MDC Final Exam
Why are older adults at an increased risk for falls? - ✔️✔️- decreased strength
- impaired mobility and balance
- improper use of mobility aids*
- unsafe clothing*
- environmental hazards
- endurance limitations
- decreased sensory perception
What are some factors that put a patient at a high risk for falls? - ✔️✔️History of falls
Polypharmacy
BP meds
Sedatives (drowsiness)
Opioids
Immobility
Urinary frequency
Hypotension
Confusion ("cognitive dysfunction") - can't follow directions
nearsightedness
_______ occurs when the eye overbends the light and images converge in front of the
retina. Near vision is normal, but distance vision is poor. It is corrected with a concave
lens in eyeglasses or contact lenses. - ✔️✔️myopia
Risk factors for infection - ✔️✔️o Age (Older adult/young children)
o Wound/Break in first line of defense (break in skin/skin breakdown, insect bite,
insertion of IV-creates a portal of entry)
o Illness or Injury
o Tobacco Use (chemicals paralyze cilia)
o Substance Abuse (alcohol diminishes hunger, paralyzes cells in intestines)
o Multiple Sex partners (STI, cervical CA)
o Environmental Factors (work situation, living situation)
o Chronic Disease (hypertension, DM,...think poor circulation)
o Medications (immunosuppressants, NSAIDs, chemo, antibiotics)
o Invasive Nursing and Medical Procedures (urinary cath/IV line )
o Impaired immune system***
- the totality of socially transmitted behavior patterns, arts, beliefs, values, customs,
lifeways, and all other products of human work and thought characteristics of a
population of people that guides their worldview and decision making
- can be taught - ✔️✔️Culture
,- how does it affect healthcare? preferences, healthcare views, how they view illness
and disease, pain, death rituals, patient education, alternative therapies
*identifying that culture and heritage can be passed down through generations, it will
often impact their interactions with healthcare
List the fall preventions - ✔️✔️- complete a fall-risk assessment at admission & regular
intervals
- ensure patient has and knows how to use the call light
- use fall-risk alerts (color-coded wristbands)
- provide regular toileting and orientation of clients who have cognitive impairment
- provide adequate lighting
- place clients at risk for falls near a nurses station
- provide hourly rounding
- make sure personal items are within reach
- keep bed low, lock the breaks
- side rails up (for unconscious patients, sedated, etc.)
- non-skid footwear
- use gait belts and other assistive equipment when moving patients
- keep floor clean (no clutter, cords, scatter rugs, etc.)
- electronic safety monitors (chair or bed sensors)
Home Safety: Preschoolers and School Age Children
- Firearms - ✔️✔️- keep firearms unloaded, locked up, and out of reach
- teach to never touch a gun or stay at a friend's house where a gun is accessible
- store bullets in a different location from guns
Home Safety: Preschoolers and School Age Children
- Poison - ✔️✔️- teach child about the hazards of alcohol, cigarettes, and prescription,
non-prescription, and illicit drugs
- keep potentially dangerous substances out of reach
Home Safety: Preschoolers and School Age Children
- Motor Vehicles - ✔️✔️- use booster seats for children under 4'9" tall and weigh less
than 40 lb
- use seatbelt properly after booster seat
- teach child safety rules of the road
Home Safety: Preschoolers and School Age Children
- Drowning - ✔️✔️- be sure child has learned to swim and knows rules of water safety
- have the child wear a life jacket when near water. Implement a buddy system for the
school-aged child
- place locked fences around home and neighborhood pools
- provide supervision near pools or water
Fire Safety: Elements of a Home Safety Plan - ✔️✔️- keep emergency numbers near
the phone for prompt use in the event of an emergency of any type
,- ensure that the number and placement of fire extinguishers and smoke alarms are
adequate, that they are functional, and that family members understand how to operate
them. Set a time to routinely change batteries in smoke alarms
- have a family exit plan for fires that is reviewed and practiced regularly. Be sure to
include closing windows and doors if able and to exit a smoke-filled area by covering
the mouth and nose with a damp cloth and getting down as close to the floor as
possible
- "stop, drop, and roll"
Oxygen safety measures - ✔️✔️· use and store oxygen equipment according to the
manufacturer's recommendations
· place a "no smoking" sign in a conspicuous place near the front door of the home and
client's bedroom
· inform the client and family of the danger of smoking in the presence of oxygen.
Family members and visitors who smoke should do so outside the home
· ensure that electrical equipment is in good repair and well grounded
· replace bedding that can generate static electricity (wool, nylon, synthetics) with items
made from cotton
· keep flammable materials (heating oil and nail polish remover) away from the client
when oxygen is in use
· follow general measures for fire safety in the home (having a fire extinguisher readily
available and an established exit route if a fire occurs
How often should smoke detectors have their batteries checked? - ✔️✔️every 6
months
Why do we bathe clients? - ✔️✔️bathe clients to cleanse the body, stimulate
circulation, provide relaxation, and enhance healing
infection prevention strategy = regular bathing...it maintains intact skin (our primary host
defense)
Foot Care - ✔️✔️o inspect daily
o use lukewarm water, and dry feet thoroughly
o apply moisturizer
o avoid over-the-counter meds with alcohol or other strong chemicals
o clean socks
o check shoes for objects, rough seams, or edges
o cut nails straight across
o avoid self-treating corns or calluses
o do not apply heat
Before administering pain medication, what do you need to assess? - ✔️✔️- drug
interactions
- allergies
, - vital signs - know RR and oxygenation status, their effort of breathing (are they
breathing shallow? often?)
- side effects
Common side effects of pain medication - ✔️✔️- low BP
- low HR
- sedation
- respiratory depression
- orthostatic hypotension
- urinary retention
- nausea/vomiting
- constipation
Follow-up of pain medication - ✔️✔️- reevaluate pain level
- if given orally, follow up q 1 hour
- if given IV, follow up q 15 min
- check vital signs!
Time orientation - ✔️✔️- varies among people of different cultures
- some persons tend to be past- present- or future- oriented
- Groups from the Far East tend to be past-oriented and value traditions and
relationships over time and deadlines.
- In contrast, European Americans tend to be future-oriented, and Latin Americans and
Filipinos are more present-oriented and enjoy living in the moment.
- Differences in time orientation can be important as you plan nursing interventions. For
example, clients who are past-oriented may show up late (or not at all) for follow-up
appointments; therefore, you should provide a written or telephone reminder of their
appointment.
Health disparity - ✔️✔️- Health status
- Quality of care
- Access to care
- recognize that your patients in poorer communities might not have access to
healthcare, and if they DO it might not be as good of a quality. There is a well known
statistical disparity in infant death rates
Therapeutic Communication - ✔️✔️o Silence
o Presenting reality
o Active listening
o Asking questions
o Open-ended questions
o Clarifying techniques
§ Restating
§ Reflecting
§ Paraphrasing
