NR-226 Fundamentals – Patient Care

Final Exam Review & Final Study Guide

• Review your nursing process, priorities, and safety

o ADPIE

 Assessment, Diagnosis, Planning, Implementation, Evaluation

o Priorities

 First-level Priority

 ABC’s (Airway, Breathing, Circulation), and Vital Sign

concerns

 Second-level Priority

 Requiring your prompt intervention to forestall further

deterioration (e.g., mental status change, acute pain,

acute urinary elimination problems, untreated medical

problems, abnormal laboratory values, risks of infection,

or risk to safety or security).

 Third-level Priority

 Problems with lack of knowledge, activity, rest, or family

coping

o Patient Safety First

 Ex. In case of fire, get patient out of the room first; keep

patients with high fall risk near nursing station

• Review calculations (ALL)

o 1 oz = 30 ml

o 1tbs = 15 ml

o 1 tsp = 5 ml

o 1 cup = 8 oz

o 1 kg = 2.2 lb

• Review pain management, PCA pumps

o Patient-controlled analgesia (PCA)

 Medication delivery system that allows clients to self

administer safe dose of opioids

 Small, frequent dosing ensures consistent plasma

levels.

 Clients have less lag time between identified need and

delivery of medication, which increases their sense of

control and can decrease the amount of medication they

need.

 Morphine, hydromorphone, and fentanyl are typical

opioids for PCA delivery

 Clients should let the nurse know if using the pump

does not control the pain

 To prevent inadvertent overdosing the client is the

only person who should push the PCA button.

• Review expected physiological changes for older adults

o Integumentary

 Decreased skin turgor, subcutaneous fat, and connective

tissue (dermis), which leads to wrinkles and dry, transparent

skin

 Loss of subcutaneous fat, which makes it more difficult for

older adults to adjust to cold temperatures.

 Thinning and graying of hair, as well as a more sparse

distribution

 Thickening of fingernails and toenails

o Cardiovascular/ Pulmonary

 Decreased chest wall movement, vital capacity, and cilia,

which increases the risk for respiratory infection

 Reduced cardiac output

 Decreased peripheral circulation

 Increased blood pressure

o Neurosensory

 Slower reaction time

 Decreased touch, smell, and taste sensations

 Decreased saliva production

 Decline in visual acuity

 Decreased ability for eyes to adjust from light to dark leading

to night blindness, which is dangerous when driving.

 Inability to hear high-pitched sounds (Presbycusis)

 Reduced spatial awareness

o GI

 Decreased digestive enzymes

 Decreased intestinal motility, which can lead to increased risk

of constipation

 Increased dental problems

o Neuromuscular

 Decreased height due to intervertebral disk changes

 Decreased muscle strength and tone

 Decalcification of bones

 Degeneration of joints

o Genitourinary

 Decreased bladder Capacity

 Prostate hypertrophy in men

 Decline in estrogen or testosterone production

 Atrophy of breast tissue in women

o Endocrine

 Decline in Triiodothyronine (T3) production, yet overall

functions remain effective

 Decreased sensitivity of tissue cells to insulin

• Review nutrition, complete and incomplete proteins, carb sources,

vegetarian, iron-deficiency, which foods contain the highest amounts

of nutrients, etc.

o Complete Protein (Contain all of the essential amino acids;Usually

from animal sources)

 Beef

 Whole milk

 Poultry

 Soy

o Incomplete Protein (Do not contain all the essential amino acids;

Generally come from plant sources)

 Nuts

 Legumes

 Grains

 Fruit

 Vegetables

o Carbohydrate Sources

 Whole grain breads

 Baked potatoes

 Brown rice

o Iron

 Green leafy vegetables

o Calcium

 Milk

o Which foods contain the highest amount of nutrients:

o Salmon,kale, seaweed, garlic, shellfish, potatoes, liver, blueberries,

Egg yolks

• Review sleep and comfort, insomnia interventions

o Nursing Considerations

 Help clients establish and follow a bedtime routine

 Limit walking clients during the night.

 Promote a quiet sleeping environment

 Help with personal hygiene needs or a back rub prior to sleep

to increase comfort.

 Consider continuous positive airway pressure (CPAP) devices

for clients who have sleep apnea

 Consult the provider about trying sleep-promoting over-thecounter products (melatonin, valerian, chamomile).

 As a last resort, suggest that the provider prescribe a

pharmacologist agent. Medication of choice for insomnia are

benzodiazepine - like medications, which include the sedativehypnotics zolpidem, eszopiclone, and zaleplon

o Client Education

 Exercise regularly at least 2 hr before bedtime

 Establish a bedtime routine and a regular sleep pattern

 Arrange the sleep environment for comfort

 Limit alcohol, caffeine, and nicotine at least 4 hour before

bedtime

 Limit fluid 2 to 4 hours before bedtime

 Engage in muscle relaxation if anxious or stressed

o

• Review GERD interventions, complications, teachings, etc. related to

bowel elimination

o GERD (Gastroesophageal Reflux Disease): Leakage of gastric

content/ enzymes into the esophagus

 Treatments

 Diet/ Lifestyle changes

 Medications

 Antacids

 Neutralize excess acid

 H2 (histamine 2) receptor antagonist

 Reduces secretion of acids

 suffix- tidine

 ranitidine, famotidine

 Proton pump inhibitor

 Reduce gastric acid by inhibiting cellular

pump necessary for secretion

 suffix- zole

 ex. pantoprazole, omeprazole

 Prokinetics

 Promote motility of esophagus/ stomach