1. Weed Out: what is important?

2. Validate- clarify, is the data correct?

3. Organize & Categorize:head to toe, systems, or Gordon's FHP

Health Perception/management

Activity/exercise

Nutrition/metabolic

Elimination

Sleep/rest

Cognitive/perceptual

Coping/stress

Self/perception

Sexuality/reproduction

Role/relationship

Value/belief

It is a way to prioritize your nursing:

Look at your data

Look at Maslow's Hierarchy of Needs

Choose most important needs to address first

Self-actualization

Esteem

Love/belonging

Safety

Physiological

One part: wellness diagnosis & syndrome

ie: selfcare deficit syndrome

Two part: risk or possible nursing diagnosis

Three part: actual nursing diagnosis

Title/Label    R/T     Etiology

or

Problem      R/T     Cause/Risk Factors/Influencing Factors

Title/label            R/T          Etiology             AEB          S&S

or

Problem                 R/T           Cause                AEB           S&S

The expected outcome, which is patient centered

A: address the nursing diagnosis

P: patient centered

R: realistic/attainable

O: one behavior

M: measurable

T: time frame

It is the intervention, done by the nurse

A: address the nursing diagnosis

N: nurse performed

A: assist client to meet outcomes

S: specific to the client

T: teaching

to help move the client toward meeting the outcome

Based on knowledge/principles from science/arts

1. Look at the outcome- is it realistic/attainable?

2. Look at the interventions- are they effective? Should you change the approach?

3. Look at the assessment data- reassess PRN

4. Look at NDx- is it accurate or need change?

Psychosexual development

Id, Ego, Superego

Oral, Anal, Phallic, Latency, Puberty

Interpersonal theory

interpersonal relationships influenced by culture

Cognitive development theory

sensory motor through formal operations

Stages of development

childhood through end of life- "developmental tasks to accomplish"

trust vs. mistrust, automy vs. shame, ego integrity vs. despair

Cardiovascular

Pulmonary

Renal and Genitourinary

Oropharyngeal and Gastrointestinal

Musculoskeletal

Nervous System and Cognition

What cardiovascular changes happen as you age?

 What does it imply?

• Arterial wall thickening and stiffening-decreased complience
• Left ventricular and atrial hypertrophy
• Sclerosis of atrial and mitral valves
• Isolated systolic hypertension
• Risk of arrythmias, postural and diuretic induced hypertension, syncope possible

Implies: ↓ cardiac reserve. no change in heart rate, cardiac output at rest, w/↑ activity. ↓ maximal heart rate & cardiac output

Result is shortness of breath (SOB), slow recovery from tachycardia & fatigue

ECG, heart rate, rhythm, murmurs, heart sounds

Blood pressure (lying, sitting, standing) and pulse pressure

Palpatation of carotid arteries and peripheral pulses for symmetry

falls prevention

encourage and support healthy aging lifestyles-healthy body weight, diet, exercise

↓ respiratory muscle strength

Deminished ciliary & macrophage activity-drier, ↓ cough reflex

↓ response to hypoxia & hypercapnia (too much CO₂ in blood)

Reduced pulmonary reserves-can lead to dyspnea, ↓ exercise tolerance

Respiration: rate, rhythm, regularity, volume, depth, exercise capacity

Auscultate lung sounds in all areas

Inspect chest and obtain smoking history

Monitor: secretions, positioning, blood gases, pulse oximetry (especially in acute/rehab)

Assess cough

Keep airway open, positioning, oxygen, bronchodilators as ordered

Incentive spirometry

Maintain hydration & mobility

Education on coughing techniques & smoke cessation

↓ in kidney mass, glomular filtration rates, ↓ drug clearance

Reduced bladder capacity, elasticity, muscle tone

↑ post void residuals & nocturnal urine production

In males prostate enlargement w/risk of BPH

↓ reserves, risk of complications in illness

Nephrotoxic injury & adverse effects from drugs

Risk of volume overload, dehyrdration, hyponatremia, hypernatremia, hyperkalemia, ↓ excretion of acid load

↑ risk of urinary urgency, incontinence, UTI, nocturnal polyuria, & falls risk

Maintain drug levels-review lab values and assess for drug toxicities

Assess for fluid electrolyte imbalances & maintain minimums

For nocturnal polyuria ↓ fluids in evening, avoid caffiene, use voiding schedules

Fall prevention essential at night

↓ in strength of mastication & taste/thirst perceptions

↓ gastric motility w/delayed emptying

Malabsorption of carbs, B12, D, folic acid, and calcium

Impaired sensation to defecate

Reduced hepatic reserve = ↓ metabolism of drugs

Risk of chewing impairment: fluid/electrolyte imbalance, poor nutrition

Gastric changes: GERD, NSAID induced ulcers, etc.

Constipation is NOT normal

Stable liver function tests, risk of adverse drug effects

Assess abdomen: bowel sounds

Asses oral cavity, chewing/swallowing, dysphagia

If asperates: assess lunges for infection and other symptoms

Monitor weight, BMI, determination of dietary intake

Assess for GERD, constipation, impaction

Sarcopenia: decline in muscle strength & mass associated w/aging

• ↑ muscle weakness & poor exercise tolerance
• lean body mass replaced by fat
• bone loss in women and men
• ↓ ligament and tendon strength, cartilage erosion, changes in stature

Sarcopenia- ↑ risk of disability, falls, & unstable gait

Risk of osteopenia & osteoporosis

Limited ROM, risk of osteoarthritis

Encourage physical activity

Pain management to help manage symptoms & enhance functionality

Prevent osteoporosis

Falls risk assessements

1.) clinical assessment is essential: look for patterns & changes from the baseline or out of normal ranges for older adults

2.) Educate & demystify the myths of aging

3.) Exercise, diet, medication management, pain management, & falls prevention are key to assissting older adults in "aging well"

Person centered care

SPICES assessment

Sleep

Nutritional interventions

Decubitus ulcer & pressure sore care

Pain management

Medication management

Focuses on the needs of older adults and incorportaing their personal beliefs, values & thoughts is critical in delivering quality care

Culture, ethnicity, environment or situation as well as the ethical considerations for care helps to develop a quality individualized plan of care for the older adult

Assessment for older adults:

S: sleep disorders

P: problems with eating/feeding

I: incontinence

C: confusion

E: evidence of falls

S: skin breakdown

Should try not to give sleeping meds

If trouble sleeping: quiet, turn on fan, lights, etc. notify dr. about drugs that cause sleeplessness

Tired older adults=confusion/disorientation which ↑ falls

Confusion comes from incomplete REM cycle

It is NOT a normal part of aging

Different types:

• Urge: do you feel a need to go and then can't wait?
• Stress: do you go when you cough/sneeze/laugh?
• Bowel: is there an urge sensation?

Plan to toilet regularly, use least restrictive products (adult briefs vs. cath)

Change beverages, reduce caffiene, provide commode or urinal.

Decreased mobility

Decreased nutritional status

Decreased healing abilities due to medications, etc.

Skin integrity issues

Regular assessment is important

Monitor unlicensed assistive personel

Use DME as needed

Interdisciplinary approach is best

1.) Know the medication side effects and whether there is a potential impact on older adults

2.) Actively education older adults on the meds that they have and develop systems to assist an older adult in how to manage their meds

3.) Review the medications regularly with all older adults, report any changes in understanding or cognition to primary care provider

4.) Family caregivers are often primary administrators of meds; make sure they are educated, and comfortable w/the meds being given

Pain is subjective

Assessing pain is a vital nursing skill for older adults

Use of most appropriate/UTD pain scale is essential in assessing pain

Dementia, Delirium, Depression

Hearing, Vision, Taste, Smell

Acute onset w/fluctuations in presentation of symptoms

Confusion caused by physiological or other medical issues

• infection can be anywhere but make sure to check mouth, feet, UTI, resp. infections
• Dehydration
• Medication
• Pain

Assessment:

take vital signs, including temp.

complete full body assessment (head to toe) & Cam (confusion assessment measurement)

Interventions:

discuss abrupt changes w/CNA staff including feeding/drinking patterns

If confusion is due to acute med. problem, access emergency assistance (like a fall, head injury, systemic infection)

• forgetfullness, loss of memory which impairs ADLs

• pt often develops a pattern prior to hopitalization or change in home setting. Sometimes not noticed until there is a change

• longer term onset, identified forgetfulness- clear medical workup is essential to make sure there is not a med reason for the dementia

• not to be confused with Alzheimer's disease- dementia is seen in Alzheimer's diease pts though.

Assessment tools: pain management, communication, etc.

Alz. Assoc. has newly developed recommendations for dementia care for NF and Assisted living programs

Hypersensitive to stimulation

Must pay attention to body language

Use family as resources; they usually will know schedules/food/etc.

nurses observe depressive symptoms; do not diagnose

Feelings of profound sadness, unable to perform ADLs, isolation, lack of self worth, suicidal thoughts

Ensure oxygenation, fluid balance, monitor labs/meds regularly, conduct regular system assessments to ensure there is no changes

Report sudden changes in cognition

For longer term changes, support environmental changes, meds monitoring, caregiver education

Acute: due to immediate damage to the ear through noise, physical injury, damage to vestibulocochlear cranial nerve (VIII)

Chronic: often long term exposure to higher levels of noise or genetic; damage can be @ low decibel, high decibel or both

• Be sensitive to how a person likes to be referred to-there is a deaf culture
• Face the person
• Turn off background noise
• Speak clearly
• Use assitive devices if you can (not always covered by insurance)
• Provide interpretor services
• Use local support services

Vision loss is an issue of aging:

• presbyopia- reduction in ability to see up close
• cataracts, macular degeneration, are common problesm seen in aging

1. Vision loss can impact ADLs ie: driving, reading, work, etc.
2. Assistive devices are helpful ie:glasses, magnifiers
3. Ensure good lighting, large print w/good contrast

Taste: loss is a part of aging:

can also be impacted by meds, cancer treatments, smoking, alcohol

• May impact ability to eat
• Offer a colorful and variety of foods
• Add spices to help with flavor
• Maintain good mouth care

Smell: diminishes as we age

Can also be impacted by meds, chronic sinusitis, colds, etc.

• Especially important sense if you live alone ie: smoke/fire, cooking, etc. 
• May need to adapt environment to accommodate smell loss

• Route
• Food/fluids administered w/the drug
• Status of the absorptive surface
• Rate of blood flow to SI
• Acidity of stomach
• GI motility

Stat orders

Single dose orders

Standing orders

PRN orders

Name

Date/time

Name of drug

Dose

Route

Frequency/time

Signature

Right Drug-check 3 times, be familiar w/trade & generic

Right Dose-appropriate for age/status, recheck dose calc.

Right Time-any special considerations? ie: food-drug or drug-drug

RIght Route- never assume, confirm

Right Client- need two identifiers, two ways

Right Documentation- after med is taken document right then/there

1.) check over the order

2.) check when pouring the med

3.) check prior to giving to pt

Enteral: oral, sublingual, buccal, tube

Parenteral: Intradermal, SQ, IM, IV

Topical: skin, mucus membranes (rectal/vaginal/otic/ophthalmic/ intranasal/inhalants)

Sublingual:

sips of H₂O before giving med; mouth needs to be wet

make sure pill is completely dissolved before eating/drinking/smoking

Buccal:

B/T the gum & cheek

Use guaze pad to hold tongue or cheek

local vs systemic

always assess skin first

use gloves and tongue blade

wipe on in direction of hair growth

• Types of rectal meds: enemas, suppositories, ointments
• Not to be used in heart pts, those with rectal/prostrate surgery
• Pt should lie in sims position and remain for 10 minutes

• Types of vaginal meds: creams, gels, suppositories, ointments
• Pt should be in dorsal-recumbant or sims position
• Pt should wear a peri-pad afterwards

Douching is not good

• Assess first
• Can cause N/V
• Pediatric age group pull ear down and back
• Adult age group pull ear up and out

• Assess first
• If more than one allow 5 minutes in b/t
• Be careful of cross contamination

• Assess
• Medication dependancy
• Watch for rebound effect with decongestant sprays

• Assess!!!!!
• If respiratory med: auscultation prior & after administration
• Good mouth care
• MDI: metered dose inhaler
• DPI: dry powder inhalers
• Immediate Absorption

What are intradermal injections used for?

Where do you place it?

How much, what size needle, and what angle do you use?

Use: skin tests & local anesthetic

Placement: just under the dermis

Quantity: 0.01-0.1ml

Needle: 25-27g, /38-1/2 inch length

Angle: 10-15^o

What are subQ shots used for?

How much do you administer?

What size needle do you use?

What method?

What angle?

Use: insulin & heparin

Volume: 0.5-1ml

Needle: 25-29g, 3/8-1/2inch

Method: pinch the skin

Angle: 45-90^o

What are intramuscular injections used for?

How much volume?

Size of needle?

Method of administration?

Angle?

Use: faster med absorption, secondary to increased vascularity

Volume: up to 3ml

Needle: 21-23g, 1-2 inch

Method: Z-track, 10-10-10 rule

Angle: 90^o

• The preferred site for vaccines/immunizations
• Small volumes, use no more than 1ml
• Two fingers down from ball of shoulder
• Needle should be 1-1 1/2 inches

• Should always give IM's here- 1st choice
• Can use larger volumes: 3-5mls
• Use longer needles
• Can give IM shots in this spot in kids over 7months
• Much less painful

10 seconds to asperate

10 seconds to give med

10 seconds  pause after

1 second per 0.1ml

Meds that if given incorrectly could kill your patient!

1.) Insulin

2.) Opiates/Narcotics

3.) Injectable Potassium

4.) IV Anticoagulants

5.) Sodium Chloride >0.9%

Always have another RN check your med calc before giving

1.) Special syringes (usually orange top)

2.) U-100 or U-50

3.) Orders are written in UNITS

4.) Sliding Scale Coverage

5.) No shaking-roll

6.) Mixing: clear insulin THEN cloudy

↓ gastric emptying

↓ movement through GI tract

↓ blood flow to GI tract

↓ absorptive surve area d/t flattened intestinal villi

↑ fat content

↓ production of protein by the liver: causing ↓ protein binding of drugs

metabolism:

aging liver produces less enzymes

decrease blood flow to liver

excretion:

decrease GFR

decrease number of intact nephrons