Nursing Interventions to Promote Healthy Physiologic Responses (BS Nursing/First Year, Session #12) PDF

Fundamentals of Nursing Practice - Lecture STUDENT ACTIVITY SHEET BS NURSING / FIRST YEAR Session # 12 LESSON TITLE: NURSI...

Fundamentals of Nursing Practice - Lecture STUDENT ACTIVITY SHEET BS NURSING / FIRST YEAR Session # 12 LESSON TITLE: NURSING INTERVENTIONS TO PROMOTE Materials: HEALTHY PHYSIOLOGIC RESPONSES Pen and notebook ▪ HYGIENE ▪ SKIN INTEGRITY ▪ MOBILITY / ACTIVITY ▪ REST AND SLEEP LEARNING OUTCOMES: Upon completion of this lesson, you can: 1. Describe factors that influence personal hygiene practices; 2. Discuss the role that critical thinking plays in providing hygiene; 3. Discuss different approaches used in maintaining a patient's comfort and safety during hygiene care; 4. Describe the pressure ulcer staging system; 5. Discuss the normal process of wound healing; 6. Describe the differences in wound healing by primary and secondary intention; 7. Describe complications of wound healing; 8. Explain the factors that impede or promote wound healing; 9. List appropriate nursing interventions for a patient with impaired skin integrity; 10. Identify changes in physiological and psychosocial function associated with immobility; 11. Assess for correct and impaired body alignment and mobility; 12. Formulate appropriate nursing diagnoses for patients with impaired mobility; 13. Describe interventions for improving or maintaining patients' mobility; 14. Explain the effect that the 24-hour sleep-wake cycle has on biological function; 15. Discuss mechanisms that regulate sleep; 16. Describe the stages of a normal sleep cycle; 17. Compare and contrast the sleep requirements of different age-groups; 18. Discuss characteristics of common sleep disorders; and, Reference: 19. Identify nursing diagnoses appropriate for patients with Potter, P. A., Perry, A.G., et al. (2021). Fundamentals sleep alterations. of nursing (10th ed.). Singapore: Elsevier. LESSON PREVIEW/REVIEW Answer the posted question based on your understanding. Use the back sheet of this page for your answers. Here is the task: What are the greatest risks for each developmental stage in Patient Safety and Quality? Discuss. This document and the information thereon is the property of PHINMA 1 of 22 Education (Department of Nursing) MAIN LESSON You will study the contents of this lesson and read your book, if available. HYGIENE → Personal hygiene affects patients’ comfort, safety, and well-being. → When people are ill, they often require assistance with their self-care. → A variety of personal, social, and cultural factors influence hygiene practices. → Integrate other nursing activities during hygiene care, including assessment and interventions such as range-of-motion (ROM) exercises, application of dressings, or inspection and care of intravenous (IV) sites. → Preserve as much of the patient’s independence as possible, assess his or her ability to perform hygiene care, ensure privacy, convey respect, and foster his or her physical comfort. Scientific Knowledge Base ▪ Apply knowledge of pathophysiology to provide preventive hygiene care. ▪ Recognize disease states that create changes in the integument, oral cavity, and sensory organs. ▪ Use time spent providing hygiene care to identify abnormalities and initiate appropriate actions to prevent further injury to sensitive tissues. The Skin ▪ Functions include ✔ Protection, secretion, excretion, temperature regulation, and sensation ▪ Primary layers ✔ Epidermis: shields underlying tissue ✔ Dermis: contains bundles of collagen, nerve fibers, blood vessels, sweat glands, sebaceous glands, and hair follicles ✔ Subcutaneous tissue ▪ Lies just beneath the skin; contains blood vessels, nerves, lymph, and loose connective tissue filled with fat cells The Feet, Hands, and Nails ▪ Feet, hands, and nails require special attention to prevent infection, odor, and injury. ▪ The condition of a patient’s hands and feet influences his or her ability to perform hygiene care. ▪ The normal nail is transparent, smooth, and convex, with a pink nail bed and a translucent white tip. The Oral Cavity ▪ The oral cavity is lined with mucous membranes. ▪ Normal oral mucosa is light pink, soft, moist, smooth, and without lesions. ▪ Medications, exposure to radiation, and mouth breathing can impair salivary secretion. ▪ Xerostomia—dry mouth. ▪ Gingivitis—inflammation of the gums. ▪ Dental caries—tooth decay. Hair ▪ Growth, distribution, and pattern indicate general health status. ▪ Hormonal changes, nutrition, emotional stress, physical stress, aging, infection, and other illnesses can affect hair characteristics. ▪ The shaft itself is lifeless, and physiological factors do not directly affect it. ✔ However, hormonal and nutrient deficiencies of the hair follicle cause changes in hair color or condition. Eyes, Ears, and Nose ▪ When hygiene care is provided, the eyes, ears, and nose require careful attention. ▪ Clean the sensitive sensory tissues in a way that prevents injury and discomfort for a patient, such as by taking care to not get soap in his or her eyes. ▪ The sense of smell is an important aid to appetite. Nursing Knowledge Base ▪ Many factors influence personal hygiene. ▪ Use communication skills to promote the therapeutic relationship. This document and the information thereon is the property of PHINMA 2 of 22 Education (Department of Nursing)  ▪ Hygiene care is never routine. ▪ During hygiene, assess: ✔ Emotional status ✔ Health promotion practices ✔ Health care education needs Factors Influencing Hygiene Social practices Personal preferences Body image Socioeconomic status Health beliefs and motivation Cultural variables Developmental stage Physical condition Critical Thinking Integrate nursing knowledge. Consider developmental and cultural influences. Think creatively. Be nonjudgmental and confident. Draw on your own experiences. Rely on professional standards. Nursing Process: Assessment ▪ Through the patient’s eyes ✔ Assess patient expectations about hygiene ▪ Assess: Self-care ability Skin Feet and nails Oral cavity Hair and hair care Eyes, ears, and nose Use of sensory aids Hygiene care practices Cultural influences ▪ Patients at risk for hygiene problems Nursing Diagnosis ▪ Common diagnoses associated with hygiene: ✔ Activity intolerance ✔ Impaired oral mucous membrane ✔ Bathing self-care deficit ✔ Ineffective health maintenance ✔ Dressing self-care deficit ✔ Risk for infection ✔ Impaired physical mobility ▪ Use the patients’ actual alteration or the alteration for which they are at risk. Implementation Use caring to reduce anxiety, promote comfort. Administer meds for symptoms before hygiene. Be alert for patient’s anxiety or fear. Assist and prepare patients to perform hygiene as independently as possible. Discuss signs and symptoms of problems. Inform patients about community resources. ▪ Health promotion ✔ Make instructions relevant. ✔ Adapt instruction to patient’s facilities and resources. ✔ Teach the patient ways to avoid injury. ✔ Reinforce infection control practices. ▪ Acute, restorative, and continuing care ✔ Hygiene measures vary by patient needs and health care setting. This document and the information thereon is the property of PHINMA 3 of 22 Education (Department of Nursing)  ▪ Consider normal grooming routines, and individualize care ▪ Bathing and skin care ✔ Therapeutic: sitz, medicated ✔ Complete bed bath, shower ✔ Partial bed bath ✔ Soap and water vs. Chlorhexidine Gluconate (CHG) ✔ Perineal care ✔ Bath Guidelines: Provide privacy. Maintain safety. Maintain warmth. Promote independence. Anticipate needs. ▪ Back rub ▪ Foot and nail care ▪ Oral hygiene ✔ Brushing removes particles, plaque, and bacteria; massages the gums; and relieves unpleasant odors and tastes. ✔ Flossing removes tartar at the gum line. ✔ Rinsing removes particles and excess toothpaste. ▪ Patients with special needs: diabetes, artificial airways, unconscious, chemotherapy ▪ Denture care ✔ Keep dentures covered in water when they are not worn ✔ Store in an enclosed, labeled cup with the cup placed on patient’s bedside stand ▪ Hair and scalp care ✔ Brushing and combing → Distributes oil → Prevents tangling, as does braiding → Obtain permission before braiding or cutting. → Combing is more effective than use of pediculicidal/ ovicidal liquid shampoo in the case of head lice ▪ Shampooing ✔ Frequency depends on patient routines and hair condition ▪ Shaving ▪ Mustache and beard care ▪ Care of the eyes, ears, and nose: ✔ Medical devices ✔ Basic eye care ✔ Eyeglasses ✔ Contact lenses ✔ Artificial eyes ✔ Ear care ✔ Hearing aid care ✔ Nasal care ▪ Patient’s room environment ✔ Maintaining comfort → Temperature, noise, lighting, ventilation, odors ✔ Room equipment ▪ Foot boots ▪ Bed making ▪ Special mattresses ▪ Surgical or recovery Bed ▪ Beds ▪ Linens This document and the information thereon is the property of PHINMA 4 of 22 Education (Department of Nursing) Safety Guidelines for Nursing Skills ▪ Identify the patient with two identifiers. ▪ Move from the cleanest to less clean areas. ▪ Use clean gloves for contact with non intact skin, mucous membranes, secretions, excretions, or blood. ▪ Test the temperature of water or solutions. ▪ Use principles of body mechanics and safe patient handling. ▪ Give proper direction to NAP when delegating. SKIN INTEGRITY AND WOUND CARE ▪ The skin is the body’s largest organ, accounting for 15% of the total body weight. The skin provides: ✔ A protective barrier against disease-causing organisms. ✔ A sensory organ for pain, temperature, and touch. ✔ Vitamin D synthesis. ▪ Injury to the skin poses risks to safety and triggers a complex healing response. Knowing the normal healing pattern will help students recognize alterations that require intervention. Scientific Knowledge Base ▪ Skin ✔ Epidermis → Top layer of skin ✔ Dermis → Inner layer of skin → Collagen ✔ Dermal–epidermal junction → Separates dermis and epidermis ▪ Pressure ulcers ✔ Pressure sore, decubitus ulcer, or bed sore ▪ Pathogenesis ✔ Pressure intensity → Tissue ischemia → Blanching ✔ Pressure duration ✔ Tissue tolerance ▪ Risk factors for pressure ulcer development ✔ Impaired sensory perception ✔ Impaired mobility ✔ Alteration in LOC ✔ Shear ✔ Friction ✔ Moisture This document and the information thereon is the property of PHINMA 5 of 22 Education (Department of Nursing) Classification of Pressure Ulcers ▪ Wound classifications ✔ Process of wound healing → Partial-thickness wounds: shallow in depth, moist and painful, and the wound base generally appears red → Full-thickness wounds: extends into the subcutaneous layer, and the depth and tissue type will vary depending on body location ✔ Primary intention → Edges are approximated ✔ Secondary intention This document and the information thereon is the property of PHINMA 6 of 22 Education (Department of Nursing)  ▪ Wound repair ✔ Partial-thickness wound repair: inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers ✔ Full-thickness wound repair: hemostasis, inflammatory, proliferative, and maturation. ▪ Complications of wound healing ✔ Hemorrhage → Hematoma ✔ Infection ✔ Dehiscence ✔ Evisceration Nursing Knowledge Base ▪ Prediction and prevention of pressure ulcers o Risk assessment ▪ Braden scale o Prevention ▪ Economic consequences of pressure ulcers Medicare and Medicaid: no additional reimbursement for care related to stage III and stage IV pressure ulcers that occur during the hospitalization ▪ Factors influencing pressure ulcer formation and wound healing o Nutrition o Tissue perfusion o Infection o Age o Psychosocial impact of wounds Critical Thinking ▪ Integrate knowledge from nursing and other disciplines, previous experiences, and information gathered from patients to understand the risk to skin integrity and wound healing ▪ Use Wound, Ostomy and Continence Nurses Society (WOCN) guidelines when planning care ▪ Be disciplined, creative, and diligent Nursing Process: Assessment ▪ Skin ✔ Continually assess skin for signs of breakdown and/or ulcer development ▪ Pressure ulcers ✔ Predictive measures ✔ Nutritional status ✔ Mobility ✔ Body fluids ✔ Pain ▪ Wounds ✔ Emergency setting ✔ Wound closures ✔ Stable setting ✔ Palpation of wound ✔ Wound appearance ✔ Wound cultures ✔ Character of wound drainage → Gram stains ✔ Drains → Biopsy Nursing Diagnosis Nursing diagnoses associated with impaired skin integrity and wounds: ▪ Risk for infection ▪ Impaired physical mobility ▪ Imbalanced nutrition: less than body ▪ Impaired skin integrity requirements ▪ Risk for impaired skin integrity ▪ Acute or chronic pain ▪ Ineffective peripheral tissue perfusion ▪ Impaired tissue integrity This document and the information thereon is the property of PHINMA 7 of 22 Education (Department of Nursing) Implementation ▪ Health promotion ✔ Prevention of pressure ulcers ✔ Topical skin care and incontinence management ✔ Positioning ✔ Support surfaces ▪ Acute Care ✔ Management of pressure ulcers ✔ Wound management → Debridement → Education → Nutritional status → Protein status → Hemoglobin ▪ First Aid for Wounds ▪ Hemostasis ✔ Control bleeding. → Allow puncture wounds to bleed. → Do not remove a penetrating object. This document and the information thereon is the property of PHINMA 8 of 22 Education (Department of Nursing)  ✔ Bandage ▪ Cleaning ✔ Gentle ✔ Normal saline ▪ Protection ▪ Dressings ✔ Purposes of dressings → Protects from microorganisms → Aids in hemostasis → Promotes healing by absorbing drainage or debriding a wound → Supports wound site → Promotes thermal insulation → Provides a moist environment ✔ Types of dressings → Gauze → Hydrogel → Transparent film → Foam → Hydrocolloid → Composite ✔ Changing dressings → Know the type of dressing, placement of drains, and equipment needed. → Prepare the patient for a dressing change. 1. Review previous wound assessment. 2. Evaluate pain and, if indicated, administer analgesics so peak effects occur during dressing change. 3. Describe procedure steps to lessen patient anxiety. 4. Gather all supplies. 5. Recognize normal signs of healing. 6. Answer questions about the procedure or wound. ✔ Packing a wound → Negative-pressure wound therapy ✔ Securing → Tape → Ties → Binders ✔ Comfort measures → Administer analgesic medications 30 to 60 minutes before dressing changes → Carefully remove tape → Gently clean wound edges → Carefully manipulate dressings and drains to minimize stress on sensitive tissues → Turn and position patient carefully ✔ Cleaning skin and drain sites → Basic Skin Cleaning 1. Clean from least contaminated to the surrounding skin 2. Use gentle friction 3. When irrigating, allow the solution to flow from the least to most contaminated area → Irrigation 1. Wound irrigations ✔ Suture care → Staple removal → Suture removal ✔ Drainage Evacuation → Constant, low-pressure vacuum to remove and collect drainage ✔ Bandages and binders → Principles for applying bandages and binders → Binder application This document and the information thereon is the property of PHINMA 9 of 22 Education (Department of Nursing)  o Slings → Bandage application ✔ Heat and Cold Therapy → Assessment for temperature tolerance → Bodily responses to heat and cold → Local effects of heat and cold o Effects of heat application o Effects of cold application → Factors influencing heat and cold tolerance o Exposure time o Exposed skin o Temperature o Age o Perception of sensory stimuli → Application of heat and cold therapies o Choice of moist or dry o Warm, moist compresses o Warm soaks o Sitz baths o Commercial hot and cold packs o Cold, moist, and dry compresses o Cold soaks o Ice bags or collars Safety Guidelines for Nursing Skills ▪ Position patient to prevent the patient from rolling over the side of the bed. ▪ Keep a plastic bag within reach to discard dressings and prevent cross-contamination. Keep extra gloves within reach to allow a change of gloves if the gloves become soiled. ▪ If irrigating a wound, use appropriate PPE. ▪ When applying an elastic bandage, check the extremity for temperature or sensation changes. IMMOBILITY ▪ Mobility is also essential for self-defense, activities of daily living (ADLs), and recreational activities. ▪ Many functions of the body depend on mobility. ▪ Intact musculoskeletal and nervous systems are necessary for optimal physical mobility and functioning. ▪ Clinical nursing practice related to mobility and immobility requires the incorporation of scientific and nursing knowledge and skills to provide competent care. Nature of Movement ▪ Body mechanics o Coordinated efforts of the musculoskeletal and nervous systems ▪ Alignment and balance o Also refers to posture ▪ Gravity o Weight force exerted on the body ▪ Friction o Force that occurs in a direction opposite to movement ▪ Skeletal system o Provides attachments for muscles and ligaments, protects vital organs, aids in calcium regulation o Provides leverage for mobility o Bones are long, short, flat, or irregular o Joints o Ligaments, tendons, and cartilage ▪ Muscle movement and posture o Skeletal muscles are working elements of movement ▪ Nervous system o Regulates movement and posture This document and the information thereon is the property of PHINMA 10 of 22 Education (Department of Nursing) Pathological Influences on Mobility ▪ Postural abnormalities ▪ Damage to central nervous system (CNS) ▪ Muscle abnormalities ▪ Musculoskeletal trauma Nursing Knowledge Base: Factors Influencing Mobility-Immobility ▪ Mobility refers to a person’s ability to move about freely, and immobility refers to the inability to do so ▪ Bed rest ▪ Effects of muscular deconditioning o Disuse atrophy o Psychological o Physiological o Social Systemic Effects Metabolic Respiratory Endocrine, calcium absorption, and GI function Atelectasis and hypostatic pneumonia Musculoskeletal changes Cardiovascular Loss of endurance and muscle mass and decreased Orthostatic hypotension, thrombus stability and balance Muscle effects Skeletal effects Loss of muscle mass, muscle atrophy Impaired calcium absorption, joint abnormalities Urinary elimination Integumentary Urinary stasis, renal calculi Pressure ulcer, ischemia Metabolic Changes ▪ Changes in mobility alter o Endocrine metabolism o Calcium resorption o Functioning of the GI system ▪ Endocrine system helps maintain homeostasis ▪ Immobility disrupts normal metabolic functioning o Decreases metabolic rate ▪ Alters metabolism ▪ Causes GI disturbances Respiratory Changes ▪ Immobile patients are at high risk for developing pulmonary complications o Atelectasis o Hypostatic pneumonia Cardiovascular Changes ▪ Orthostatic hypotension ▪ Increased cardiac workload ▪ Thrombus formation Musculoskeletal Changes ▪ Muscle effects ▪ Skeletal effects o Lean body mass loss o Disuse osteoporosis o Muscle weakness/ atrophy o Joint contracture Urinary Elimination Changes ▪ Urinary stasis ▪ Infection ▪ Renal calculi Integumentary Changes ▪ Pressure ulcers o Inflammation o Ischemia ▪ Older adults at greater risk This document and the information thereon is the property of PHINMA 11 of 22 Education (Department of Nursing) Psychosocial Effects ▪ Emotional and behavioral responses o Hostility, giddiness, fear, anxiety ▪ Sensory alterations o Altered sleep patterns ▪ Changes in coping o Depression, sadness, dejection Developmental Changes Infants, Toddlers, Preschoolers Adolescents Prolonged immobility delays gross motor skills, intellectual Delayed in gaining independence and in accomplishing skills development, or musculoskeletal development Social isolation can occur Adults Older Adults Physiological systems are at risk Decreased physical activity Changes in family and social structures Hormonal changes Bone reabsorption Nursing Process: Assessment ▪ See through the patient’s eyes ▪ Mobility o Range of motion ▪ Planes of the body o Sagittal o Transverse o Frontal ▪ Range of motion o Contractures: develop in joints not moved periodically through their full ROM o Neck, shoulder, elbow, forearm, wrist, fingers and thumb, hip, knee, ankle and foot, and toes ▪ Mobility o Gait (a particular manner or style of walking) o Exercise (physical activity for conditioning the body, improving health, and maintaining fitness) o Activity tolerance ✔ Physiological ✔ Emotional ✔ Developmental o Body alignment is used for: ✔ Determining normal physical changes ✔ Identifying deviations in body alignment ✔ Patient awareness of posture ✔ Identifying postural learning needs of patients ✔ Identifying trauma, muscle damage, or nerve dysfunction ✔ Obtaining information on incorrect alignment (i.e., fatigue, malnutrition, psychological problems) ▪ Body alignment o Standing o Sitting o Lying ▪ Physiologic hazards of mobility o Metabolic o Respiratory o Cardiovascular This document and the information thereon is the property of PHINMA 12 of 22 Education (Department of Nursing)  o Musculoskeletal o Integumentary o Elimination o Psychosocial o Developmental Nursing Diagnosis ✔ Impaired physical mobility ✔ Risk for disuse syndrome ✔ Ineffective airway clearance ✔ Ineffective coping ✔ Impaired urinary elimination ✔ Risk for impaired skin integrity ✔ Social isolation Implementation: Health Promotion ▪ Prevention of work-related musculoskeletal injuries ▪ Exercise ▪ Bone health in patients with osteoporosis Implementation: Acute Care ▪ Metabolic o Provide high-protein, high-calorie diet with vitamin B and C supplements. ▪ Respiratory o Cough and deep breathing every 1 to 2 hours. o Provide chest physiotherapy. ▪ Cardiovascular o Reducing orthostatic hypotension o Reducing cardiac workload o Preventing thrombus formation o SCDs, thromboembolic disease (TED), hose, and leg exercises ▪ Musculoskeletal system o Prevent muscle atrophy and joint contractures ▪ Integumentary system o Reposition every 1 to 2 hours. o Provide skin care. ▪ Elimination system o Provide adequate hydration. o Serve a diet rich in fluids, fruits, vegetables, and fiber. ▪ Psychosocial changes ▪ Developmental changes Positioning Techniques ▪ Trochanter roll ▪ Hand roll ▪ Trapeze bar ▪ Supported Fowler’s ▪ Supine ▪ Prone ▪ Side-lying ▪ Sims’ position ▪ Moving patients o Safety is first priority o Ask patient to help as much as possible This document and the information thereon is the property of PHINMA 13 of 22 Education (Department of Nursing)  o Determine if patient comprehends what is expected o Determine patient’s comfort level o Determine if you need assistance in moving the patient ▪ Restorative and continuing care o IADLs (Instrumental Activities of Daily Living) o ROM exercise o Walking Safety Guidelines for Nursing Skills ▪ Communicate clearly with members of the health care team ▪ Assess and incorporate the patient’s priorities of care and preferences ▪ Use the best evidence when making decisions about your patient’s care SLEEP ▪ Proper rest and sleep are as important to health as good nutrition and adequate exercise. ▪ Physical and emotional health depends on the ability to fulfill these basic human needs. Individuals need different amounts of sleep and rest. Without proper amounts, the ability to concentrate, make judgments, and participate in daily activities decreases; and irritability increases. ▪ Identifying and treating patients’ sleep pattern disturbances are important goals. To help patients you need to understand the nature of sleep, the factors influencing it, and patients’ sleep habits. ▪ Sleep provides healing and restoration. ▪ Some patients have preexisting sleep disturbances; other patients develop sleep problems as a result of an illness or hospitalization. Physiology of Sleep ▪ Circadian rhythms o Affected by light, temperature, social activities, and work routines. ▪ The biological rhythm of sleep frequently becomes synchronized with other body functions. Physiology of Sleep: Sleep Regulation ▪ Regulated by a sequence of physiological states integrated by central nervous system (CNS) activity ▪ Hypothalamus ▪ Reticular activating system (RAS) ▪ Homeostatic process (Process S) Stages of the Adult Sleep Cycle ▪ Four stages of NREM ▪ Sleep cycle lasts 90 to 100 minutes ▪ Sleep goes through stages 1 to 4, then reversal from 4 to 3 to 2, followed by REM Functions of Sleep ▪ Purpose of sleep o Remains unclear o Physiological and psychological restoration o Maintenance of biological functions ▪ Dreams o Occur in NREM and REM sleep o Important for learning, memory, and adaptation to stress Physical Illness ▪ Physical illness can cause pain, physical discomfort, anxiety, depression, and sleep disturbances: o Hypertension o Respiratory disorders o Nocturia o Restless leg syndrome (RLS) o American Academy of Sleep Medicine Classification of Sleep Disorders This document and the information thereon is the property of PHINMA 14 of 22 Education (Department of Nursing) Sleep Disorders ▪ Insomnia o Adjustment sleep disorder (acute insomnia), Inadequate sleep hygiene, Behavioral insomnia of childhood, Insomnia caused by medical condition ▪ Sleep apnea o Primary central sleep apnea, central sleep apnea caused by medical condition, obstructive sleep apnea syndromes, excessive daytime sleepiness ▪ Narcolepsy o Cataplexy, Sleep paralysis ▪ Sleep deprivation o Emotional stress, Medications, Environmental disturbances, Symptoms ▪ Parasomnias o Somnambulism (sleepwalking), Night terrors, Nightmares, Nocturnal enuresis (bed-wetting), Body rocking, Bruxism Sleep and Rest ▪ Rest contributes to: o Mental relaxation o State of mental, physical, and spiritual o Freedom from anxiety activity ▪ Bed rest does not guarantee that a patient will feel rested. Normal Sleep Requirements and Patterns Neonates Infants 16 hours a day 8 to 10 hours at night for a total of 15 hours per day Toddlers Preschoolers Total 12 hours a day 12 hours a night School Age Adolescents 9 to 10 hours Get ~7½ hours Young Adults Middle and Older Adults Get 6 to 8½ hours Total number of hours declines Factors Influencing Sleep This document and the information thereon is the property of PHINMA 15 of 22 Education (Department of Nursing)  Drugs and substances Hypnotics, diuretics, narcotics, antidepressants, alcohol, caffeine, beta-blockers, anticonvulsants Lifestyle Usual sleep patterns Work schedule, social activities, routines May be disrupted by social activity or work schedule Emotional stress Environment Worries, physical health, death, losses Noise, routines Exercise and fatigue Food and calorie intake Moderate exercise and fatigue cause a restful sleep Time of day, caffeine, nicotine, alcohol Assessment ▪ Through the patient’s eye ▪ Sleep assessment o Sources for sleep assessment = Patient, family o Tools for sleep assessment ▪ Sleep history o Description of sleeping problems, usual sleep pattern, current life events, physical and psychological illness, emotional and mental status, bedtime routines, bedtime environment, behaviors of sleep deprivation ▪ Description of sleeping problems o Conduct a more detailed history when a patient has a sleep problem. This ensures that you provide appropriate therapeutic care. o Open-ended questions help a patient describe a problem more fully. o Ask specific questions related to the sleep problem. ▪ Usual sleep pattern o Have patients describe their normal sleep patterns. ▪ Physical and psychological illness ▪ Current life events ▪ Emotion and mental status ▪ Bedtime routines ▪ Bedtime environment ▪ Behaviors of sleep deprivation Implementation ▪ Health promotion o Environmental controls o Establishing periods of rest and sleep o Promoting bedtime routines o Stress reduction o Promoting safety o Bedtime snacks o Promoting comfort o Pharmacological approaches ▪ Environment controls ▪ Promoting bedtime routines ▪ Promoting safety ▪ Promoting comfort ▪ Establishing periods of rest and sleep ▪ Stress reduction ▪ Bedtime snacks ▪ Pharmacological approaches ▪ Acute care o Environmental controls o Establishing periods of rest and sleep o Promoting comfort o Promoting safety o Stress reduction ▪ Restorative or continuing care o Promoting comfort o Controlling physiological disturbances This document and the information thereon is the property of PHINMA 16 of 22 Education (Department of Nursing)  o Pharmacological approaches Evaluation ▪ Through the patient’s eyes ▪ Patient outcomes o Determine whether expected outcomes have been met. → Are you able to fall asleep within 20 minutes of getting into bed? → Describe how well you sleep when you exercise. → Does the use of quiet music at bedtime help you to relax? → Do you feel rested when you wake up? CHECK FOR UNDERSTANDING You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to the correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in your answer/ratio is not allowed. 1. You are caring for a non–English-speaking male patient. When preparing to assist him with personal hygiene, you should: a. use soap and water on all types of skin. b. ensure that culture and ethnicity influence hygiene practices. c. shave facial hair to make the patient more comfortable. d. know that all patients need to be bathed daily. ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 2. A young girl with long hair is experiencing a problem with matting. The most appropriate action to take would be: a. cutting the matted hair away. b. braiding the hair to reduce tangles. c. using a grease-type product to tame the hair. d. keeping the hair oil free by applying powder every morning. ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 3. The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges: a. are approximated. c. appear slightly pink. b. migrate across the incision. d. slightly overlap each other. ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 4. A postoperative patient arrives at an ambulatory care center and states, “I am not feeling good.” Upon assessment, you note an elevated temperature. An indication that the wound is infected would be: a. it has no odor. b. a culture is negative. c. the edges reveal the presence of fluid. d. it shows purulent drainage coming from the incision site. ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 5. A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides: a. an absorbent surface to collect wound drainage. b. decreased incidence of skin maceration. c. protection from the external environment. This document and the information thereon is the property of PHINMA 17 of 22 Education (Department of Nursing)  d. moisture needed for wound healing. ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 6. Match the pressure ulcer categories/stages with the correct definition. I. Category/stage I II. Category/stage II III. Category/stage III IV. Category/stage IV a. Non-blanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. c. Full thickness tissue loss; muscle and bone visible. May include undermining. d. Partial-thickness skin loss or intact blister with serosanguinous fluid. ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 7. Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) a. Use a transfer device (e.g., transfer board) b. Have head of bed elevated when transferring patient c. Have head of bed flat when repositioning patient d. Raise head of bed 60 degrees when patient positioned supine e. Raise head of bed 30 degrees when patient positioned supine ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 8. When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? a. Necrotic tissue b. Wound drainage c. Wound circumference d. Cleansed wound ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 9. What is the correct sequence of steps when performing wound irrigation to a large open wound? a. Use slow, continuous pressure to irrigate wounds. b. Attach a 19-gauge angiocatheter to syringe. c. Fill the syringe with irrigation fluid. d. Place a waterproof bag near bed. e. Position angiocatheter over wound. ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 10. For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound-care product helps prevent edema formation, control bleeding, and anesthetize the body part? a. Binder c. Elastic bandage b. Ice bag d. Absorptive dressing ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ This document and the information thereon is the property of PHINMA 18 of 22 Education (Department of Nursing) 11. You notice a respiratory change in your immobilized postoperative patient. The change you note is most consistent with: a. atelectasis. c. orthostatic hypotension. b. hypertension. d. coagulation of blood. ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 12. During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift. This condition is known as: a. cataplexy. c. narcolepsy. b. insomnia. d. sleep apnea. ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 13. A 4-year-old pediatric patient resists going to sleep. To assist this patient, the best action to take would be: a. adding a daytime nap. b. allowing the child to sleep longer in the morning. c. maintaining the child’s home sleep routine. d. offering the child, a bedtime snack. ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 14. A patient suffers from sleep pattern disturbance. To promote adequate sleep, most important nursing intervention is: a. administering a sleep aid. b. synchronizing the medication, treatment, and vital signs schedule. c. encouraging the patient to exercise immediately before sleep. d. discussing with the patient the benefits of beginning a long-term night time medication regimen. ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 15. A 72-year-old patient asks the nurse about using an over-the-counter antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response? a. “Antihistamines are better than prescription medications because these can cause a lot of problems.” b. “Antihistamines should not be used because they can cause confusion and increase your risk of falls.” c. “Antihistamines are effective sleep aids because they do not have many side effects.” d. “Over-the-counter medications when combined with sleep hygiene measures are a good plan for sleep.” ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 16. The school nurse is teaching health-promoting behaviors that improve sleep to a group of high school students. Which points should be included in the education? (Select all that apply.) a. Go to bed at the same time each night. b. Study in your bedroom to have a quiet place. c. Turn on the television to help you fall asleep. d. Avoid drinking coffee or soda before bedtime. e. Turn off your cell phone at bedtime. ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 17. Which sleep-hygiene actions at bedtime can the nurse delegate to the nursing assistant? (Select all that apply.) a. Giving the patient a backrub This document and the information thereon is the property of PHINMA 19 of 22 Education (Department of Nursing)  b. Turning on quiet music c. Dimming the lights in the patient's room d. Giving a patient a cup of coffee e. Monitoring for the effect of the sleeping medication that was given ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 18. Which statement made by the parent of a school-age child requires follow-up by the nurse? a. “I encourage evening exercise about an hour before bedtime.” b. “I offer my daughter glass warm milk before bedtime.” c. “I make sure that the room is dark and quiet at bedtime.” d. “We use quiet activities such as reading a book before bedtime.” ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 19. The nurse is developing a plan of care for a patient experiencing obstructive sleep apnea (OSA). Which intervention is appropriate to include on the plan? a. Instruct the patient to sleep in a supine position. b. Have the patient limit fluid intake 2 hours before bedtime. c. Elevate head of bed and assume a side or prone position. d. Encourage patients to take an over-the-counter sleep aid. ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ 20. The effects of immobility on the cardiac system include which of the following? (Select all that apply.) e. Thrombus formation f. Increased cardiac workload g. Weak peripheral pulses h. Irregular heartbeat i. Orthostatic hypotension ANSWER: ________ RATIO:___________________________________________________________________________________________ _________________________________________________________________________________________________ RATIONALIZATION ACTIVITY The instructor will now provide you the rationalization to these questions. You can now ask questions and debate among yourselves. Write the correct answer and correct/additional ratio in the space provided. 1. ANSWER: ________ RATIO:________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ 2. ANSWER: ________ RATIO:________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ 3. ANSWER: ________ RATIO:________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ 4. ANSWER: ________ RATIO:________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ This document and the information thereon is the property of PHINMA 20 of 22 Education (Department of Nursing) 5. ANSWER: ________ RATIO:________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ 6. ANSWER: ________ RATIO:________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ 7. 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ANSWER: ________ RATIO:________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ 14. ANSWER: ________ RATIO:________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ 15. ANSWER: ________ RATIO:________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ 16. ANSWER: ________ RATIO:________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ 17. ANSWER: ________ RATIO:________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ 18. ANSWER: ________ RATIO:________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ This document and the information thereon is the property of PHINMA 21 of 22 Education (Department of Nursing) 19. ANSWER: ________ RATIO:________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ 20. ANSWER: ________ RATIO:________________________________________________________________________________________ ______________________________________________________________________________________________ ___________________________________________________________________ LESSON WRAP-UP You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you track how much work you have accomplished and how much work there is left to do. You are done with the session! Let’s track your progress. AL Activity: CAT 3-2-1 This strategy provides a structure for you to record your own comprehension and summarize your learning. Three things you learned: 1. _______________________________________________________________________________________ 2. _______________________________________________________________________________________ 3. _______________________________________________________________________________________ Two things that you’d like to learn more about: 1. _______________________________________________________________________________________ 2. ________________________________________________________________________________________ One question you still have: 1. ________________________________________________________________________________________ This document and the information thereon is the property of PHINMA 22 of 22 Education (Department of Nursing)