Ch. 4
The names of the steps in ADPIE
Assess, Diagnose, Plan, Implement, Evaluate (The nursing process)
A scoring tool to calculate fall risk
What is Morses Fall Scale
Assist patient with toileting, brushing teeth, remove glasses/hearing aids, place all items within reach
What is bedtime (HS) care
Blood clots, Pneumonia, Constipation, Pressure injuries, Urinary retention, Contractures
What are some effects of immobility on the body systems
confused, incompetent, incapable of caring for themselves, hard of hearing, senile, unhappy, depressed, in poor health, forgetful, cranky, and boring.
What are common misconceptions about aging.
Physiological needs are prioritized first in this hierarchy of needs
What is Maslow's
Bed alarms, chair alarms, keep the bed in the lowest position, stay with patient when ambulating or in the restroom, use a nightlight, move patient closer to the nurses station
What are fall prevention strategies / Restraint alternatives
Needing another person to wash hard-to-reach areas such as the back, feet, and lower legs, assistance in helping a patient out of the tub or shower, or help obtaining necessary items for care, such as a bath basin with water.
What is assisted care
What is the Handle with Care campaign
Stroke, TIA, Delirium, Dementia, and hallucinations
What are examples of changes in neurological functions due to aging
A specific & realistic action the patient is willing to perform. The action is measurable and completed within a definite time frame
What is an outcome statement
Rescue, Alarm, Confine, Extinguish
Bed position used for patients who have very low blood pressure (shock) to return blood to the brain and vital organs.
What is Trendelenberg's
Pillows, blanket roll, hand roll
What examples of positioning devices
caution about giving personal information over the telephone, via the mail, or over the Internet. Caution to avoid letting strangers into home without proper ID
What are interventions for elderly safety concerns
The type of intervention when the nurse assesses a patient’s urine or takes a set of vital signs
What is an independent intervention
The steps in PASS
Pull, Aim, Squeeze, Sweep
softened skin caused by continuous exposure to moisture
What is maceration
A repositioning technique that requires three staff members. One stands at the patient’s head, one stands at the patient’s waist, and one stands at the patient’s thighs. The staff member standing at the head controls the turn.
What is logrolling
Reasons for taking each medication, side effects, safety precautions, dosage for each medication
What are teaching topics for polypharmacy
The type of intervention when a nurse gives medication or completes a task that requires a physicians order
What is dependent intervention
Wear a lead apron during procedures, Wear a film badge, limit the amount of time spent with these patients, do not care for these patients if pregnant
What are ways to protect yourself from radiation hazards
scrapes on the skin, that may be the result of scratching or that may occur during care
What is excoriation
using a wide base of support and standing close to the object being moved, keeping your back straight, and avoiding twisting your torso.
What are proper body mechanics
Dehydration, poor hygiene, sedation, fractures, bruising, burns
What are examples of elderly abuse