NR226 FINAL REVIEW 8/24/18 ---- Past Study Guides at very bottom
Review your nursing process, priorities, and safety
o ADPIE
Assessment,
... [Show More] Diagnosis, Planning, Implementation, Evaluation
o Priorities
First-level Priority
ABC’s (Airway, Breathing, Circulation), and Vital Sign
concerns
Second-level Priority
Requiring your prompt intervention to forestall further
deterioration (e.g., mental status change, acute pain,
acute urinary elimination problems, untreated medical
problems, abnormal laboratory values, risks of infection,
or risk to safety or security).
Third-level Priority
Problems with lack of knowledge, activity, rest, or family
coping
o Patient Safety First
Ex. In case of fire, get patient out of the room first; keep
patients with high fall risk near nursing station
Review calculations (ALL)
o 1 oz = 30 ml
o 1tbs = 15 ml
o 1 tsp = 5 ml
o 1 cup = 8 oz
o 1 kg = 2.2 lb
Review pain management, PCA pumps
o Patient-controlled analgesia (PCA)
Medication delivery system that allows clients to self
administer safe dose of opioids
Small, frequent dosing ensures consistent plasma
levels.
Clients have less lag time between identified need and
delivery of medication, which increases their sense of
control and can decrease the amount of medication they
need.
Morphine, hydromorphone, and fentanyl are typical
opioids for PCA delivery
Clients should let the nurse know if using the pump
does not control the pain To prevent inadvertent overdosing the client is the
only person who should push the PCA button.
Review expected physiological changes for older adults
o Integumentary
Decreased skin turgor, subcutaneous fat, and connective
tissue (dermis), which leads to wrinkles and dry, transparent
skin
Loss of subcutaneous fat, which makes it more difficult for
older adults to adjust to cold temperatures.
Thinning and graying of hair, as well as a more sparse
distribution
Thickening of fingernails and toenails
o Cardiovascular/ Pulmonary
Decreased chest wall movement, vital capacity, and cilia,
which increases the risk for respiratory infection
Reduced cardiac output
Decreased peripheral circulation
Increased blood pressure
o Neurosensory
Slower reaction time
Decreased touch, smell, and taste sensations
Decreased saliva production
Decline in visual acuity
Decreased ability for eyes to adjust from light to dark leading
to night blindness, which is dangerous when driving.
Inability to hear high-pitched sounds (Presbycusis)
Reduced spatial awareness
o GI
Decreased digestive enzymes
Decreased intestinal motility, which can lead to increased risk
of constipation
Increased dental problems
o Neuromuscular
Decreased height due to intervertebral disk changes
Decreased muscle strength and tone
Decalcification of bones
Degeneration of joints
o Genitourinary
Decreased bladder Capacity Prostate hypertrophy in men
Decline in estrogen or testosterone production
Atrophy of breast tissue in women
o Endocrine
Decline in Triiodothyronine (T3) production, yet overall
functions remain effective
Decreased sensitivity of tissue cells to insulin
Review nutrition, complete and incomplete proteins, carb sources,
vegetarian, iron-deficiency, which foods contain the highest amounts
of nutrients, etc.
o Complete Protein (Contain all of the essential amino acids;Usually
from animal sources)
Beef
Whole milk
Poultry
Soy
o Incomplete Protein (Do not contain all the essential amino acids;
Generally come from plant sources)
Nuts
Legumes
Grains
Fruit
Vegetables
o Carbohydrate Sources
Whole grain breads
Baked potatoes
Brown rice
o Iron
Green leafy vegetables
o Calcium
Milk
o Which foods contain the highest amount of nutrients:
o Salmon,kale, seaweed, garlic, shellfish, potatoes, liver, blueberries,
Egg yolks
Review sleep and comfort, insomnia interventions
o Nursing Considerations
Help clients establish and follow a bedtime routine
Limit walking clients during the night.
Promote a quiet sleeping environment
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