Nursing Interventions for skin integrity - turn q2h, use draw sheet, heels on
pillows, bladder training
discharge instructions for cardiac patients -
... [Show More] pace yourself
rest periods
conserve energy
UAP and fall prevention - toilet q2h
no loose socks
physiological changes in older adults - decreased peristalsis
decreased cardiac output
Relocation Stress Syndrome - pt frequently irritable
pt stays in room
S/S of stress - muscle tension
hyperventilation
decreased HR
dizziness
Patients at greatest risk of stress related problems - Also have chronic illness
loss of spouse
relocated
decreased income
screenings for older adults to assess stress - BMI
BP
cognitive
functional
potential nutritional complications for older adults - limited income
limited transportation
neighborhood only has convenience stores
external stressors - heat, cold, noise, light, physical trauma
intrinsic motivation - internal motivation
what do older adults fear the least - death
Ostomies - change when 1/3 full
chronic fatigue syndrome - lasts more than 6 months and is accompanied by
muscle and joint pain, headaches, and sleep and memory problems
priority to report to MD - obstructive sleep apnea
diet for sacral ulcer - high protein
if patient has stress - focus on emotion focus coping
Vitamin D toxicity - liver is affected
Flu vaccine - primary prevention
Hearing aide care - keep dry, ear mold with mild soap and water and dry
completely, check batteries(extras), lowest setting,
Valsalva maneuver - Any forced expiratory effort against a closed airway such as
when an individual holds his or her breath and tightens his or her muscles in a
concerted, strenuous effort to move a heavy object or change positions in bed.
Open mouth breathing
decreased appetite - caused by decreased peristalsis
if pt has low bone density - need to do weight bearing exercises
fall risk - Morse Fall Scale (MFS)
fluid volume deficit - hypovolemia, dehydration, diarrhea, DI.
• S/s: ^HR, hypotension, dysrhythmias, ^RR, dyspnea, lethargic, weakness,
decreased UO, tenting, constipation, hypernatremia
• Rx: IVF, O2
fluid volume excess - hypervolemia: water intoxication d/t excessive Na intake
• S/s: ^HR, ^BP, distended neck veins, dysrthymias, ^RR, altered LOC, ^UO,
pitting edema, diarrhea, hyponatremia
• Rx: diuretics, restrict fluid/Na, monitor I&O, monitor daily weight [Show Less]