Not the Final!!

Rest, Sleep, and Wakefulness

• Rest refers to a decreased state of activity, with a feeling of being refreshed.
• Sleep is a state of rest accompanied by altered consciousness and relative inactivity, part of the sleep-wake cycle.
• Wakefulness is a time of mental activity and energy expenditure.

Stages of Sleep

• A normal sleep cycle consists of four stages of NREM (non-rapid eye movement) sleep.
• The stages are consecutive, then reversed, and finally enter REM (rapid eye movement) sleep.
• The cycle repeats, with the person re-entering NREM sleep at stage II.

Circadian Cycle

• The circadian cycle is a biological clock that exists in all humans.
• The body prepares for sleep at night by decreasing body temperature and releasing melatonin.

Developmental Patterns of Sleep

• Newborns and infants: 16-24 hours of sleep in a day, in 4 hour increments.
• Toddlers: 11-14 hours of sleep at night, with 2 naps in the day.
• Preschoolers: 10-13 hours of sleep per night, with a similar REM sleep pattern to adults.
• School-aged children: 9-12 hours of sleep, with sleep peaking during times of physical growth.
• Teenagers: 8-10 hours of sleep, but often only 7-7.5 hours due to lifestyle factors.
• Young adults: 7-9 hours of sleep, with decreased REM sleep.
• Middle-aged adults: total sleep time decreases, with decreased stage 4 sleep and increased time spent awake.
• Older adults: average 7-8 hours of sleep, with less sound sleep and decreased stage 4 sleep.

Factors Affecting Rest and Sleep

• Developmental considerations (e.g., age-related sleep patterns).
• Motivation (e.g., staying awake for a party or event).
• Culture (e.g., cultural orientation towards privacy and quiet).
• Lifestyle and habits (e.g., working shifts, organizing priorities).
• Environmental factors (e.g., sleeping in a new environment affects REM and non-REM sleep).
• Psychological stress (e.g., affecting sleep patterns).
• Illness (e.g., GERD, insomnia, thyroid disorders).
• Medications (e.g., diuretics, timed medications).

Lifestyle and Habits

• Activity and exercise increase fatigue and promote relaxation followed by sleep.
• Dietary habits:
  • Amino acid L-tryptophan promotes sleep.
  • Small protein snack with a complex carbohydrate before bed improves sleep.
  • Large quantities of alcohol limit REM and delta sleep.
  • Caffeine blocks adenosine, leading to difficulty falling asleep.
• Avoid exercising less than 2 hours before bed.
• Avoid smoking and nicotine, associated with poor sleep.

ICSD Classification of Sleep Disorders

• The ICSD classification includes various sleep disorders, including insomnia.

Insomnia

• Signs and symptoms: difficulty falling asleep, intermittent sleep, or difficulty maintaining sleep.
• 30-35% of adults in the US complain of insomnia.
• Often associated with depression, disruptions in circadian rhythms, and recent weight gain.

Sleep-Related Breathing Disorders

• Obstructive Sleep Apnea (OSA): characterized by 5 or more predominant obstructive respiratory events.
• Symptoms: absence of breathing, irregular snoring, and gasping for air.
• Treatment: CPAP machine.

Central Disorders of Hypersomnolence

• Idiopathic Hypersomnia: excessive sleep, particularly during the day.
• Narcolepsy: excessive daytime sleepiness, frequent overwhelming urges to sleep.

Parasomnias

• Disruptive sleep-behaviors, including:
  • Somnambulism (sleepwalking).
  • REM sleep behavior disorder (RBD).
  • Sleep terrors (occurring in deepest stages of sleep).
  • Nightmare disorder (frightening dreams, more common in children).
  • Sleep enuresis (bedwetting, more common in males).
  • Sleep paralysis (brief state of immobility upon waking).
  • Sleep-related eating disorder (eating while asleep, with no recollection upon waking).

Pain Management

• Patient pain assessments should include:
  • Verbalization and description of pain.
  • Onset and duration of pain.
  • Etiology (cause) or mechanism of injury.
  • Location of pain.
  • Quality, character, and intensity of pain.
  • Aggravating or causal factors.
  • Alleviating or relieving factors.
  • Effect on function.
  • Pain management goal.
• Pharmacologic pain relief measures:
  • Analgesic administration.
  • Opioid (e.g., morphine).
  • Adjuvant (e.g., Gabapentin).
  • Nonopioid (e.g., Tylenol, Motrin).
• Complementary health approaches and integrative health care:
  • Distraction.
  • Humor.
  • Music.
  • Imagery.
  • Mindfulness practice.
  • Cutaneous stimulation.
  • Acupuncture.
  • Hypnosis.
  • Biofeedback.
  • Healing/therapeutic touch.
  • Animal-assisted intervention.

Types of Pain

• Acute pain: rapid onset, varying in intensity from mild to severe.
• Chronic pain: maladaptive pain that persists or recurs for more than 3 months.
• Localization: pain localized to the place of injury.
• Somatic pain: scattered pain in tendons, ligaments, bones, blood vessels, and nerves.
• Visceral pain: produced by a disease, often occurring as organs stretch abnormally.
• Cutaneous/superficial pain: pain in the skin.
• Referred pain: pain referred to a different area than the source of the pain.

Duration of Pain

• Acute pain: rapid in onset, varies in intensity and duration.
• Chronic pain: persists or recurs for more than 3 months.

Analgesic Administration

• Opioid administration: example, morphine.
• Adjuvant administration: example, Gabapentin.
• Nonopioid administration: example, Tylenol, Motrin.

Pain Treatment in Special Populations

• Children.
• Older adults.
• Nonverbal cues are important in assessing pain in these populations.

Additional Methods for Administering Analgesics

• Patient-controlled analgesia (PCA) pumps.
• Epidural analgesia and peripheral nerve blocks.
• Topical anesthesia.### Protein Intake
• RDA for adults is 0.8 g/kg of body weight, which accounts for 10% to 35% of total calorie intake
• Protein intake is extremely important for all patients, especially those recovering from surgery or trauma, as it is essential for generating new cells and wound healing

Vitamins

• Organic compounds needed by the body in small amounts, but do not provide calories
• Required for metabolism of carbohydrates, protein, and fat
• Can be classified into two categories:
  • Water-soluble: C, B-complex vitamins; not stored in body, need to be taken daily
  • Fat-soluble: A, D, E, K; absorbed through the intestinal wall directly into bloodstream

Food Intake

• Can be categorized into two components:
  • Decreased (anorexia, loss of appetite)
  • Increased (obesity, BMI ≥30)

Diets

• Modified consistency diets:
  • Clear liquid: Jello, carbonated beverages, apple juice
  • Pureed: Pudding
  • Mechanically altered: Items that can be blended
• Types of nutritional therapy:
  • TPN (total parenteral nutrition): bypasses gastrointestinal tract, administered through central vein
  • PPN (peripheral parenteral nutrition): for clients with inadequate oral intake, requires supplementation through peripheral vein
  • PEG (percutaneous endoscopic gastrostomy): surgically placed gastrostomy tube
  • PEJ (percutaneous endoscopic jejunostomy): surgically placed jejunostomy tube

Pain

• The process of pain transmission:
  • Action potential propelled along neuron by exchange of ions through nerve cell membrane
  • Sodium rushes in, potassium rushes out, changing charge on membrane surface
• Gate theory: explains why mechanical and electrical interventions or heat and pressure may provide effective pain relief

Factors Affecting Pain Experience

• Cultural and ethnicity variables
• Family, biologic sex, gender, and age variables
• Religious beliefs and spirituality
• Environment and support people
• Anxiety and other stressors
• Past pain experience

Pain Assessment

• Patient's verbalization and description of pain
• Onset and duration of pain
• Etiology (cause) or mechanism of injury, if known
• Location of pain
• Quality, character, and intensity of pain
• Aggravating or causal factors
• Alleviating or relieving factors
• Effect on function
• Pain management goal

Pain Relief Methods

• Pharmacologic measures:
  • Analgesic administration (e.g., morphine)
  • Adjuvant therapy (e.g., gabapentin)
  • Nonopioid therapy (e.g., Tylenol, Motrin)
• Nonpharmacologic measures:
  • Distraction
  • Humor
  • Music
  • Imagery
  • Mindfulness practice
  • Cutaneous stimulation
  • Acupuncture
  • Hypnosis
  • Biofeedback
  • Healing/therapeutic touch
  • Animal-assisted intervention

Sleep and Rest

• Factors affecting rest and sleep:
  • Developmental considerations
  • Motivation
  • Culture
  • Lifestyle and habits
  • Environmental factors
  • Psychological stress
  • Illness
  • Medications
• Circadian rhythm: biological clock that exists in all humans
• Sleep disorders:
  • Insomnia: difficulty falling asleep or staying asleep
  • Sleep apnea: characterized by five or more obstructive respiratory events per hour
  • Narcolepsy: excessive daytime sleepiness and frequent overwhelming urges to sleep
  • Central disorders of hypersomnolence: excessive sleepiness and sleep episodes

Sleep Diary

• Records:
  • Time patient retires
  • Time patient tries to fall asleep
  • Approximate time patient falls asleep
  • Time of awakening in morning
  • Presence of stressors affecting sleep
  • Record of food, drink, or medication affecting sleep
  • Record of physical and mental activities
  • Record of activities performed 2 to 3 hours before bedtime