Med Surg Test 1 - Medical Surgical Nursing Test 1 Notes PDF

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Ignatavicius: Medical-Surgical Nursing, 8th Edition Chapter 02: Common Health Problems of Older Adults Key Points

Priority concepts applied in this chapter include nutrition, mobility, sensory perception, cognition, elimination, and tissue integrity.        

 Learning about the special needs of older adults is important for health care professionals in a variety of settings.  The percentage of people older than age 65 years in the United States is about 13%.  The four subgroups of the older adult population are the young old, middle old, old old, and elite old.  The fastest growing subgroup is the old old, sometimes referred to as the “advanced older adult” population. Members of this subgroup are sometimes referred to as the “frail elderly,” although a number of 85- to 95-year-olds are very healthy.  Frailty is a clinical syndrome in which the older adult has unintentional weight loss, weakness and exhaustion, and slowed physical activity, including walking. Frail elders are also at high risk for adverse outcomes.  The vast majority of older adults live in the community at home or within an environment that offers assistance. Only 5% are in long-term care (LTC).  Considerations of multiple older adult health issues in other types of institutions (prisons) include alcohol and substance abuse and poor nutrition.  The number of homeless older adults, including veterans of war, continues to rise. These individuals are often faced with chronic health problems, including mental/behavioral disorders.

HEALTH ISSUES FOR OLDER ADULTS IN COMMUNITY-BASED SETTINGS          

 Health status can affect the ability to perform daily activities and participate in social activities.  Increased dependence on others may have a negative effect on morale and life satisfaction.  Loss of autonomy is a painful event with far-reaching effects.  Older adults often experience personal losses that can affect their sense of control over their lives.  Many older adults are not prepared for retirement in view of increased expenses and income that is not adequate to meet basic needs, health care treatments, and medications.  Many are discharged from health care facilities and require home health services or live in long-term care settings.  Coordinate care by collaborating with members of the health care team when providing care to older adults in the community or inpatient setting.  Provide information regarding community resources for older adults to help them meet their basic needs.  Common health issues and geriatric syndromes affecting the older adults include decreased nutrition and hydration, decreased mobility, stress and loss, accidents, drug use and misuse, mental health/cognition problems (including substance abuse), and elder neglect and abuse.  Decreased nutrition and hydration are two health problems experienced by older adults.  o Reduced income, chronic disease, fatigue, and decreased ability to perform activities of daily living are other factors that contribute to inadequate nutrition among older adults.  o Some older adults are at risk for geriatric failure to thrive (GFTT)—a complex syndrome including under-nutrition, impaired physical functioning, depression, and cognitive impairment.  o Many older adults are at risk for under-nutrition, most often protein-calorie malnutrition, also known as protein-energy malnutrition.  o Older adults may respond to loneliness, depression, and boredom by not eating.  o Diminished senses of taste and smell often result in a loss of desire for food, and poor dental status can affect their ability to chew.  o The risk for dehydration is greater in older adults because of many factors, including diuretics, incontinence concerns, and decreased thirst mechanism.   Decreased mobility  o Exercise and activity are important for older adults as a means of promoting and maintaining health.  o Teach older adults about the benefits of regular physical exercise.     Stress and Loss

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o Stress can speed up the aging process over time, or it can lead to diseases that increase the rate of degeneration. It can also impair the reserve capacity of older adults and lessen their ability to respond and adapt to changes in their environment. o Relocation stress syndrome is the physical and emotional distress that occurs after the person moves from one setting to another and may cause sleep disturbance and physical symptoms, such as GI distress.  Accidents o The biggest concern regarding accidents among older adults in both the community and inpatient setting is falls.   Older adults need to be aware of safety precautions to prevent accidents, such as falls.   Incapacitating accidents are a primary cause of decreased mobility in old age.   Changes in vision, touch, and motor ability can create challenges for older adults in any environment.  o Motor vehicle accidents are the most common cause of injury-related death in the young old population, those between 65 and 74 years of age.   Health care professionals play a major role in identifying driver safety issues.   Drug Use and Misuse o Medication use in older adults is often a problem when they commit errors when self-medicating, avoid needed medications, or have problems understanding their medication regimen. o Physiologic changes of aging predispose older adults to toxic effects of medication; drugs are absorbed, metabolized, and distributed more slowly. They are also excreted more slowly by the kidneys. o Older adults may not tolerate standard dosing traditionally prescribed for younger adults. o Chronic disease added to physiologic changes of aging results in drug reactions with a more dramatic effect and a longer time to correct. o Older adults may commit errors when self-medicating, avoid needed medications, or have problems understanding their medication regimen. o Polypharmacy is the use of multiple drugs, duplicative drug therapy, high-dosage medications, and drugs prescribed for too long a period of time. o The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults assessment tool is very useful in screening for medication-related risks in older adults who have chronic health problems.  Mental Health/cognition Problems (including substance abuse)  o Decreased reaction time to stimuli and an impairment of memory for recent events are changes in cognition that are age related.  o Two forms of competence exist: legal competence and clinical competence.  o If determined in court that a person is not legally competent, a guardian is appointed to make financial and health care decisions.  o A clinically competent person is legally competent and capable of making clinical decisions.  o Depression is the most common, yet most underdiagnosed and undertreated, mental health/behavioral health disorder among older adults. The Geriatric Depression Scale—Short Form (GDS-SF) was developed as a basic screening measure for depression in older adults.  o Depression is broadly defined as a mood disorder that can have cognitive, affective, and physical manifestations.  o Depression increases with admission to the hospital or nursing home.  o Dementia is a broad term used for a syndrome that involves a slowly progressive cognitive decline, sometimes called chronic confusion.  o Delirium is an acute state of confusion. Delirium differs from dementia in that it is usually short term and reversible, often occurring in unfamiliar settings.  o Confusion is not part of the normal aging process.  o Promote sleep and rest for older adults to decrease the incidence of delirium and prevent falls. Screen older adults for alcohol abuse or alcoholism and refer those with identified problems to appropriate resources. The CAGE questionnaire has four items and is used frequently in primary care for screening for alcohol misuse in older adults.  Elder Neglect and Abuse o Neglect or abuse may occur in older adults, especially those who are dependent.  o The abuser is often a family member who becomes frustrated or distraught over the burden of caring for the older adult.  o Abuse may be composed of neglect or failure to provide basic needs, physical abuse, financial abuse, or emotional abuse.

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 The ways in which individuals adapt to old age depends on personality traits and coping strategies they have used throughout their lives.  Many older adults return to work to help pay for health care and other expenses, and provide socialization.

HEALTH CARE ISSUES FOR OLDER ADULTS IN HOSPITALS AND LONG-TERM CARE SETTINGS  Older adults who are admitted to hospitals and long-term care settings such as nursing homes have special needs and potential problems.   Many of these problems are similar to those seen among community elders.   Whereas nursing homes have multiple federal and state laws to prevent negative patient outcomes, hospitals are not required to follow these protective laws.   The Joint Commission and other agencies have recently addressed some of the most common problems seen in older adults.   Since 1996, the Hartford Institute for Gerontological Nursing has worked to ensure that all hospitalized patients 65 years of age and older be given quality care.   The Fulmer SPICES framework was developed as part of the NICHE project and identifies six serious “marker conditions” that can lead to longer hospital stays, higher medical costs, and even deaths. These conditions are:  o Sleep disorders  o Problems with eating or feeding  o Incontinence  o Confusion  o Evidence of falls  o Skin breakdown   Use the SPICES assessment tool for identifying serious health problems that can be prevented or managed early.   Follow The Joint Commission’s National Patient Safety Goals (NPSGs) and best practice guidelines to prevent agency-acquired pressure ulcers.  Physical and chemical restraints should not be used for older adults until all other alternatives have been tried. If necessary, use the restraint that is least restrictive first.  The most common accident among older patients in a hospital or nursing home setting is falling. A fall is an unintentional change in body position that results in the patient’s body coming to rest on the floor or ground.  Maintaining tissue integrity is a major safety goal in the care of older adults. Prevention is key! The nurse uses evidence-based treatment for pressure ulcers, shear injuries, and skin tears. Supervising unlicensed assistive personnel in protecting fragile skin and coordinating interventions with the health care team is necessary to prevent harm and promote healing. 

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Ignatavicius: Medical-Surgical Nursing, 8th Edition Chapter 03: Assessment and Care of Patients with Pain Key Points

Priority concepts applied in this chapter are pain, palliation, cognition, and sensory perception.       

 pain is a universal, complex, and subjective experience.  Acute pain is usually short lived, whereas chronic pain can last a person’s lifetime.  Chronic pain is the most common cause of long-term disability, affecting millions of Americans and others throughout the world.  The nurse is legally and ethically responsible for acting as an advocate for patients experiencing pain.  In 2000, The Joint Commission published pain standards that were approved by the American Pain Society. This document states that patients in all health care settings, including home care, have a right to effective pain management.  Multidisciplinary pain teams, consisting of one or more nurses, pharmacists, case managers, and physicians, consult with staff and prescribers on how best to control the patient’s pain.  Coordinate the patient’s plan of care as he or she transfers between health care agencies. Be sure that the plan of care is communicated clearly.

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 Provide information to the patient and family about complementary and alternative therapies as needed. These modalities are additions to, not replacements for, the established plan of care.  Consider the special needs of older adults when assessing and managing their pain.  Be aware that some nurses and physicians have biases about pain assessment and management. Be objective when caring for any patient in pain.  Provide information to patients who have misperceptions about pain and pain management.

SCOPE OF THE PROBLEM   

 Pain is a leading cause of disability that affects the quality of life of many, especially older adults.  Pain is inadequately treated in all health care settings. High-risk populations and lack of adequate staffing are factors in pain management.  Communication and collaboration among the health care team are essential when caring for the patient with pain.

DEFINITIONS OF PAIN   

Pain is what the patient says it is. Self-report is always the most reliable indication of pain. Factors that affect PAIN and its management include age, gender, genetics, and culture. Three major types of pain have been identified—acute, chronic cancer, and chronic non-cancer.

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CATEGORIZATION OF PAIN BY DURATION 

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The two major types of pain are acute and chronic.  Acute pain often results from sudden, accidental trauma (e.g., fractures, burns, lacerations) or from surgery, ischemia, or acute inflammation. As injured tissue heals, sensory perception changes.  Chronic pain or persistent pain is further divided into two subtypes.  o Chronic cancer pain is associated with cancer or another progressive disease such as acquired immune deficiency syndrome (AIDS). The cause of pain is usually life threatening.  o Chronic non-cancer pain is associated with tissue injury that has healed or is not associated with cancer, such as arthritis or chronic back pain. This type of pain is the most common.  Acute pain serves as a warning to the body, causing sympathetic responses such as increased heart rate, increased blood pressure and pulse, dilated pupils, and sweating.  Both types of chronic pain do not cause sympathetic reactions. Therefore, some patients do not appear to be in pain, even when they are.

CATEGORIZATION OF PAIN BY UNDERLYING MECHANISMS               

 Painful stimuli often originate in the periphery of the body. o To be perceived, the stimuli must be transmitted from the periphery to the spinal cord and then to the central areas of the brain.  Nociceptive Pain o Normal pain processing, believed to be sustained by tissue damage or inflammation. Duration can be acute and/or chronic. o The gate control theory involves a gating mechanism in the spinal cord. When the gate is opened, pain impulses ascend to the brain; when closed, the impulses do not get through and pain is not perceived. o Nociception has four processes, including sensory perception (involves the conscious awareness of pain). o Somatic pain arises from the skin and musculoskeletal structure. o Visceral pain arises from organs.  Neuropathic Pain o Sustained from abnormal processing of stimuli and can occur in the absence of either tissue damage or inflammation. o Difficult to treat and often resistant to first-line pain agents. o Pain descriptors include “burning,” “shooting,” “stabbing,” and feeling “pins and needles.”  Tolerance implies that the patient has adapted to a drug and, over time, its effects decline.  Physical dependence is manifested by a withdrawal reaction.  Addiction is a primary, chronic disease that occurs over a long period. Behaviors in addiction include craving, compulsive drug use, and continued use despite harm.

PATIENT-CENTERED COLLABORATIVE CARE Pain Assessment        

 Nurses are responsible for thorough pain assessment.  Perform a complete pain assessment, including duration, location, intensity, and quality of pain. Initial and ongoing pain assessments are required.  The American Pain Society refers to pain as the fifth vital sign.  Ask the patient about the pain experience, including precipitating, aggravating, and relieving factors; the nature of adjustments in life or family responsibilities; localization, character quality, and duration; and beliefs.  Because of difficulty reporting their pain, patients with cognition problems are at high risk for undertreatment. There are common behavioral assessment tools that are used for cognitively impaired patients with delirium or dementia.  Pain may be described as localized, projected, radiating, and referred pain. Although physiologic changes occur in response to acute noxious stimuli, these are usually not reliable indicators of pain.  Pain intensity scales assess and measure pain and determine the effectiveness of pain relief interventions in the clinical or home setting.  Nonverbal, intubated, and cognitively impaired patients do feel pain that needs to be managed.

Pain Management                   

 Never use placebos for any patient; their use in non–research-based practice is unethical.  Non-opioid drugs are the first-line therapy for mild to moderate pain. o Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (Tylenol) are commonly used drugs in this category. o NSAIDs should be used with caution in older adults because of adverse effects, such as GI disturbances, bleeding, and sodium and water retention. o Acetaminophen can cause hepatotoxicity and nephrotoxicity with long-term use.  The opioid full agonists are most effective for both acute and chronic pain management. They bind to mu receptors and block pain transmission. o Equianalgesic charts are useful when changing from one opioid to another. A morphine dose of 10 mg is the standard dose against which other opioids are measured. o Morphine and similar mu agonists are the gold standard drugs for both acute and chronic pain and are available in many forms, both short acting and long acting. o Other commonly used mu agonists include oxycodone, hydromorphone, and fentanyl. o Meperidine is an outdated drug and is rarely used. Its toxic metabolite (normeperidine) can accumulate, especially in the older adult or someone with decreased renal clearance, and can cause seizures and confusion. o Observe for and prevent common side effects of opioids, including nausea and vomiting, constipation, sedation, and respiratory depression.  Multimodal (balanced) analgesia for epidural pain management is a combination of opioids, nonopioids, and/or local anesthetics to relieve acute pain, usually postoperative pain.  Assess for sedation in patients receiving patient-controlled analgesia (PCA) or epidural medication.  Nonpharmacologic therapies for pain management may be used in place of or in combination with drug therapy. These therapies are classified as physical modalities or cognitive-behavioral therapies.  Examples of physical measures to manage pain are transcutaneous electrical nerve stimulation (TENS), heat, cold, massage, and low-impact exercises.  Distraction, imagery, relaxation techniques, and hypnosis are examples of cognitive-behavioral therapies.  Acupuncture, magnet therapy, and herbal supplements are examples of other complementary and alternative therapies used for chronic pain management.  Pain can be managed in any setting, including the home. Some patients require parenteral pain medications at home; therefore, provide health teaching to ensure continuity of care.  Refer patients whose pain is difficult to manage to pain specialists and/or pain centers.

Ignatavicius: Medical-Surgical Nursing, 8th Edition Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances

Key Points

The priority concept in this chapter is fluid and electrolyte balance. HOMEOSTASIS 

 The body has many control mechanisms, called homeostatic mechanisms, to prevent fluctuations in fluid and electrolytes.

PHYSIOLOGIC INFLUENCES ON FLUID AND ELECTROLYTE BALANCE        

 Body fluids are composed of water and part...