NURS 101 Test 3 – Flashcards
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Purpose of Sleep
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Need 8 Hours Of Sleep -Tissue Repair -Clearer Thinking -Better Decision Making -Rest For The Heart -Increase Immunity -Protection -Weight Loss Is Greater
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Sleep Assessment
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They Look: unkept, dark circles under eyes, red eyes, slouched. They Feel: Irritable, have trouble focusing, tired, anorexic, accident prone. They Act: Yawning, grumpy, disinterested, doze off. Labs: Especially hgb, Na, K SpO2: Less than 90%
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Sleep Apnea
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A disorder in which the individual during their regular sleep cycle, experiences lack of airflow through their nose and mouth from 10 seconds to 2 minutes several times a night.
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Who Is At Risk For Sleep Apnea
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-Males -African American -Family Hx -Increasing Age -Medical Conditions -Post-Menopausal Women -Overweight -Alcohol Use -Large Neck -Smoking
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Sleep Apnea Danger
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-Angina (Chest Pain) -Heart Attack -Hypertension -Stroke -Dysrhythmias->Improper beating of the heart
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Signs & Symptoms of Sleep Apnea
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-Awakens Feeling Tired -Grumpy or Irritable when awake -Falls Asleep Driving -Dozes During The Day -Difficulty Focusing -Snores Loudly Most Nights
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Diagnosing Sleep Apnea
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-Symptoms->Frequently Reported by Family -Risk Factors->The more present the higher the risk -Testing->Assessment & (polysomnography) sleep study.
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Nursing Diagnosis for Sleep Apnea
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-Disturbed Sleep Pattern -Sleep Deprivation
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Treatment for Sleep Apnea
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-If overweight-loose weight (decrease calories & increase exercise) -Alcohol Use-Decrease to minimal intake -Smoking- Stop!
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What is Insomnia
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-Difficulty falling asleep -Frequently awakens during the night -Sleeps for only short periods of time -Not rested in the morning -Feels tired/anxious during the day
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Sleep Nursing Diagnosis
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Sleep Deprivation
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How to help with sleep
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*Provide bedtime routine *Adjust environment *Provide snack *Active listening *Comfort measures *Medications -Sedatives -Analgesics
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H.S. (bedtime) Snack
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L-Tryptophan Selections -Dairy products (cheese, milk, yogurt, ice cream) -Turkey Sandwhich -Less is better than more -Herbal Tea
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These Foods increase insomnia
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*These are diuretics & result in being up to the bathroom (nocturia)* -Alcohol -Coffee -Tea -Colas **Avoid Caffeine Beverages (Stimulant)**
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Types of beverages with amount of caffeine
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-Coffee 100-120mg -Black Tea 30-60mg -Green Tea 25-50mg -Decaf Tea 1-8mg -Herbal Tea 0mg
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Sleep PM Care
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-Tighten sheets & blanket -Assist to restroom or bedside commode -Assist with oral or denture hygiene -Perform Peri-care or catheter care -Offer back rub -Offer bedtime snack
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How to Mentally Relax
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-Deep breathe -Guided Imagery -Music -Fragrance -Meditation -Change in surroundings -Conversation -Reading -Writing -Creative activities
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How to Physically Relax
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-Walking -Cooking -Shopping -Sports (basketball, tennis, fishing) -Biking -Boating and skiing -Picnicking -TV -Remodeling -Gardening and yard work
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Purposes of Exercise
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-Relieves tension -Strengthens muscles -Keeps joints mobile -Clears thinking -Lowers cholesterol -Increase metabolism -Promotes Digestion -Morning exercise increase sleep by 70%
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You should exercise??
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20 minutes a day and at least 3 times a week
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Sleep Goal
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Pt. will experience usual pattern of sleep AEB: -Reports feeling rested -Sleeps 4-6 hours -Alert and energetic
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Evaluation of Sleep
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Reports, "I feel rested" Sleeps 4 hours Involved in ADLs
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Assessment of safety
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Patient Environment Nurse
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Fall Risk Assessment
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-History of falls (3-6 months) -Age 65+ (increase risked) -Patient Care Equipment -IV -Foley -Drainage Tubing -Poly Pharmacy (4 or more) ESP CNS depressants -Narcotics -Sedatives -Anticonvulsants -Anti-anxiety -diuretics -Anti-Hypertensive -Laxatives -Elimination (Bowel & Bladder)-> Incontinence, urgency, frequency. -Mobility->Requires assistance of person or equipment. -Cognitive->Oriented, forgetful, confused
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Fall Prevention
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-Do fall risk assessment -On admission -Daily -Fall Risk Alert Bracelet (Charm) -Side Rails up -Call light within reach -Bed in low position -Room Arranged Conveniently -Water & telephone handy -Tissues nearby -Blanket applied if needed
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Safety Diagnosis
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-Risk for injury R/T impaired mobility -Risk for injury R/T sensory (visual, hearing, tactile (touch), or speech) impairment. -Risk for injury R/T cognitive impairment (confusion, delayed development, depression, dementia, decrease in LOC)
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Sudden Infant Death Syndrome (SIDS)
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-Leading cause of infant death in USA in infants 1 month to 1 year -The cause in unknown -Smoking exposure increases the chance of SIDS by 4 times.
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Prevention of SIDS
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-Sleep on back or side -Use pacifier -Sleep alone in crib -No blankets or pillows -Use sleep sacks -No sleeping in car seat or swing
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Aging-Integumentary
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-Dry Skin *Bathe every other day *Use mild soap *Use lotions *Pat dry -Thin, loose skin *Be careful not to tear -Age Spots *Limit sun exposure *Wear sun screen
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Integumentary Nursing Diagnosis
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Risk for impaired skin integrity R/T thin skin
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Aging-Musculoskeletal
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-Muscles (Thinning) *Stretch *Exercise -Bones (Brittle) *Osteoporosis->May shrink 6" *Calcium & Vit D *Exercise
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Musculoskeletal Nursing Diagnosis
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Impaired physical ability R/T weakness
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Aging Vision
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-Presbyopia->Decreased Close Vision *Corrective lenses (Bifocals) -Cataracts->Surgery *Fixable -Glaucoma->Eye Drops *Preventable
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Presbycusis
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Decreased Hearing *Look at the person *Speak slowly and clearly *Wear hearing aids Cerumen->Ear Wax *Dries and hardens *Practice good ear hygiene
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Hearing Nursing Diagnosis
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Sensory impairment hearing R/T side effects of streptomycin Streptomycin causes ototoxicity (aminoglycoside)
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Aging-Touch
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Decreased ability to feel (tactile): -Heat -Cold -Pain
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Touch Nursing Diagnosis
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Risk for injury R/T inability to feel hot or cold.
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Orthostatic Hypotension
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-Rest-> 8hrs at HS (Bedtime) -Rise-> Slowly -Walk-> 3 days a week -Limit Caffeine -Keep weight WNL -3 hugs/day-> releases endorphins -Smile and laugh PRN -Talk to those you love -Know your VS (B/P and P)
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Orthostatic Hypotension Nursing Diagnosis
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Risk for falls R/T dizziness
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Dyspnea
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-Pace yourself -Walk to increase lung capacity -Plan rest periods
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Dyspnea Nursing Diagnosis
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Activity intolerance R/T insufficient O2 for demand
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How to help with Indigestion
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-Select a balanced diet -Eat lighter meal in p.m. -5 fruits/veggies/day -6-8 glasses of H2O -Enjoy meals with others
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Indigestion Nursing Diagnosis
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Imbalanced nutrition: less than body requirements R/T intolerance of spicy foods
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Genitourinary Frequency
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-Plan toileting -6-8 glasses H2O every day -Limit caffeine -Diuretics in A.M. -Practice kegel exercises
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Constipation
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-Exercise -Eat fresh fruits & veggies -Drink 6-8 glasses H2O -Plan regular toileting time -Reading materials
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Constipation nursing diagnosis
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constipation R/T decreased peristalsis
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What can you do to keep your mind sharp
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-Keep busy -Do things differently -Travel new routes -Read the newspaper -Become involved in problem solving
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Aging-Body Temperature
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-Frequently Cold -Warmer room -Sweaters -Blankets -Temperature -Watch for elevation
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Integrity
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Ability to accept the facts of ones life & face death without great fear
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Despair
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Feeling a loss of all hope and confidence
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Biological Clock
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Cyclical nature if body functions; functions controlled from within the body are synchronized with environmental factors.
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Non-Rapid Eye Movement (NREM)
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Sleep that occurs during the first four stages of normal sleep.
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Rapid Eye Movement (REM)
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Stage of sleep in which dreaming and rapid eye movements are prominent; important for mental restoration.
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NREM Stage 1
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-Stage includes lightest level of sleep -Stage lasts few minutes -Decreased physiological activity begins with gradual fall in vital signs and metabolism -Sensory stimuli such as noise easily arouse sleeper. -If awakened, person feels as though daydreaming has occurred.
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NREM Stage 2
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-Stage is period of sound sleep -Relaxation progresses -Arousal is still relatively easy -Stage lasts 10-20 minutes -Body functions continue to slow
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NREM Stage 3
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-It involves initial stages of deep sleep -Sleeper is difficult to arouse and rarely moves -Muscles are completely relaxed -Vital signs decline but remain regular -Stage lasts 15-30 minutes
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NREM Stage 4
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-It is deepest stage of sleep -It is very difficult to arouse sleeper -If sleep loss has occurred, sleeper spends considerable part of night in this stage -Vital signs are significantly lower than during waking hours -Stage lasts approximately 15-30 minutes -Sleepwalking and enuresis sometimes occurs
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REM Sleep
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-Vivid, full-color dreaming occurs -Stage usually begins about 90 minutes after sleep has begun -Stage is typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates and increased or fluctuating blood pressure. -Loss of skeletal muscle tone occurs -Gastric secretions increase -It Is very difficult to arouse sleeper -Duration of REM sleep increases with each cycle and averages 20 minutes.
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Nocturia
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Nighttime urination
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Narcolepsy
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Syndrome involving sudden sleep attacks that a person cannot inhibit; uncontrollable desire to sleep may occur several times during the day
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Narcolepsy with Cataplexy
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Condition characterized by sudden muscular weakness and loss of muscle tone.
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Sleep pattern for a normal adult
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-An adult has 4-6 sleep cycles, each with NREM sleep and REM sleep during a normal nights sleep. -About every 90 minutes, REM sleep recurs. When a sleeper awakens at any stage of the sleep cycle, the cycle must start again at stage 1.
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Anxiety does what to sleep
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-Anxiety stimulates the sympathetic nervous system resulting in less sleep. -The chemical change causes increasing norepinephrine levels in the blood, lessens Stage IV REM and REM sleep and results in more awakenings.
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What drug classification is temazepam
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Hypnotic
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Mr. Owen asks the nurse if he can start taking temazepam again?
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The patient should always be re-evaluated before resuming any medication. A new prescription needs to be filled if indicated. Continued evaluation is also needed if temazepam is used for more than 2 weeks or in high doses, both of which put the client at risk for tolerance and or physical dependence.
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The RN assess Mr. Owens for which other symptoms that are commonly associated with sleep deprivation?
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-Nocturia-> Urination during the night that disrupts the sleep cycle and contributes to sleep deprivation. -Sleep Apnea-> Occurs when there is a lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep, resulting in sleep deprivation.
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Which statement reflects an expected outcome for the nursing diagnosis of "Disturbed sleep pattern related to stress from new job"?
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-Patient will report a 50% decrease in night awakenings within 1 week. -The outcome is directly related to the nursing diagnosis, is specific and measurable and is realistically timed.
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Which intervetions should the RN add to Mr. Owens plan of care?
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-Monitor bedtime food and beverage intake, which might interfere with sleep. (Food and drinks containing caffeine, stimulants or alcohol can interfere with sleep patterns) -Instruct the patient to get out of bed if unable to fall back to sleep within 30 minutes and to do a quiet activity until becoming sleepy. (Lying in bed awake for more than 30 minutes may increase anxiety and inhibit the onset of sleep. A quiet activity such as reading or muscle relaxation can be helpful)
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The RN educates Mr. Owens on the effects that diet, exercise, stress reduction medications and the environment have on sleep patterns. What information reflects correct client teaching?
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-The presence of unusual stimuli or the absence of familiar stimuli may inhibit sleep. (Any change in the environment can inhibit sleep, including a quiet, peaceful environment when the client is accustomed to noise.
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When teaching the client and his wife about actions to promote rest and sleep, the RN demonstrates by administering a back massage on Mr. Owens. Which statement describes correct teaching?
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-Effleurage the entire back using slow movement and light pressure. (Effleurage is a French term meaning "to touch lightly". This type of massage typically uses a gentle, sweeping, relaxing stroke that glides over the skin.
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Petrissage means?
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To knead or rub with force. Used to break down tightness and tension in large muscles, not small ones!
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The use of a pulse oximeter?
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-Measures the arterial blood oxygen saturation using a noninvasive finger sensor. -Arterial blood oxygen is non-invasively measure and the percentage of hemoglobin that is saturated with oxygen is reported.
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How to explain OSA?
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-There is a lack of airflow through the nose and or mouth for periods of 10 seconds or longer during sleep. -This is Obstructive Sleep Apnea. Efforts by the brain and respiratory muscles continue but the airflow is obstructed.
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Obstructive Data
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-What is seen, heard, or measured by the RN -Client yells at his wife when she says he is irritable! (RN observed this!) -Client has gained an additional 5 pounds. (RN measured and assessed this)
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To promote sleep for a hospitalized client, which intervention should the RN implement?
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-Close the door to the patients room whenever possible to decrease the noise level and light coming into the room. -Reducing the amount of light and the noise of call lights, hallway traffic, and overhead paging are import nursing interventions to facilitate sleep for a hospitalized client.
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Patient with OSA (Obstructive Sleep Apnea) sounds the pulse oximeter alarm. The RN enters the room and the patient is sleeping and the oxygen saturation has decrease to 84% what should the RN do?
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-Gently shake the patient to awaken him. -Although the RN wants to promote sleep, the client must be awakened to relieve the obstruction and increase oxygen saturation.
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Heart rate drops from 80-65bpm while sleep is this normal?
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-Yes! A decrease of up to 20bpm during NREM sleep is considered a normal finding and a part of the bodys circadian rhythm.
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In managing postoperative care, which task should the RN delegate to the unlicensed assistive personnel (UAP)
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-Obtain pulse oximetry and respiratory rate every 2 hours -Serve the prescribed breakfast tray to the client. -VS can be delegated -Assessments cannot be delegated they need to be completed by a nurse. -ANY prescribed medications need to be given by the RN.
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The RN enters the patients room with medications. He is asleep and the wife states to leave the medication at the bedside for self-administration when he wakes. What is the correct nursing action?
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-Wake the client and administer the first dose of antibiotic. -Although the client may need sleep his need for the antibiotic is greater.
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Communicating with older adults
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-Maintain a quiet environment that is free from background noise -Avoid shifting from subject to subject; allow time for conversation -Be an attentive listener. Use explorative questions to facilitate conversation. -Avoid long sentences to explain the subject. Try to keep it short, simple, and to the point. -Allow older adults the opportunity to reminisce. Reminiscing has therapeutic properties that increase the sense of well-being. -If you are experiencing problems understanding a patient, let the patient know and facilitate methods that help him or her speak more clearly. -Include a patients family and friends in conversations particularly in subjects known to the patient. -Be aware of cultural differences among patients.
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Biological Clock
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Cyclical nature of body functions; functions controlled from within the body are synchronized with environmental factors; same meaning as biorhythm.
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Carbon Monoxide
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Colorless, odorless, poisonous gas produced by the combustion of carbon or organic fuels.
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Cataplexy
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Condition characterized by sudden muscular weakness and loss of muscle tone
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Chemical Restraints
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Medications, such as anxiolytics and sedatives that are used to manage a patients behavior and are not a standard treatment for a patients condition.
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Circadian Rhythm
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Repetition of certain physiological phenomena within a 24 hour cycle.
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Excessive Daytime Sleepiness
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Extreme fatigue felt during the day. Signs of this include falling asleep at inappropriate times such as while eating, talking or driving. May indicate a sleep disorder.
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Heat Exhaustion
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Abnormal condition caused by depletion of body fluid and electrolytes resulting from exposure to intense heat or the inability to acclimatize to heat
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Hypnotics
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Class of drug that causes insensibility to pain and induces sleep.
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Hypothermia
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Abnormal lowering of body temperature below 35 degree C or 95 degrees F usually caused by prolonged exposure to cold.
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Narcolepsy
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Syndrome involving sudden deep attacks that a person cannot inhibit, uncontrollable desire to sleep may occur several times during a day.
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Never Events
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Particularly shocking medical errors (such as wrong site surgery) that should never occur. The list of Never Events has expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability) and usually preventable.
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Pathogen
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Microorganisms capable of producing disease
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Immunizations
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A process by which resistance to an infectious disease is induced or augmented.
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Insomnia
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Condition characterized by chronic inability to sleep or remain asleep though the night
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Restraint
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Device to aid in the immobilization of a patient or patients extremity.
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Serious Reportable Events
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Adverse events (including never events) that occur in hospitals and that are serious, largely preventable and of concern to both the public and health care providers.
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Sedative
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Medications that produce a calming effect by decreasing functional activity, diminishing irritability and allaying excitement.
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Sleep
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State marked by reduced consciousness, diminished activity of the skeletal muscles and depressed metabolism.
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Sleep Deprivation
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Condition resulting from a decrease in the amount, quality, and consistency of sleep.
