FUNDS
Common Post-Op Immobility Problems (5 Items)
1. Atelectasis
2. Constipation
3. Insomnia
4. Pulmonary Embolism
5. DVT
Adverse effects to decreased activity tolerance
Change in original vital signs
Express chest pain / difficulty breathing
what concern would you have if your client was experiences nausea/vomiting/diarrhea?
Electrolyte imbalance.
Sleep disturbance patient education 6 items
1. Comfortable sleep environment
2. Exercise can help with sleep
3. Limit amount of food and drink before bed
4. Naps can make it difficult to fall asleep
5. Avoid caffeine and stimulants
6. Bed time routines
Two concerns for impaired continence of fecal matter
Self concept
Compromised skin integrity
Teaching for UTI prevention 4 things
1. Drink water. Avoid drinks that could increase risk of infection (sugary)
2. Avoid bubble baths
3. Wipe from front to back
4. Empty bladder completely
Nursing interventions for sensory function
Hearing assessment - their ability to interact and converse with others
Visual - remove tripping hazards, colored tape for step edges
*goal- prevent injury, maintain sense, promote communication, perform ADLs, reduce isolation
Nursing interventions that prevent pressure injuries (4 items)
1. Q2 turns with wedge or pillow
2. Elevate hells off bed
3. Prevent sliding/shearing force
4. Use of waffle mattress/weight distribution mattresses
Braden Scale Assessments to evaluate for pressure injury risk (6 items)
1. Sensory perception
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction and shear
once regenerated, is scar tissue is either stronger/as strong as/less strong compared to original tissue?
Never as strong as the original tissue
what type of wound cares a nurse can do without a doctor’s order
The nurse can cleanse the wound and loosely fill it with saline-moistened gauze
the descriptions for identifying each pressure injury stage: (4 stages)
Stage 1: An area over bony prominence with non-blanchable redness
Stage 2: A shallow, open ulcer with a pink wound bed
Stage 3: A deep crater or hole reaching up to the fatty layer
Stage 4: Full thickness skin loss with exposed muscle, tendon, or bone
What does it mean when a wound is healing by secondary intention?
• It is left open to heal
• Scarring may be more pronounced
• There is a greater risk for infection than if we were to surgically close the wound up
the signs and symptoms of infection of a wound (3 items)
• Any kind of purulent drainage
• Increasing pain at the wound site
• Increasing swelling & warmth around the wound
what happens and can be seen in each stage of wound healing 4
1. Homeostasis
2. Inflammation
3. proliferation / granulation
4. Maturation
Note:when granulation occurs, the tissue easily bleeds oftentimes when the nurse performs wound care
Hospice is for people with _____ months for less to live
6
What is the difference between home health and a SNF (senior nursing facility)?
Home health - a nurse comes once a day
SNF - all day around the clock care
How do you if someone came out with integrity vs despair?
A person who shows a sense of pride and wisdom come out with integrity
Confusion is not normal part of aging. What could cause delirium?
Delirium - reversible
Dementia - irreversible
UTI, Electrolyte imbalance
Health promotion is your focus for older adults. What are common changes seen in older adults?
Cardiovascular, respiratory, musculoskeletal, Metabolic and endocrine changes, skin and hair
Cardio - increased HR and CO, decrease BP
Resp - increase RR
Muscu - ligamentous laxity, postural adjustments
meta & endo - increased metabolic rate, alterations to hormone levels
What are the skin and hair changes? (3 items normal)
1. senile lentigines (liver spots)
2. seborrheic keratosis (mole like)
3. actinic purpura (purplely in color)
What is sarcopenia?
What is presbyopia?
What is presbycusis?
sarcopenia - muscular changes
presbyopia - vision loss
presbycusis - hearing loss
What are common but not expected health issues in older adults?
Injuries and falls, chronic and mental health issues, addiction and elder abuse
What is the gate control theory?
when non painful input can inhibit pain signals at the spinal cord level (the nurse hitting the patient while giving a shot)
What is the difference between chronic and acute pain?
acute pain is a fight or flight response