N109: Foundations in Nursing Practice

N109: Foundations in Nursing Practice Study Guide hangover or steady your nerves? o Short Portable Mental Status Questionnaire: This ten-question test is used to assess cognitive ability and organic brain deficit in elderly patients when problems are suspected. Less than two errors indicates normal cognition, 3-4 errors indicate mild impairment, 5-7 errors indicate moderate impairment, and eight or more errors indicates severe cognitive impairment. The 10 questions are:  What is the date, month, and year?  What is the day of the week?  What is the name of this place?  What is your phone number?  How old are you?  When were you born?  Who is the president?  Who was the last president?  What was your mother’s maiden name?  Can you count backward from 20 by threes? o Geriatric Depression Scale (GDS): The GDS is a 30 itemself-report assessment designed to identify depression in the elderly. Many medical problems common to older people may be related to, or intensified by, a depressive disorder. Examples of questions on the GDS includes:  Are you basically satisfied with your life?  Are you hopeful about the future?  Do you often get restless and fidgety?  Do you frequently get upset over little things?  Do you enjoy getting up in the morning? • Laboratory tests: Age and developmental level appropriate lab tests will be ordered and should be evaluated for abnormalities. Analysis Using the assessment data and knowledge about common problems in each age range, the nurse should collaborate with the individual, family, caregiver, and other healthcare team members to develop and prioritize nursing diagnoses related to functional ability. Use Maslow’s hierarchy of needs (see figure below) to help address basic needs prior to higher level needs. Each diagnosis should be stated in terms of the diagnosis as it relates to some component of functional ability. Examples of diagnoses that might be included are: • Activity intolerance • Bowel or urinary incontinence • Risk for delayed development • Disabled family coping • Failure to thrive (pediatric or geriatric) • Risk-prone health behavior • Risk for compromised human dignity • Risk for disorganized infant behavior • Sedentary lifestyle • Risk for loneliness

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