A&E I Exam 1 Study Guide PDF

Preview

Summary

Download A&E I Exam 1 Study Guide PDF

Description

Week 1: Introduction to the Care of Older Adults 



 

The number of older adults (65+) in the United States is growing quickly, due in large part to an increase of the average life span. The 85+ age group is predicted to triple between 2012 and 2040, and reach 14.1 million. This is primarily due to medical advances, and reflects the global aging trend, as well. o We live long lives, but compared to other high-income counties we live more unhealthy lives. This is due to healthcare costs, income disparity, stress, etc. Aging does not automatically lead to disability and dependence – most older people remain functionally independent despite the increasing prevalence of chronic disease. Therefore, age does not predict health. o Only about 3.5% of older adults live in nursing homes. o Chronic disease has replaced infectious disease as the major cause of death. Ageism typically undermines the self-confidence of older adults, limits their access to care. Negative stereotypes negatively affect quality of care. Avoid “elder speak” and speak directly to the patient rather than their caregiver. Some frequently observed physiological changes in older adults are normal, but make them vulnerable to some common clinical conditions and diseases:

System Integumentary

Respiratory Cardiovascular Gastrointestinal Musculoskeletal Neurological Sensory Eyes Ears Taste Smell Touch Proprioception

Genitourinary Reproductive Endocrine Immune System

Common Changes Loss of skin elasticity with fat loss in extremities; pigmentation changes, increase in lesions/age spots; glandular atrophy (oil, moisture, sweat glands); thinning hair, with hair turning grey-white (facial hair: decreased in men, increased in women); slower nail growth; thinning of dermis Decreased cough reflex; decreased cilia; increased anterior-posterior chest diameter; increased chest wall rigidity; fewer alveoli; decreased muscle strength; increased risk of respiratory infections; dryer mucous membranes Decreased cardiac contractile strength, arterial compliance, and baroreceptor sensitivity Periodontal disease; decrease in saliva, gastric secretions, and pancreatic enzymes; smooth-muscle changes with decreased peristalsis and small intestinal motility; increased stomach pH, hemorrhoids; decreased liver function Decreased muscle mass and strength, decalcification of bones, degenerative joint changes, deterioration of vertebral support (kyphosis common) Loss of axons and neurons, decrease in neurotransmitters, decrease in rate of conduction impulses, slowing of coordinated movements Decreased accommodation (presbyopia), difficulty adjusting to changes from light to dark, yellowing of the lens, increased sensitivity to glare; High-frequency hearing loss (presbycusis), sclerosis of inner ear; cerumen buildup; Fewer taste buds, salivary secretion is reduced; Smell often diminished; Decreased skin receptors; Decreased awareness of body positioning in space Fewer nephrons, decreased in renal blow flow, decreased bladder capacity; hypertrophy of prostate in males; increased stress incontinence in women Male – sperm count diminished, smaller testes, erections less firm and slow to develop; Female – decreased estrogen production, degeneration of ovaries, atrophy of vagina, uterus, breasts Alterations in hormone production with decreased ability to respond to stress; diminished thyroid secretions; decreased sensitivity to insulin Thymus and T-cell function decreases; core temperature elevation is lowered





 

 





A comprehensive assessment of an older adult may take more time than the assessment of a younger adult because of the longer life and medical history, the potential complexity of the history, and the time it takes for an older adult to respond to questions. o Classic signs and symptoms of diseases are sometimes absent, blunted, or atypical in older adults. o Older adults manifest atypical symptoms as mental status changes. The leading cause of death among older adults is chronic conditions. Most older adults have at least one chronic condition, and many have multiple conditions. o The most commonly diagnosed conditions include arthritis, hypertension, heart disease, or cancer. o Chronic diseases reduce quality of life, limit activity, require assistance, increase health care costs and number of hospitalizations, and impact emotional health. Common health issues among community-dwelling older adults include poor nutrition (due to access to transportation, decreased funds, loss of appetite), stress and loss, and impaired mobility. Common conditions affecting cognition are delirium, dementia, and depression: o Delirium, or acute confusion state, is a sudden and potentially reversible cognitive impairment that often has a physiological cause (e.g. drugs, elimination, liver, infection, respiratory, injury, unfamiliar environment, metabolic.). o Dementia is a generalized impairment of intellectual functioning that interferes with social and occupational functioning. Cognitive function deterioration leads to a decline in the ability to perform basic ADLs and IADLs. Unlike delirium, a gradual, progressive, irreversible cerebral dysfunction characterizes dementia. o Depression is the most common, yet most undetected and untreated, impairment in older adulthood, commonly associated with social isolation. White men age 85 and older have the highest suicide rate in the U.S. Polypharmacy, the concurrent use of many medications, increases the risk for adverse drug effects. Medication reconciliation should be performed upon admission and discharge. Hospitalization of older adults increases the risk of polypharmacy (adverse drugs effects), iatrogenesis (inadvertent and preventable induction of disease or complications by medical treatment, such as invasive procedures and nosocomial infections), psychological decompensation (delirium), and poor outcomes. Fulmer SPICES is an efficient and effective instrument for obtaining the information necessary to prevent health alterations in the older adult patient. SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention: o S is for Sleep Disorders o P is for Problems with Eating or Feeding o I is for Incontinence o C is for Confusion o E is for Evidence of Falls o S is for Skin Breakdown Together, ADLs and IADLs represent the skills that people usually need to be able to manage in order to live as independent adults. Activities of daily living (ADLs) are basic self-care tasks, akin to the kinds of skills that people usually learn in early childhood; they involve caring for and moving the body. Instrumental activities of







daily living (IADLs) are the complex skills needed to successfully live independently. These skills are usually learned during the teenage years and include the following: o Managing finances o Handling transportation (driving or navigating public transit) o Shopping o Preparing meals o Using the telephone and other communication devices o Managing medications o Housework and basic home maintenance The Katz Index of Independence in Activities of Daily Living is the most appropriate instrument to assess functional status as a measurement of the client’s ability to perform activities of daily living (bathing, dressing, toileting, transferring, continence, and feeding) independently.

The geriatric cascade is the phenomenon of rapid decline resulting from frailty, acute illness, and stress of institutional care (most often from acute hospitalization). o Frailty is a syndrome of age-related vulnerability resulting from impaired homeostatic reserve and a reduced capacity to withstand stress; the older adult experiences unintentional weight loss, weakness and exhaustion, and slowed physical activity, including walking.  Chronic illness, a harmful social/psychological environment, and physiological changes with aging all contribute to frailty. As the population ages and life expectancy increases, emphasis on health promotion and disease prevention increases. General preventative health measures for older adults include routine health screening, regular exercise, weight reduction if overweight, eating a low-fat/well-balanced diet, moderate alcohol use, regular dental visits, smoking cessation, and immunization. o SMART goals are specific, measurable, attainable, realistic, and time-sensitive.

Week 2: Fall Preventions & Complications of Immobility 

 





A safe environment reduces the risk for illness and injury and helps to contain the cost of health care by preventing extended lengths of treatment and/or hospitalization, improving or maintaining a patient’s functional status, and increasing a patient’s sense of well-being. A fall is an unexpected event in which the participant comes to rest on the ground, floor, or lower level – they are not a normal part of aging and considered a geriatric syndrome. Falls are the leading cause of death from injury for adults over 65. 30-40% of community-dwelling older adults fall every year (an underestimation due to underreporting), and 50-75% of older adults in long-term care settings fall every year. 20-30% of older adults who fall suffer serious injuries. o Falls result in 2.8 million injuries treated in emergency departments daily – over 800,000 hospitalizations and more than 27,000 deaths. In 2013, the total cost of fall injuries was $34 billion. o Protocol dictates that patients whose falls were not witnessed require a CT. Risk factors for falls include: o Intrinsic (non-modifiable): older age, history of falls, culture, gait impairment, balance disorders, orthostatic or postural hypotension, depression, muscle weakness, chronic conditions such as dementia, arthritis, Parkinson’s Disease, etc. o Extrinsic/Environmental (modifiable): polypharmacy, loose carpets, use of adaptive devices such as cane and wheelchairs, inadequate lighting and footwear, use of physical restraints, diet/nutrition, etc. The Hendrich II Fall Risk Model assessment helps healthcare providers identify patients at risk for falls. However it’s important to realize that risk factors in this model won’t always give us the whole picture – use your best clinical judgment!







 



The diagnosis of delirium by the confusion assessment method (CAM) is the presence of features 1 and 2 and either 3 or 4: 1. Acute onset and fluctuating course (e.g., Is there evidence of an acute change in mental status from the patient's baseline? 2. Inattention (e.g., Does the patient have difficulty focusing attention or keeping track of what is being said?) 3. Disorganized thinking (e.g., Is the patient's thinking and conversation disorganized or incoherent?) 4. Altered level of consciousness (e.g., Is the patient lethargic, hyperalert, or difficult to arouse?) A patient assessed as being at fall risk receives a fall risk identification bracelet, is given information about personal fall risks, and receives additional individualized nursing interventions: o Keep bed height at the lowest position, and 1-3 bed rails up. o Implementation of purposeful, hourly nursing rounds with nurses visiting patients improves outcomes by reducing patient falls. Purposeful rounding includes specific nursing actions such as addressing toileting, assessing pain level, turning, and ensuring that possessions are within reach. o Bed safety alarms or motion detectors are used to signal nurses. Patients who are confused or disoriented and who wander or repeatedly fall or try to remove medical devices often require the temporary use of restraints to keep them safe. However, they can only be used with a physician’s order after all alternatives have been exhausted (including close monitoring, moving room closer to nurses station, evolution medication including change of medication, use of therapeutic communication/psychosocial intervention, and use of diversion). o If restraints are used, ensure they’re the right size and assess skin integrity, circulation and ROM every hour and document. Mobility refers to a person’s ability to move about freely, and immobility refers to the inability to do so. Patient mobilization includes turning, bed to chair, ambulation, and migration. Periods of immobility due to disability or injury or prolonged bed rest during hospitalization cause major physiological, psychological, and social effects. The greater the extent and the longer the duration of immobility, the more pronounced the consequences. Systemic effects of immobility can appear within 24-48 hours, and may include:

System Effected Metabolic

Cardiovascular

Urinary elimination

Changes

Intervention

Negative nitrogen balance Altered GI function Fluid and electrolyte imbalance (sodium levels) Orthostatic hypotension Thrombus formation

Provide high-protein, high-caloric diet (Ensure) with vitamin B and C supplements

Urinary stasis Renal calculi

Progress from bed to chair to ambulation Sequential Compression Devices (SCDs) Thrombo-embolic device (TED) Leg exercises Anticoagulation therapy (Heparin) Adequate hydration Diet rich in fluids, fruit, vegetables, fiber

Respiratory

Atelectasis (alveoli collapse) Hypostatic pneumonia

Musculoskeletal changes

Loss of endurance and muscle mass Decreased stability and balance Muscle atrophy Impaired calcium absorption Joint abnormalities Pressure ulcer Ischemia (and tissue death)

Integumentary

 







Cough and deep breathe every 1 to 2 hours (incentive spirometer) Chest physiotherapy Passive ROM vs. active ROM Isotonic vs. isometric exercises

Reposition every 1 to 2 hours Skin care

Immobile patients must be turned every 2 hours during awake hours. Assessment of patient mobility focuses on ROM, gait, exercise and activity tolerance, and body alignment. When unsure of a patient’s abilities, begin assessment of mobility with the patient in the most supportive position and move to higher levels according to their tolerance. There are a variety of different patient positioning techniques: o High Fowler’s: the head of the bed is elevated 80-90 degrees o Supported/Standard Fowler’s: the head of the bed is elevated 45-60 degrees, and the patient’s knees are slightly elevated without pressures to restrict circulation in the lower legs o Semi-Fowler’s: the head of the bed is elevated 30-45 degrees o Supine: patients rest on their backs o Prone: patient lies face or chest down o Side-Lying: patient rests on the side with the major portion of body weight on the dependent hip and shoulder Encourage patient who are hospitalized to do stretching exercises, active ROM exercises, and low-intensity walking, depending on their condition. Physical therapists can assist with isometric exercises, and when patients cannot participate in active ROM, implement passive ROM exercises. The rate of work-related injuries in health care settings has increased in recent years. Body mechanics is a term that describes the coordinated efforts of the musculoskeletal and nervous systems necessary when positioning and transferring patients: o Assess the weight to be lifted, determine the assistance needed, and evaluate available resources o When a patient is able to assist, use a wide base of support, lower the center of gravity (bend at the knees), take a position close to patient, tighten abdominal muscles, and face the direction of movement o Rolling, turning, or pivoting requires less work than lifting o Use safe patient-handling equipment when a patient is unable to assist in transfer o Lift teams reduce the risk of injury to the patient and members of the health care team

Week 3: Safety & Skin and Wound Care 





 



The Institute of Medicine – the advisory to policy makers on healthcare policy and safety – says healthcare isn’t as safe as it could be. About 48,000 to 98,000 people are killed by medical errors (more than motor vehicular accidents, breast cancer, and AIDS put together). Quality care is: o Safe – avoid injury and harm to patient o Timely – reducing waits o Effective – care based on evidence and educated providers o Efficient – avoiding waste ($) o Equitable – quality does not vary because of gender, ethnicity, socioeconomic status; available to everyone o Patient-centered – respectful and responsive care based on patient values Errors and harm may be further classified as to where they occur in the health system: o Latent failure – arising from decisions that affect organizational policies, procedures, and allocation of resources. This is sometimes called the “blunt” end. o Active failure – direct contact with the patient. This is sometimes referred to as the “sharp” end. o Organizational system failure – indirect failures related to management, organizational culture, protocols/processes, transfer of knowledge, and external factors. o Technical failure – indirect failure of facilities or external resources. The Swiss Cheese Model is a theory that explains why healthcare errors occur. Every step in a process has the potential for failure, to varying degrees. The ideal system is analogous to a stack of slices of Swiss cheese. Consider the holes to be opportunities for a process to fail, and each of the slices as “defensive layers” in the process. An error may allow a problem to pass through a hole in one layer, but in the next layer the holes are in different places, and the problem should be caught. For a catastrophic error to occur, the holes need to align for each step in the process allowing all defenses to be defeated and resulting in an error, so the more defenses you put up, the better. Common errors in healthcare include medication errors, surgical errors, diagnostic/laboratory inaccuracies, equipment failure, blood transfusion error, and systems failure. A pressure ulcer is a localized injury to the skin and other underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. Pressure injuries are mostly preventable, yet about 60,000 patients die as a direct result of a pressure injury each year. o Factors such as pressure intensity, pressure duration, and tissue tolerance are important. o Low pressure intensity (patient laying supine) for a longer period of time will cause the same injuries as high pressure intensity (patient sitting up) for a shorter period of time. Risk factors for pressure injuries include impaired sensory perception, impaired mobility, alteration in level of consciousness, shear (sliding) and friction, moisture, decreased general health, history of healed ulcers, and use of braces, collars, oxygen tubes, and other pressure-forming devices. The Braden Scale is used to assess a patient’s risk level for development of pressure ulcers.

 

The most common sites for pressure sores are bony prominences, such as the back of the head and ears, the shoulders, the elbows, the lower back and buttocks, the hips, the inner knees, and the heels. One method for assessment of a pressure ulcer is the use of a staging system, developed by The National Pressure Ulcer Advisory Panel. Staging systems for pressure ulcers are based on describing the depth of tissue loss. Accurate staging requires knowledge of the skin layers. A major drawback of a staging system is that you cannot stage an ulcer covered with necrotic tissue because the necrotic tissue is covering the depth of the ulcer. Once you have staged the pressure ulcer, this stage endures even as it heals. o Stage 1: Nonblanchable Redness. Intact skin presents with nonblanchable redness of a localized area, usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness, or pain may also be present. o Stage 2: Partial-Thickness. Partial thickness loss of dermis presents as a sha...