Name
University of Phoenix
NSG/498 Senior Leadership Practicum
Prof. Name
Date
Mastering NSG 506 Exam 1 requires a firm grasp of geriatric care principles and cardiovascular pathophysiology across adult and pediatric populations. Successful clinical decision-making relies on your ability to differentiate the “3 Ds” of cognitive change (dementia, delirium, and depression), safely manage polypharmacy using the Beers Criteria and the 4Ms Framework, and prioritize assessments for complex cardiovascular conditions such as acute coronary syndrome (ACS), heart failure, and pediatric congenital cardiac shunts.
Caring for older adults begins with understanding normal age-related physiological changes and establishing a accurate baseline cognitive assessment. Because acute systemic illnesses in older adults frequently manifest as sudden changes in mental status, knowing a patient’s baseline is essential for early clinical intervention.
Cognitive alterations in older adults generally fall into three distinct categories: dementia, delirium, and depression. Differentiating among these conditions is a high-yield skill for nursing exams and clinical practice.
Dementia is a chronic, progressive decline in executive function, memory, and spatial orientation that permanently impairs daily independence. It develops gradually over months or years, with memory loss typically presenting as the earliest sign. Although consciousness remains unimpaired, the condition is generally irreversible. Common underlying etiologies include Alzheimer’s disease, vascular dementia, Lewy body dementia, Parkinson’s disease dementia, and frontotemporal dementia.
Delirium, by contrast, is an acute and fluctuating disturbance of attention, awareness, and cognition that develops rapidly over hours or days. It is often triggered by underlying systemic issues such as acute infections (e.g., urinary tract infections), dehydration, hypoxia, electrolyte imbalances, medication side effects, or severe constipation. Delirium presents in three forms: hyperactive (marked by agitation and hallucinations), hypoactive (marked by lethargy and withdrawal), or mixed (fluctuating between states). Crucially, delirium is considered a medical emergency and is often reversible once the primary physical cause is treated. For severe hyperactive agitation that threatens patient safety, low-dose haloperidol may be indicated per protocol.
Depression is a treatable mood disorder that is frequently underdiagnosed and should never be dismissed as a normal part of aging. It often coexists with dementia, creating a diagnostic overlap sometimes referred to as pseudodementia. Diagnosis requires a persistent depressed mood or loss of interest alongside at least four core symptoms, including fatigue, sleep changes, appetite alterations, feelings of worthlessness, or suicidal ideation. Unlike dementia, depression responds well to therapeutic and pharmacological interventions.
Onset: Dementia is gradual; Delirium is sudden (hours to days); Depression develops over weeks to months.
Course & Duration: Dementia is progressive and permanent; Delirium fluctuates and resolves with treatment; Depression varies but is treatable.
Attention & Consciousness: Dementia leaves attention intact early on with normal consciousness; Delirium severely impairs attention with fluctuating consciousness; Depression leaves attention and consciousness generally intact.
Managing drug therapy in older adults requires distinguishing between polypharmacy and polymedicine. Polypharmacy refers specifically to the inappropriate or excessive use of multiple medications, which dramatically heightens the risk of adverse drug reactions, drug-drug interactions, falls, nonadherence, and preventable hospitalizations. Polymedicine, conversely, is the clinically appropriate prescription of multiple medications to manage coexisting chronic conditions.
High-risk medications in geriatric care—frequently highlighted in board questions—include anticoagulants like warfarin, narrow therapeutic index drugs like digoxin, and glycemic agents like insulin. To minimize drug-induced harm, nurses rely on the American Geriatrics Society Beers Criteria®, an evidence-based guideline that identifies potentially inappropriate medications that should generally be avoided or used with extreme caution in older populations.
The 4Ms Framework provides a structured approach to delivering safe, person-centered care for older adults across healthcare settings:
What Matters: Align clinical care with the patient’s specific health goals, values, and end-of-life preferences.
Medication: Optimize drug therapy by deprescribing unnecessary medications and selecting age-appropriate drugs.
Mentation: Proactively prevent, identify, and manage delirium, dementia, and depression across care transitions.
Mobility: Ensure older adults move safely every day to preserve functional independence and prevent fall-related injuries.
Cardiovascular care spans acute ischemic events in adults to structural congenital heart defects in pediatric patients. Mastering these concepts requires understanding hemodynamic principles and diagnostic indicators.
Acute Coronary Syndrome (ACS) encompasses a continuum of myocardial ischemia resulting from a sudden reduction in coronary artery blood flow. It includes unstable angina, non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). If coronary perfusion is severely restricted or blocked for longer than 30 to 40 minutes, irreversible cellular necrosis and myocardial tissue damage occur.
A critical nursing priority is distinguishing NSTEMI from STEMI based on diagnostic findings:
NSTEMI: Results from a partial coronary artery occlusion. Electrocardiogram (ECG) tracings typically show ST-segment depression or T-wave inversion, accompanied by elevated cardiac biomarkers (such as troponin). It requires urgent medical evaluation and anti-ischemic management.
STEMI: Results from a complete coronary artery occlusion. ECG tracings show characteristically elevated ST segments. A STEMI is an emergent medical crisis requiring immediate reperfusion therapy (either percutaneous coronary intervention or fibrinolytic therapy) to prevent extensive tissue death.
Any chest pain lasting longer than 15 minutes that remains unrelieved by rest or nitroglycerin must be treated immediately as a potential myocardial infarction.
Heart failure occurs when the myocardium is unable to pump an adequate volume of blood to satisfy the body’s metabolic demands. While compensatory activation of the sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS) initially helps maintain blood pressure, sustained neurohormonal activation ultimately accelerates ventricular remodeling and worsens heart failure.
Left-sided heart failure primarily impairs the left ventricle’s ability to pump blood into systemic circulation, causing blood to back up into the pulmonary vasculature. This produces pulmonary congestion, manifesting clinically as dyspnea, orthopnea, paroxysmal nocturnal dyspnea, crackles on auscultation, and pulmonary edema.
Right-sided heart failure usually develops secondary to left-sided heart failure or chronic pulmonary disease. As the right ventricle fails, blood backs up into the systemic venous circulation. This leads to systemic fluid overload, characterized by peripheral edema, jugular venous distention (JVD), hepatomegaly, ascites, and sudden daily weight gain.
Diagnostic evaluation relies on a combination of tools: an electrocardiogram to check rhythm, a chest X-ray to assess cardiomegaly and pulmonary edema, an echocardiogram to determine left ventricular ejection fraction and valvular structure, and serum B-type natriuretic peptide (BNP) levels to quantify myocardial stretch and fluid overload severity.
Congenital Heart Disease (CHD) stems from abnormal structural development of the heart during fetal life, influenced by genetic factors (such as Trisomy 21, 18, 13, and DiGeorge syndrome) and maternal environment (such as uncontrolled diabetes, systemic lupus erythematosus, maternal rubella, or intrauterine exposure to lithium).
Unlike adult patients, infants with heart failure rarely present with overt peripheral edema or classic shortness of breath. Instead, pediatric congestive heart failure manifests as poor feeding, excessive sweating (diaphoresis) during feeds, resting tachycardia, tachypnea, poor weight gain, and failure to thrive.
Pediatric management strategies aim to reduce myocardial oxygen demand while maximizing cardiac output:
Pharmacotherapy: Diuretics like furosemide reduce preload, while digoxin improves myocardial contractility. Because digoxin has a narrow therapeutic index, nurses must recognize that vomiting in a child taking digoxin is often the primary sign of toxicity and requires immediate clinical hold and evaluation.
Nursing Care Interventions: Cluster nursing activities to allow uninterrupted rest, elevate the head of the bed during feedings, keep individual feeding sessions under 30 minutes to reduce energy expenditure, feed high-calorie formulas, and monitor daily weights closely.
Diagnostic modalities evaluate specific structural, electrical, and hemodynamic aspects of the heart:
Electrocardiogram (ECG): Rapidly evaluates cardiac conduction, dysrhythmias, and signs of active myocardial ischemia or infarction.
Echocardiography: Uses ultrasound to assess ejection fraction, cardiac valve anatomy, wall motion abnormalities, and chamber dimensions.
Cardiac Catheterization: An invasive procedure used to measure intracardiac pressures and map coronary artery patency. Post-procedure nursing care centers on strict bleeding prevention at the access site, monitoring frequent vital signs, assessing peripheral pulse quality distal to the puncture site, and maintaining the affected extremity completely flat per institutional guidelines.
Cardiopulmonary bypass (CPB) temporarily takes over systemic circulation and arterial oxygenation during open-heart surgery. Postoperative care requires vigilance for systemic inflammatory response syndrome (SIRS), microvascular bleeding, electrolyte shifts, pulmonary atelectasis, transient renal dysfunction, myocardial stunning, and impaired thermoregulation.
In pediatric cardiac care, understanding pulmonary blood flow ratios ($Q_p:Q_s$) is essential. Normal cardiovascular circulation maintains a pulmonary-to-systemic blood flow ratio ($Q_p:Q_s$) of 1:1. In acyanotic congenital heart defects featuring a left-to-right shunt (such as an atrial or ventricular septal defect), oxygenated blood flows back from the high-pressure left side of the heart into the lower-pressure right side. This increases overall pulmonary blood flow ($Q_p:Q_s > 1$), causing pulmonary overcirculation while the infant typically maintains a pink systemic color.
Cognitive Baselines: Always contrast current cognitive status against the patient’s verified baseline; delirium develops abruptly and is often reversible, whereas dementia is slow, progressive, and permanent.
Safety & Pharmacology: The Beers Criteria guides safe prescribing in older adults to prevent polypharmacy risks. In pediatric cardiac care, vomiting is a classic red-flag indicator of digoxin toxicity.
Cardiovascular Alerts: STEMI represents complete coronary arterial occlusion and demands rapid emergency reperfusion therapy. Unrelieved chest pain lasting past 15 minutes is treated as an active acute MI.
Fluid Indicators: Daily weight measurements serve as the most sensitive, reliable clinical indicator of fluid retention or loss in patients with heart failure. Left-sided heart failure causes pulmonary symptoms, whereas right-sided heart failure leads to systemic venous congestion.
Dementia is a chronic, gradual, and progressive cognitive decline that is generally irreversible. Delirium is an acute, temporary disturbance of attention and consciousness that fluctuates throughout the day and typically resolves when the underlying medical cause is treated.
Establishing a baseline allows nurses to immediately recognize acute mental status changes. Sudden deviation from baseline is often the earliest clinical sign of acute physical illnesses, such as urinary tract infections, hypoxia, or adverse drug events in older adults.
Polypharmacy refers to the excessive or clinically inappropriate use of multiple drugs, which increases the risk of side effects and adverse interactions. Polymedicine is the appropriate, evidence-based use of multiple medications to manage several distinct chronic medical conditions.
The 4Ms Framework consists of What Matters (aligning care with patient preferences), Medication (optimizing safe drug use), Mentation (managing dementia, delirium, and depression), and Mobility (preserving functional movement and reducing fall risk).
NSTEMI usually indicates partial coronary occlusion and shows ST-segment depression or T-wave inversion on ECG with elevated cardiac troponins. STEMI indicates complete coronary artery occlusion, showing ST-segment elevation on ECG, and requires immediate emergency reperfusion.
Pediatric heart failure typically presents with feeding difficulty, excessive sweating during feedings, poor weight gain, resting tachycardia, tachypnea, irritability, and frequent respiratory infections.
American Geriatrics Society. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052–2081. https://doi.org/10.1111/jgs.18372
American Heart Association. (2025). Advanced Cardiovascular Life Support (ACLS) Provider Manual. American Heart Association. https://cpr.heart.org
Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2023). Wong’s nursing care of infants and children (13th ed.). Elsevier. https://www.us.elsevierhealth.com
Institute for Healthcare Improvement. (2024). Age-Friendly Health Systems: The 4Ms Framework. https://www.ihi.org/initiatives/age-friendly-health-systems
Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M., Kwong, J., & Roberts, D. (2023). Medical-surgical nursing: Assessment and management of clinical problems (12th ed.). Elsevier. https://www.us.elsevierhealth.com
Lilley, L. L., Collins, S. R., & Snyder, J. S. (2023). Pharmacology and the nursing process (10th ed.). Elsevier. https://www.us.elsevierhealth.com
