findings in assessing the OA

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3
Q

Who are the older adults?

A

Heterogeneous population with varying needs

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4
Q

Young-old

A

65-75

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5
Q

Middle-old

A

75-84

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6
Q

Old-old

A

85-99

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7
Q

Elite-old

A

100+

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8
Q

aging in place

A

in home as long as possible

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9
Q

FL has the highest percentage of…

A

ppl 65 and older

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10
Q

Normal aging

A

changes that occur in all older people

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11
Q

When assessing an older adult, what considerations should you remember?

A
  • allow adequate time for patient to answer questions and report information
  • bright, glare-free lighting
  • warm room
  • clarify answers or restate if you dont understand
  • list of meds
  • review typical day
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12
Q

Avoid prolonged…

A

exposure

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13
Q

Assist with…

A

position changes

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14
Q

Palpate and percuss gently to avoid…

A

trauma to frail skin

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15
Q

Do not move joints beyond point of pain to…

A

avoid injury

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16
Q

Patient may demonstrate rapid fluctuations in..

A

condition due to changes in older adult

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17
Q

Holistic/Comprehensive Assessment

A

essential to understanding the health needs of the older adult

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18
Q

Holistic/Comprehensive Assessment should be done…

A
  • yearly assessment
  • after any abrupt change
  • when hospitalized for acute illness or injury
  • nursing home placement or change in living status
  • when 2nd opinion is wanted
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19
Q

Fulmer Spices Assessment Tool

A

conditions that warrant further assessment for fall risk

S: sleep disorders
P: problems with eating and feeding
I: incontinence
C: confusion
E: evidence of falls
S: skin breakdown
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20
Q

When is Fulmer Spices used?

A

on admission to prompt fall risk precautions if needed

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21
Q

MDS

A

minimum data set

-periodic, multidisciplinary assessment

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22
Q

What does MDS validate for?

A

need for care and justifies reimbursement

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23
Q

Patience is..

A

a virtue when obtaining a hx from an older adult

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24
Q

Thought and verbal processes are…

A

slower than those of younger clients

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25
Allow adequate...
time to answer questions and report information
26
When an OA client comes in for assessment with a large bag full of multiple medications, what nursing dx is apparent?
At risk for ADR related to polypharmacy
27
Neurological changes in the OA: | -Changes from decreased velocity of...
nerve impulse conduction and decreased sensory perception
28
Responses to stimuli...
take longer
29
Slowing of the ANS may contribute to...
orthostatic hypotension
30
orthostatic hypotension
aka postural hypotenstion -stand up---> drop in BP (>15mmHg in sys)
31
Functional implications of Neurological changes in the OA
- slowed speed of cognitive processing - increased risk of sleep disorders, neurological dz, and delirium - increased risk of sensory overload or deprivation
32
Sensory changes in the OA
- alterations in taste/smell | - dry mouth is common
33
Alterations in taste/smell related to..
- med side effects - poor dentition - improperly fitting dentures
34
Functional implications for Sensory changes in the OA
- increased risk for falls, burn, and car accidents - increased risk for social isolation, boredom, and depression - increased risk of communication difficulties due to hearing loss - lower BMR - lower temp - febrile response muted, may have infection without febrile response
35
Cardiovascular changes in the OA
-Left ventricle thicker and less compliant
36
Thickening of the left ventricle leads to...
decreased diastole filling and cardiac output by 30 to 40%
37
Tachycardia is ________ in the OA
poorly tolerated
38
Thickened myocardium prone to...
irritability, arrhythmias, and ischemia
39
Fibrosis and sclerosis of cardiac muscle can lead to...
cardiac arrhythmias (premature beats)
40
What happens to the valves of the heart in the OA?
they become stenotic and incompetent
41
Due to the valves becoming incompetent, what happens...?
- increased BP - Arterial insufficiency - Abnormal heart sounds: S4 normal due to valve issues - S3 abnormal due to CHF and fluid overload
42
decreased baroreceptor sensitivity can lead to...
postural hypotension
43
Postural hypotension
aka orthostatic hypotension -A drop of >15mmHg in systolic BP when changing from lying to standing
44
Aging blood vessels become...
calcified and tortuous
45
What happens to the arteries in an OA?
- lose elasticity and vasomotor tone | - less able to regulate blood flow
46
Increased peripheral resistance leads to....
Increased BP
47
Functional Implications of Cardio changes in the OA
- decreased cardiac reserve - increased risk for arrhythmias - increased risk for postural hypotension - increased risk for varicosities of lower extremities - increased risk for dependent edema of lower extremities
48
Pulmonary changes in the OA
diminished lung expansion
49
What causes diminished lung expansion in the OA?
- weak respiratory muscles - calcified rib articulations - stiff chest wall - kyphosis
50
kyphosis
A forward rounding of the back. | hunchback
51
Functional implications of pulmonary changes in the OA?
- lung sounds diminished in the bases - decreased cough reflex with aspiration pneumonia risk - increased risk of infection and bronchospasm with airway obstruction
52
Musculoskeletal changes in the OA
-profound effect on bone mineralization with menopause
53
30% of bone mass...
lost by age 80 in women
54
increased pain with joint movement due to...
- eroding joint cartilage | - synovial fluid thickening
55
Muscle mass, tone, and strength...
decreases
56
What happens to tendons in the OA?
Become less elastic
57
Functional implications of musculoskeletal changes in the OA
-increased risk of fall
58
Morse Fall Scale Assessment
1. hx of falls (25 pts) 2. 2nd dx (15 pts) 3. Ambulatory aid: crutches (15 pts) furniture (30 pts) 4. IV or IV access (20 pts) 5. Gait: weak (10) impaired (20) 6. Mental status: overestimates or forgets limits (15 pts)
59
Risk levels of Morse Fall Scale Assessment
Low (0-24) Med (25-44) High (45+)
60
GI changes in the OA
- inadequate nutrition - decreased bowel motility - constipation - dependance on laxatives - increase fluids
61
What diet is recommended for the OA?
high residue/high fiber diets
62
GU changes in the OA
- decreased bladder capacity - weakened muscles - may not empty completely - urinary urgency - more frequent nighttime voiding
63
Incontinence...
not a normal sign of aging
64
Males risk with GU changes in the OA
BPH
65
BPH
Benign Prostatic Hypertrophy - inability to start stream - voids smaller amounts - more frequent urination
66
Skin changes in the OA
- loss of elasticity - loss of SubQ tissue - wrinkly skin - thin and transparent skin - increased or decreased pigmentation is common
67
Skin turgor in OAs
not a reliable hydration test
68
Most reliable hydration test in OAs..
daily weight before breakfast with same scale
69
1 liter of body fluid is approx...
1 kg or 2.2 lbs
70
Benign skin lesions are...
common
71
seborrheic keratosis
raised, pigmented, warty lesions with "stuck on" look
72
skin tags
raised tag of skin in high friction areas
73
senile lentigines
age spots | -irregular pigmented lesion with rough surface
74
OAs have increased risk of PUs due to..
- immobile - malnourished - comorbidities
75
Critical to assess _______ in OAs with risk of PU
bony prominences and areas of pressure
76
Braden Scale
Used to predict pressure sore risk (SMAMNF) 1. Sensory perception (1-4) 2. Moisture (1-4) 3. Activity (1-4) 4. Mobility (1-4) 5. Nutrition (1-4) 6. Friction and Shear (1-3)
77
How is the Braden Scale rated?
1=impaired to 4=no impairment
78
Risk Evaluation of Braden Scores
``` No risk: 19-23 Risk: 15-18 Moderate risk: 13-14 High risk: 10-12 Very high risk: 9 or less ```

OA Exam 1 (6 decks)

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