Hondros Final Exam NUR 163

NI for increasing skin integrity – 1. Turn Q 2 HR 2. Use draw sheet 3. Heels on pillows 4. Bladder training discharge instructions for cardiac patients – pace yourself rest periods conserve energy unlicensed personal and fall prevention - toilet Q 2 hours no loose socks physiological changes in older adults - decreased peristalsis decreased cardiac output relocation stress syndrome - pt frequently irritable pt stays in room S/SX of stress - muscle tension hyperventilation decreased hr dizziness PTS @ greatest risk of stress related problems - also have chronic illness loss of spouse relocated decreased income screenings for older adults to assess stress - BMI BP cognitive functional Potential nutritional complications for older adults - limited income limited transportation neighborhood only has convenience stores external stressors - hot and cold noises physical trauma Intrinsic motivation - internal motivators what do older adults fear the least - death ostomies - change when 1/3 full chronic fatigue syndrome - lasts longer than 6 months priority to report to MD - obstructive sleep apnea diet for sacral ulcer - high protein if patient has stress - focus on emotion focus coping vitamin D toxicity - liver is affected flu vacine - primary prevention hearing aides - can't get wet valsava maneuver - open mouth breathing decreased appetite - caused by decreased peristalsis of pt has low bone density - need to do weight bearing exercises fall risk - use morse fall scale fluid volume deficit - hypernatremia fluid volume excess - hyponatremia greatest risk for poly pharmacy - if pt has many doctors expressive aphasia - cannot express what they want to say best way to help relocation syndrome - same caregivers everyday patients with hip fractures are at greatest risk to - develop pneumonia ABC - airway breathing circulation when teaching oral hygiene - mention fluoride toothpaste when to get visual screenings - every 12 months DVT - has swelling in legs or feet older adults at risk for hypothermia - dementia patients highest risk for suicide - patients who abuse alcohol low self esteem behaviors - infrequent eye contact sadness anger not motivatied says "don't waste your time on me" contributing factors chronic fatigue - decreased sleep pain poor diet lack of exercise depression labs to confirm chronic fatigue - kidney function test electrolytes liver function hemoglobin NI for chronic fatigue - validate with pt that fatigue is real establish a therapeutic relationship encourage pt to avoid over exertion delegate to nursing assistance - snacks to pts empty colostomy lubricate lips older adults value and beliefs - their beliefs impact their perception of the world think their beliefs are normal nurse must be tolerant of all pt values different beliefs lead to miscommunication ineffective coping leads to - anxiety sleep disturbance altered bowel/bladder anger depression benefits of exercise - control decreased bone loss increased well being increased balance problem focused coping - the goal is to eliminate or reduce underlying cause emotion focused coping - addresses the stressor but instead to control the emotional response meaning focused coping - individual draws on values, beliefs, and goals to modify the personal interpretation and response to a problem reframing - a positive coping strategy characterized by purposeful cognitive thoughts whereby the individual identifies positvie aspect of the situation confrontational problem solving method - continuing to face the stressor and live with the consequences escape problem solving method - completely leaving the situation avoidance problem solving method - decrease contact with the stressor