NUR 111 Comprehensive Review

Sensory Perception

100

A common progressive hearing disorder in older adults

Presbycusis

200

List 5 Sensory deficits. What assessment activities can be used to identify each sensory deficient.

Box 49.2

Vision- Ask patient to read newspaper, magazine, or lettering on menu. Ask patient to identify colors on color chart or crayons. Observe patients performing ADLs.

Hearing - Assess patient’s hearing acuity (see Chapter 30) using spoken word. Assess for history of tinnitus. Observe patient conversing with others. Inspect ear canal for hardened cerumen. Observe patient behaviors in a group.

Touch - Check patient’s ability to discriminate between sharp and dull stimuli. Assess whether patient is able to distinguish objects (coin or safety pin) in the hand with eyes closed. Ask whether patient feels unusual sensations.

Smell- Have patient close eyes and identify several nonirritating odors (e.g., coffee, vanilla).

Taste- Ask patient to sample and distinguish different tastes (e.g., lemon, sugar, salt). (Have patient drink or sip water and wait 1 minute between each taste.)

300

List 4 interventions that will help a patient communicate with a hearing impairment 

Box24.9

• Check for hearing aids and glasses.

• Reduce environmental noise.

• Get patient’s attention before speaking.

• Face patient with mouth visible.

• Do not chew gum.

• Speak at normal volume—do not shout.

• Rephrase rather than repeat if misunderstood.

• Provide a sign-language interpreter if indicated.

400

List 4 interventions that will help a patient who is visually impaired 

Box24.9

• Check for use of glasses or contact lenses.

• Identify yourself when you enter the room and notify the patient when you leave the room.

• Speak in a normal tone of voice.

• Do not rely on gestures or nonverbal communication.

• Use indirect lighting, avoiding glare.

• Use at least 14-point print.

500

Differentiate between cataracts, glaucoma, and macular degeneration 

cataracts - clouded lens 

glaucoma- increased IOP resulting in peripheral vision loss 

macular denegation - loss of central vision. Leading cause of blindness and low vision

Nutrition

100

This diet is limited to broths, water, teas, coffee or other carbonated beverages and clear juices; provides fluids and carbohydrates only; short-term use only.

What is a clear liquid diet

200

What vein is total parenteral nutrition infused into

The central vein

subclavian vein, internal jugular vein, femoral vein, PICC 

300

Enteral vs Parenteral Nutrition 

Enteral nutrition (EN) provides nutrients into the GI tract. It is the preferred method of meeting nutritional needs if a patient is unable to swallow or take in nutrients orally yet has a functioning GI tract. EN provides physiological, safe, and economical nutritional support. Patients with enteral feedings receive formula via the nasoenteral route (nasogastric, nasoduodenal, and nasojejunal) or through gastric tubes inserted into the stomach (gastrostomy) or jejunum (jejunostomy).

Parenteral nutrition (PN) is a form of specialized nutritional support provided intravenously. Patients who are unable to digest or absorb EN benefit from PN. Patients in highly stressed physiological states such as sepsis, head injury, or burns are candidates for PN therap

400

Interventions for patients at risk for aspiration 

Skill 45.1 Aspiration precautions

• Position patient upright (45–90 degrees preferred) or according to medical restrictions during and after feeding.

Adjust the rate of feeding and size of bites to match the patient’s tolerance. If patient unable to feed self, place ½ to 1 teaspoon of food on unaffected side of mouth, allowing utensil to touch mouth or tongue

Provide verbal coaching: remind patient to chew and think about swallowing with comments such as the ones that follow:

• Open your mouth.

• Feel the food in your mouth.

• Chew and taste the food.

• Raise your tongue to the roof of your mouth.

• Think about swallowing.

• Close your mouth and swallow.

• Swallow again.

• Cough to clear your airway.

• Immediately report any onset of coughing, gagging, or a wet voice or pocketing of food to the nurse.

500

Patient teachings on food safety to prevent foodborne illness.

Box 45.9

• Explain that food safety is an important public health issue. Populations particularly at risk are older adults, children, and individuals who are immunosuppressed.

• Instruct patients using the following four principles:

1. CLEAN

• Wash hands with warm, soapy water before touching or eating food.

• Wash fresh fruits and vegetables thoroughly.

• Clean the inside of refrigerator and microwave regularly to prevent microbial growth.

• Clean cutting surfaces after each use.

• When possible, use separate surfaces for fruit, meat, poultry, and fish.

2. SEPARATE

• Wash cooking utensils and cutting boards with hot, soapy water.

• Wash hands after handling foods, especially meats, poultry, and eggs.

• Clean vegetables and lettuce used in salads thoroughly.

• Wash dishrags, towels, and sponges regularly or use paper towels.

3. COOK

• Use a food thermometer to verify that meat, poultry, and fish are cooked properly.

• Do not eat raw meats or unpasteurized milk.

4. CHILL

• Keep foods properly refrigerated at 40°F (4.4°C) and frozen at 0°F (−17.8°C).

• Do not save leftovers for more than 2 days in refrigerator.

Health, Wellness, Illness

100

Based on Maslow's Hierarchy of Needs. What is most vital to an individual? 

200

 Based on the Transtheoretical Model of Change, what is the most appropriate response to a patient who states: “Me, stop smoking? I’ve been smoking since I was 16!”

1. “That’s fine. Some people who smoke live a long life.”

2. “OK. I want you to decrease the number of cigarettes you smoke by one each day, and I’ll see you in 1 month.”

3. “What do you think is the greatest reason why stopping smoking would be challenging for you?”

4. “I’d like you to attend a smoking-cessation class this week and use nicotine replacement patches as directed.”

3.

Precontemplation 

300

2 Variables Influencing Illness and Illness Behavior

Provide 2 examples of each

Internal variables are a patient’s perceptions of symptoms and the nature of a disease. A patient’s coping skills and locus of control (the degree to which people believe they control what happens to them) are other internal variables that affect the way a patient behaves when ill

External variables influencing a patient’s illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support.

400

Nonmodifiable Risk Factors VS Modifiable Risk Factors

*Provide 3 Examples of each

Nonmodifiable risk factors such as age, gender, genetics, and family history cannot be changed. You use your understanding of nonmodifiable risk factors along with your patient’s assessment data and preferences (e.g., developmental stage, social networks, access to transportation, and motivation) to select appropriate secondary prevention strategies. 

Some risk factors such as lifestyle practices and behaviors can be modified. Modifiable behavioral risk factors include smoking, drinking alcohol, unhealthy diet, obesity, physical inactivity, and insufficient rest and sleep. These risk factors put people at risk for certain chronic illnesses, such as diabetes and heart disease

500

3 levels of care prevention, provide an example of each

Table 6.1

Primary prevention is true prevention. Its goal is to reduce the incidence of disease. Ex: Providing immunizations, Attention to personal hygiene, Health Education, Marriage counseling 

Secondary prevention focuses on preventing the spread of disease, illness, or infection once it occurs. EX: Adequate treatment to stop disease process and prevent further complications. Provision of facilities to limit disability and prevent death. Individual and mass screening surveys. Focused examinations to cure and prevent diseases, prevent spread of communicable diseases, prevent complications, limit disability, and prevent death

Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration. Ex: Providing retraining and education to return to highest level of functioning. Helping people with disabilities find work and accommodating them in the workplace

Cognition

100

Develops over a short period of time, usually hours to day.

Delirium 

200

Name 6 Risk factors associated with delirium

Med Surg-Table 64.17

Demographic Characteristics

    • Age 65 years or older

    • Male gender

Cognitive Status

    • Cognitive impairment

    • Dementia

    • Depression

    • History of delirium

Decreased Oral Intake

    • Dehydration

    • Malnutrition

Drugs

    • Alcohol or drug use or withdrawal

    • Aminoglycosides

    • Anticholinergics

    • Opioids

    • Sedative-hypnotics

    • Treatment with multiple drugs

    • Vasopressors

Environmental

    • Admission to ICU

    • Pain (especially untreated)

    • Restraints use

    • Sleep deprivation

    • Stress

Functional Status

    • Functional dependence

    • History of falls

    • Immobility

Medical Problems

   • Acute infection, sepsis, fever

   • Chronic kidney or liver disease

   • Electrolyte imbalances

   • Fracture or trauma

   • Hemodynamic instability

   • History of stroke

   • Hypertension

   • Hypoxia

   • Neurologic disease

   • Severe acute illness

   • Terminal illness

Sensory

   • Sensory deprivation

   • Sensory overload

   • Vision or hearing impairment

Surgery

   • Cardiac surgery

   • Noncardiac surgery

   • Orthopedic surgery

   • Prolonged cardiopulmonary bypass

300

Drug Therapy that helps treat delirium 

Short-acting benzodiazepines (e.g., lorazepam [Ativan]) can be used to treat delirium from sedative and alcohol withdrawal or in conjunction with antipsychotics to reduce extrapyramidal side effects. However, these drugs may worsen delirium caused by other factors and must be used cautiously.

Dexmedetomidine (Precedex), an α-adrenergic receptor agonist, has been used in ICU settings for sedation. The use of low-dose antipsychotics (e.g., haloperidol, risperidone [Risperdal]), though common practice, is controversial. Their use does not change the duration of delirium or the length of hospitalization.

400

4 Nursing interventions that will help a patient communicate with a cognitive impairment 

Box24.9

• Use simple sentences and avoid long explanations.

• Ask one question at a time.

• Allow time for patient to respond.

• Be an attentive listener.

• Include family and friends in conversations, especially in subjects known to patient.

• Use picture or gestures that mimic the action desired.

500

Clinical criteria for diagnosis of delirium. List 4

Box 30.32

Definition: An acute disturbance of consciousness that is accompanied by a change in cognition. It is not caused by a preexisting or evolving dementia. Delirium develops over a short period of time, usually hours to days, and tends to fluctuate during the day. It is usually a direct physiological consequence of a general medical condition. It is most common in older adults but occasionally occurs in younger patients.

• There is reduced clarity of awareness of the environment.

• Ability to focus, sustain, or shift attention is impaired (questions must be repeated).

• Irrelevant stimuli easily distract the person.

• There is an accompanying change in cognition (memory impairment, disorientation, or language disturbance).

• Recent memory commonly is affected.

• Disorientation usually occurs, with patient disoriented to time, place, or person.

• Language disturbance involves impaired ability to name objects or ability to write; speech is sometimes rambling.

• Perceptual disturbances include misinterpretations, delusions, or visual and auditory hallucinations. Neurological signs include tremor, unsteady gait, asterixis, or myoclonus.

Teaching and Learning

100

Closed-loop communication technique that assesses patient retention of the information given during a teaching session 

Teach-back

200

Purpose of The Joint Commission's Speak up Initiative 

The Joint Commission’s (TJC’s) Speak Up campaign helps patients understand their rights when receiving medical care and supports them to become more active participants in their care by asking questions 

• Speak up if you have questions or concerns. If you still do not understand, ask again. It is your body, and you have a right to know.

• Pay attention to the care you get. Always make sure that you are getting the right treatments and medicines from the right health care professionals. Do not assume anything.

• Educate yourself about your illness. Learn about the medical tests that are prescribed and your treatment plan so you can make informed decisions.

• Ask a trusted family member or friend to be your advocate (adviser or supporter).

• Know about your new medicine(s) and why you take them. Medication errors are the most common health care mistakes.

• Use a hospital, clinic, surgery center, or other type of health care organization that you have researched or checked carefully.

• Participate in all decisions about your care. You are the center of the health care team.

300

Ideal environment for learning

The ideal environment for learning is well lit and has good ventilation, appropriate furniture, and a comfortable temperature.  

400

3 purposes of comprehensive patient education 

1. Health promotion and illness preventions

2. Health Restoration

3. Coping 

Ultimately, The primary goal of patient education is to help individuals, families, or communities achieve optimal levels of health.

500

4 of 7 Factors that affect a patient's readiness and ability to learn.

• Cognitive function, including memory, knowledge, association, and judgment.

• The cognitive domain of learning currently mastered by a patient.

• The psychomotor domain of learning currently mastered by a patient. Assess physical strength, endurance, movement, dexterity, and coordination

• Sensory deficits, such as visual or hearing loss, that can affect a patient’s ability to understand or follow instruction

• Patient’s reading level

• Patient’s developmental level, which influences the selection of teaching approaches

• Pain, fatigue, depression, anxiety, or other physical or psychological symptoms that interfere with the ability to maintain attention and participate: