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If you want to help an overweight pt who has urinary incontinence regain healthy bladder skills, what should you do? Try scheduling voiding times & get him/her a toileting routine. What is the best way to assess for a risk for injury in a hospitalized pt? Looking at a pt’s history of falls – it’s better & quicker than examining the spine, doing DEXA scans, etc. How can you impact the quality of life of a pt diagnosed with RA? By helping them find safe ways to exercise their joints. Passive ROM Ice & rest Where does candidiasis like to grow? What makes this worse? Dark, damp places – like skin folds (under breasts & in the groin) Incontinence really makes this worse. Know about polymyalgia rheumatic & Giant Cell Arteritis. What is a complication of polymyalgia rheumatic? How does it manifest itself? (p. 276-277) Polymyalgia Rheumatic (PMR) more common inflammatory diseases seen in older adults may occur at the same time as OA acute onset (days), pain beginning in the neck & upper arms & possibly evolving to the pelvic & pectoral girdles fatigue & low-grade fever may occur pain greater at night & early morning, but no inflammation is usually present stiffness occurs especially in the morning & lasts more than 1 hr severe stiffness & pain in the muscles of the neck, shoulders, lower back, buttocks, & thighs - rather than the joints onset may be very sudden or slow unlike OA, PMR resolves in 1-2 yrs & requires different tx symptoms may be quickly relieved by small doses of corticosteroids occurs in people under 50 cause is unknown but associated with immune disorders, genetic factors & recent infection Giant Cell Arthritis (GCA) AKA temporal arteritis may occur at same time as PMR <50 years of age acute inflammation of the arteries & scalp & medium to large vessels, especially in the temporal area » restricts blood flow sudden pain in the temporal area or changes in vision » EMERGENCY if not treated early » blindness tx = high dose steroids How are RA and OA different from each other? RA is symmetrical - OA is particular to one joint at a time RA - morning stiffness lasts >30 min OA - morning stiffness <30 min Rheumatoid Arthritis (RA) chronic, systemic, inflammatory joint disorder autoimmune disease unknown cause affects more women than men pain & swelling occur in the small joints of wrist, knee, ankle, & hand (swollen, hot, fever) symptoms: generalized fatigue, malaise, & explained fevers risk factors: environmental & genetic tx: nonsteroidal medications Osteoarthritis (OA) cured with joint replacement most common type of arthritis degenerative disk disease risk factors: age, obesity, family hx, & repetitive use of or trauma to a joint joint stiffness is greater in morning - lasting <30 min stiffness with activity & relieved by activity monitor progression of disease & effectiveness & toxicity of tx as well as provide comfort & support care = palliative What do pre-malignant “things” look like? (Think waxy & brown, etc.) rough, scaly, sand-paper like patches pink to a reddish brown on a erythematous base ususally found on faces, lips, hands & forearms What is the best thing to do for stress incontinence? Kegel exercises What does a wound look like in the presence of altered venous circulation? Arterial insufficiency? Altered Venous Circulation (wound) (MORE COMMON) edema, swollen localized pigment loss "atrophic blanche" purple in color cool to tough Arterial insufficiency (wound) no pulses painful thin, shiny skin no hair gray or yellow fibrotic base If a suddenly becomes incontinent of urine, what should you do first? ALWAYS look at their medications; this would pretty much pertain to any sudden condition in an older adult. If you have an adult with cognitive impairment, what does the success of bladder training depend on? How well the family or caregiver can support the training. Can you take alendronate with bisphosphonate meds? Can you take it long term? How much calcium should you take with it? take on empty stomach - sit up right take with 8 oz of water calcium may affect the absorption of alendronate pt should not lie down for at least 30 min most experts recommend women only taking for 5 years What are some modifiable risk factors for tinnitus? exposure to loud noises head & neck trauma certain types of tumors cerumen build up jaw misalignment cardiovascular disease ototoxicity from meds If someone has chronic renal failure, what happens to the creatinine clearance level? To the BUN level? BUN level ? Creatinine clearance ? What are early signs of a foot ulcer in someone with peripheral vascular disease? hard, pimple, callus area on foot usually on big toe/in between toes If someone has ear impacted with cerumen, what might they complain of? Fullness of the ears What do squamous cell cancers look like? Basal cell carcinoma? Actinic keratosis? Squamous cell cancers firm, irregular, fleshy, pink-colored nodule that becomes reddened & scaly may ? rapidly in size can also be hard & wart-like with a gray top & horny texture, or ulcerated & indurated with raised, defined borders often overlooked Basal cell carcinoma most common malignant cancer triggered by extensive sun exposure, especially burns, chronic irritation, & chronic ulceration of the skin more prevalent in light skin pearly papule with prominent blood vessels or as scar-like area with no hx of trauma known to ulcerate diagnosed by biopsy Actinic keratosis precancerous lesion that may become a squamous cell carcinoma directly related to years of overexposure to UV light risk factors: older age & fair complexion found on faces, lips, hands & forearms, areas of chronic sun exposure in everyday life rough, scaly, sand-paper like patches, pink to erythematous base lesions may be single or multiple painless or mildly tender removal is easy & important, monitor by dermatologist every 6-12 months What are some ways to communicate with hearing impaired adults? speak in low tones & directly at the pt What can you do for xerostomia? mouth care oral swabs gum, hard candy How might you prevent delirium in a pt that has had bowel resection & is in ICU on a ventilator? Do they need uninterrupted periods of rest & sleep even though they are on a vent? rest is extremely important to prevent delirium - uninterrupted orient them after surgery What the Free Radical Theory? antioxidants youth = naturally occurring vitamins, hormones, enzymes, & antioxidants neutralize the free radicals as needed with age = damage caused by free radicals occurs faster than can repair; cells die Know the Explanatory Model & how to be culturally sensitive. (pg 51, box 4-5) Cultural skills = based on mutual respect - listen carefully - attend to both verbal & nonverbal communication - understand the meaning behind the 'story' How would you describe the problem that has brought you here? Who is involved in your decision making about health concerns? How long have you had this problem? When do you think it started? What do you think started it? Do you know anyone else with it? Tell me what happened to that person when dealing with this problem. What do you think is wrong with you? How severe is it? How long do you think it will last? Why do you think this happened to you? Why has it happened to the involved part? What do you fear most about your sickness? What are the chief problems your sickness has caused you? What do you think will help clear up this problem? What treatment should you receive? What are the most important results you hope to receive? If specific tests &/or meds are listed, ask what they are & do Apart from me, who else do you think can make you feel better? Are there therapies that make you feel better that I do not know? What are some good ways to teach a pt with a hx of malignant melanoma to avoid recurrence? be specific to the pt use sunscreen & protective clothing limit sun exposure perform regular checks How long does a chronic illness last? Lifetime – if you are uncertain about it, you might not cope very well. Knowledge is power. What does “self-determination” mean? How could this guide you in planning interventions to decrease the risk of injury in a pt who keeps trying to get out of bed? What is a long-term way to treat gout? Besides medicine? diet change ? avoid purine: asparagus, beef kidneys, gravy, game, mushrooms, dried beans, nuts goal = prevent another attack passive ROM to ? circulation How can you communicate with people who have Alzheimer’s & have lost memory? go into their world ? do NOT orient them When older people get disease & disability, what happens? They lose self-esteem & satisfaction with life… either one or both spouses do. What are some things that might precipitate delirium in older adults? UTIs relocation When someone takes a long list of medications, what should they do first? Call the DR? Warn them about polypharmacy? See if they know why they take them? check for interactions 1st What should you ALWAYS try to do when you have a pt with cognitive impairment? Help them keep independence. Sometimes just cueing them in how to do ADLs is enough. When should you take ASA if you are taking it for prophylactic reasons after an MI? with or before meals When you have a pt having trouble sleeping, what should you check first? Check to see what their usual sleep habits are. Do older adults lose interest in intimacy as both acute & chronic illnesses develop? Don’t think of intimacy as just sexual intercourse. NO - they enjoy cuddling, holding hands even if not sexually active think of intimacy as spending time together, paying attention to one another Why is amantadine (Symmetrel) (used for Parkinson’s) a good drug to manage side effects of an antipsychotic? What about extrapyramidal symptom control? strong antiparkinson properties treat extrapyramidal symptom What is a good non-pharmacological technique to use for joint pain in a stiff joint? Think about the least expensive & most readily available things. Why do people with CHF have a very high rate of being hospitalized? Exacerbations of related symptoms to CHF When do family members of pt’s with dementia peacefully accept the situation? They realize they need time for them to stay sane and healthy. What is the best way to teach pt’s to maintain optimal vision? ? lighting use shades & blinds large print reading material yellow/amber lenses Besides bisphosphonate therapy, what do pt’s with osteoporosis need to do to reduce bone loss? Vitamin D calcium women = estrogen What is the definitive diagnosis for Alzheimer’s? What is something else they are starting to use also? Autopsy – but they are starting to use biomarkers in blood to detect onset of the disease &/or track its progression. What is a healthy way to show that someone adjusts to the loss of a spouse? Resume previous activities. Diabetes, vascular system status, & secondary hypertension – what do these have in common? ALL deal with cardio ? risk for disease What is the best way to help a caregiver of an older adult with respiratory issues? Get them to have some time away for themselves. What is the most important thing to for a client with a lot of chronic illnesses who is going home? To make sure they know safety risks; it is highly improbably that they can get daily nursing care – Medicare won’t pay & Social Services isn’t always able to help with medical expenses. If a pt is taking max dose of Tylenol for paint & has no relief, would you give them something on top of it or change it to something different? Think about changing to a different drug so you don’t cause polypharmacy issues. If a nurse is suspected of not providing standards of care in a nursing home, will they be immediately fired or maybe reviewed first by the OBN? Would they wait 3 months & do a surprise re-evaluation or do it sooner? not fired - OBN reviews it - makes nurse do therapy - reviewed after completed What would you want to check when someone has a sudden deterioration of visual acuity? Mood & functional status; it could be a stroke. This is the 1st thing you do! If you want to minimize the effect of ageism in your practice of nursing, what should you do first? Reflect & form your own view so you don’t join on the bigotry. What is the most important thing about transferring a pt with an injury to a sub-acute care facility, like HSH? Help them regain their independence. They might not return to FULL function, so don’t give them false hope. Tell them it’s for a limited time due to insurance/Medicare stipulations. If you have a pt of another culture with a BP problem that will not stay in bed, what might you want to check? Check & see what their perceptions & treatment ideas are. What does Vitamin D do? ? risk of fracture essential for bone health & may prevent osteoporosis older adults = ? risk for vitamin D deficiency d/t changes in the skin that ? ability to synthesize vitamin D absorb calcium & promote bone growth Always use a formal interpreter (not a family member) when having a non-English speaking person sign documents. What is a good way to deal with urinary incontinence? Regular toileting What are some good interventions to use for older adults who have trouble reading at night? Reading materials with large, dark evenly spaced printing. Whenever there is a question about constipation issues after surgery, what should you do FIRST? Check the medications – before you start increased fluids & exercise. What are normal age-related changes in the small intestine? (Page 132) Villi in intestine are less functioning, affecting absorption peristalsis slows. Why would you “check for pocketing” in a pt who might be at risk for aspiration? Bacteria can cause pneumonia. If you have a homebound pt complain about the food their family brings, how would you solve this problem? Meet with both the pt & family to resolve the problem. Don’t just put the pt in a home or tell the family what to do without involving everyone in the discussion. What would a lesion mean that is multicolored, raised, & has a fuzzy border? melanoma Know about normal age-related skin changes. (pg 182) thinner, diminished melanocytes ? risk for cancer xerosis (dry skin) is common but NOT normal thinning & ? elasticity immobile older people = ? risk for pressure ulcers & fungal infections age spots/liver spots (lentigines) ? back of hands, wrists, face sensitivity to cold How can you prepare a pt that has active herpes zoster to go to PT at HSH? Cover the open wounds. What do you do for peripheral vascular disease symptoms in a person with venous insufficiency? raise the affected extremity graduated compression What is the biggest risk for injury in someone with PD (Parkinson’s)? falls If someone has vision problems what kind of environment would be good? Colors, lighting, etc. (Page 252) Contrasting colors on stairs, towels that are bright & warm, incandescent lighting, increased intensity of lighting, control glare using shades/blinds, yellow sunglasses. Why do older adults get cold so easily? ? fat tissue, thinner skin older adults are vulnerable to environmental temps areas of hypodermis atrophy causes ? sensitivity to cold What can immobility do to people who have CABG surgery? blood clots People with pulmonary fibrosis need what? balance & exercise It seems grumpy old men with this disease can get pretty angry, bossy, & demanding when they can’t do for themselves like they always did without having to rest. What are some restraint-free ways to keep older people safe? (pg 212, box 13-5) key = conducting careful individualized assessments compensate for memory loss (example: improving behavior) anticipate needs - provide visual & physical cues improve impaired mobility evaluate nocturia/incontinence night lights bed in lowest position reduce sleep disturbances personal care items within reach call light within reach toileting schedule no clutter in room What is the ABCD rule in skin assessment? (pg 185) A - asymmetry = one half doesn't match the other half B - border irregularity = edges are ragged, notched, or blurred C - color = pigment not uniform in color, having shades of tan, brown, or black, or a mottled appearance with red, white, or blue areas D - diameter = diameter > than size of a pencil eraser or ? in size Know all about constipation & older adults. (pg 162-168) potentially serious problem, especially for functionally impaired most common GI complaint extensive use of laxatives in US (older adults) - cultural habit diet & activity level = major role can lead to cognitive dysfunction & delirium with consequences of falls, prolonged hospital stays, & ? morbidity & mortality thorough assessments when dealing with complaints of constipation ? usually an underlying cause Box 10-4 on pg 163 lists all precipitating factors for constipation examine medications & eliminate constipation producing non-pharmacological interventions: fluid & fiber, exercise, environmental manipulation, combination of all of the above bowel training & regularity are important Why is it important for older people to have normal serum albumin levels when taking meds like Coumadin? meds like Coumadin, Digoxin, & NSAIDs are albumin binding ? pt with ? albumin may be more sensitive to effects of med How can you help a pt take meds if they have trouble with them sticking in their throat? Try different methods with them, such as liquid meds, crushing the meds, putting them in pudding, different swallowing techniques (tucking their chin) What lab value would you check in an older adult post-op to see if they are getting an infection? They don’t spike temps very quickly & their WBCs might not even elevate at first check out SED rates, PPTs, thrombocytes, & C-reactive protein What can age-related changes in the concentration of gastric acid do to drug absorption? ? gastric pH will retard acid-dependent drugs stomach emptying is delayed intestinal motility is slowed overall, they all affect the time in which the drug is supposed to be adsorbed. How do you diagnose diabetes mellitus? ONE random plasma glucose ?200 mg/dL when exhibiting symptoms OR TWO of any combinations of positive tests on different days: Fasting plasma glucose(FPG): ?126 mg/dL on separate occasions (This is not BGM obtained w/ a finger stick) Oral glucose tolerance test(OGTT): ?200 mg/dL 2 hours after glucose Random plasma glucose: ?200 mg/dL without symptoms If you want to get to know an older adult… Listen to them. What is the most effective way to build rapport with a pt in a health interview? First focus in the problems that the client see as important, this established good rapport from the get go. What is presbyesophagus? ? in the intensity of propulsive waves may be an age related change in the esophagus affects swallowing ability What differentiates delirium from depression & dementia? Delirium: temporary, reversible, sudden/abrupt onset orientation fluctuates but usually impaired affect varies but my look disturbed or frightened symptoms: disturbances in conciseness, attention and changes in cognition Depression: recent onset (r/t life changes) clear consciousness, normal alertness, little impairment, orientation normal, speech slow, & flat affect Dementia: permanent, irreversible onset is slow/over years generally normal alertness, trouble focusing, slowed response If someone is non-compliant with food or diet plans, what should you check before forcing them into something they probably won’t stick with? Check what they like to eat & eating habits. What is a big problem with neuroleptic meds? Side effect? Orthostatic hypotension (? risk for falls), dry mouth, constipation, urinary retention, hypotension, confusion Neuroleptic malignant syndrome (NMS) fever greater than 100.4, muscle rigidity, altered mental status, & autonomic instability Extrapyramidal symptom (SEE QUESTION 88) What are some good ways to teach older adults skills like insulin administration or wound care? Teach them by showing them examples & having them show you the skill by themselves Teach them warning signs of when to call someone else (ER) Provide them a set of large print written instructions Include caregivers, friends, or family members when providing teaching Provide them with instrument they will need to perform skill Unless older people are proven mentally incompetent by the court, they can do whatever they want! Know about herpes zoster. viral infection ? commonly called shingles (associated with chicken pox) onset begins with itching or tingling or pain in the affected dermatome tx = oral antiviral agents common in adult 50 years or older Postherpetic Neuralgia: pain for a long time after the wounds have healed ? antidepressant (tricyclic) alter the perception of this pain Vaccine available & recommended for people 60 & over If wound is weeping, keep it covered - even if crusty (could break off & reopen the infection) What are common problems for people taking Dilantin & Detrol long-term? chronic administration ? memory impairment, irritability, intellectual decline subtle onset What causes strokes? uncontrolled hypertension Risk factors: heart disease, hypertension, arrhythmias, hypercholesterolemia, diabetes, smoking, brain tumors, family history What are extrapyramidal symptoms? drug induced movement disorders, side effects of antipsychotic (neuroleptics) medicines EPS can cause movement & muscle control problems throughout your body dystonia = continuous spasms & muscle contractions akathisia = motor restlessness parkinsonism = characteristic symptoms such as rigidity, bradykinesia, & tremor tardive dyskinesia = irregular, jerky movements
