Exam (elaborations)
HESI Gerontology - Integument QUESTIONS AND CORRECT ANSWERS GRADED A+ 2024/2025
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HESI Gerontology - Integument QUESTIONS AND CORRECT ANSWERS GRADED A+ 2024/2025
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HESI Gerontology - IntegumentFoot troubles in older adults - ANSprone to foot issues because of terrible circulate,
atherosclerosis, and reduced sensation within the decrease extremities - diabetes mellitus
Encourage older adults to check out their ft day by day and file any open wounds or breaks
within the pores and skin
Untreated wounds may additionally emerge as inflamed, cause osteomyelitis, and require
surgical debridement - if contamination spreads it may result in decrease limb amputation
Skin care: - ANSDaily inspection of the affected person's complete skin
Document and record any manifestations of pores and skin contamination
Use moisturizers daily on dry skin, and observe whilst skin is damp
Keep moisture from prolonged contact with pores and skin (Dry regions in which two pores
and skin surfaces contact, absorbent pads beneath areas where perspiration collects,
moisture boundaries on pores and skin areas where wound drainage or incontinence
happens)
DO NOT rubdown bony prominences
Humidify room
Risk factors for a diabetic foot ulcer - ANSsmoking,
hypertension,
lipoprotein abnormalities (especially extended low-density lipoprotein),
persistent hyperglycemia,
absent vibratory sensation inside the lower extremities,
PVD,
poor outpatient diabetes schooling
older adults who stay alone or who've intellectual confusion
diabetes
nuropathy
Ulcers as a consequence of diabetic peripheral neuropathy: - ANSbilateral, symmetric, and
placed on the plantar floor of the foot
court cases of pain and paresthesias
First sensations stricken by neuropathy: - ANSPain and temperature
First line of defense against diabetic foot ulcers - ANSPatient training regarding a way to limit
the threat of chemical, thermal, and mechanical trauma
Semmes-Weinstein monofilament - ANSeasy and less expensive device for establishing
neuropathy
Inability to experience the 5.07 monofilament shows the patient is at chance for ulceration
and wishes orthotics (mainly outfitted shoes designed to save you ulcers and to decrease
callous formation through redistributing weight)
, Medications acknowledged to set off hypotension in older adults: - ANSamitriptyline ---
antidepressants --- antihypertensives
bromocriptine --- alpha-blockers and BBs
diphenhydramine --- diuretics --- insulin --- marijuana
minor tranquilizers --- monoamine oxidase inhibitors
narcotics or sedatives --- nitrates --- phenothiazines sildenafil --- sympatholytics ---
sympathomimetics (with prolonged use)
tricyclic antidepressants --- vasodilators --- vincristine
Assessment of an older person - ANScomplete fitness history and physical exam
syncope, falls, and near falls must be investigated with regards to food, medicinal drugs, and
environmental elements
Hydration reputation w/ CBC and serum glucose stage
Dehydration, anemia, and hypoglycemia (can cause syncope and falls)
An older adult returns to the orthopedic unit after an open reduction, internal fixation surgical
treatment for a fractured hip. Upon admission, she is combative and screaming profane
language. What is the nurse's first action?
A. Increase the customer's rate of intravenous fluids.
B. Give the patron IV morphine stat.
C. Start oxygen via mask at 6 L/min.
D. Assess for chance factors that could purpose her behaviors. - ANSD. Assess for danger
factors that would motive her behaviors.
Most crucial predictor for falls - ANSrecent records of falling
Fall danger elements - ANSHistory of falls --- Advanced age (>eighty years) --- Multiple
ailments --- Generalized weak spot or decreased mobility --- Gait and postural instability ---
Disorientation or confusion --- Use of medication that may reason accelerated confusion,
mobility boundaries, or orthostatic hypotension --- Urinary incontinence --- Communication
impairments --- Major visual impairment or visible impairment without correction --- Alcohol
or different substance abuse --- Location of affected person's room faraway from the nurses'
station --- Change of shift or mealtime (in the clinic or nursing home)
Nursing interventions for falls, regardless of danger - ANSMonitor affected person's activities
and behavior (each 30 to 60 mins) --- Remind the affected person to call for assist earlier
than getting off the bed or a chair and help the affected person get off the bed or a chair if
needed; lock all equipment (beds and wheelchairs) before transferring --- Teach to use the
grasp bars --- Provide or remind the patient to use a walker or cane for ambulating, educate
on how to use gadgets --- Remind to put on eyeglasses or a listening to resource if wanted
--- Help the incontinent patient to toilet every 1 to two hours --- Clean up spills straight away
--- eliminate muddle or obstacles that could make contributions to a fall --- adequate lighting
--- Observe for side consequences and toxic outcomes of drug remedy --- Orient affected
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