Exam 1 RN170B Study Guide PDF

**Exam 1 RN170B** **1. Healthy sleep habits** Chapter 43 "Sleep" Fundamentals ebook box 43.9 "Sleep Hygiene Habits" page 1127 Instruct patient to try to exercise daily, preferably in the morning or afternoon, and to avoid vigorous exercise in the evening within 2 hours of bedtime. Caution patient against sleeping long hours during weekends or holidays to prevent disturbance of normal sleep-wake cycle. Explain that, if possible, patients should not use the bedroom for intensive studying, snacking, television watching, or other nonsleep activity besides sex. Encourage patients to try to avoid worrisome thinking when going to bed and to use relaxation exercises. If patient does not fall asleep within 30 minutes of going to bed, advise to get out of bed and do some quiet activity until feeling sleepy enough to go back to bed. Recommend that patients limit caffeine to morning coffee and limit alcohol intake (more than one to two drinks a day interrupts sleep cycle). Recommend that patients discontinue use of electronic devices about 30 minutes before going to bed. Ask patient to examine environment. Instruct that use of earplugs and eyeshades may be helpful. Instruct patient to avoid heavy meals 3 hours before bedtime; a light snack may help. **Overview of Sleep osmosis video ref: Sherpath AI** Sticking to a consistent sleep schedule, even on weekends \- Creating a relaxing bedtime routine like taking a bath or reading \- Making the bedroom comfortable, cool, quiet, and dark \- Avoiding caffeine, large meals, and screen time before bed \- Getting regular exercise, but not too close to bedtime \- Managing stress through relaxation techniques \- Avoiding naps or keeping them short \- Reserving the bed for sleep and intimacy only.. **SHERPATH AI** **From Sherparth: Sleep: Implement and Take Action; Evaluate / Nonpharmacologic Sleep Interventions and Evaluation Sleep Hygiene Habits:** ***Regular Sleep Schedule:*** Keeping a regular sleep schedule is one of the most important aspects to achieving healthy sleep. This involves: Going to bed at the same time each night and getting up at the same time every morning, including weekends. Avoiding naps during the day, if possible. Naps disturb a normal sleep pattern. The exception would be for patients with a medically diagnosed sleeping disorder. Adequate exposure to natural light during the day. Light helps regulate the circadian rhythm and maintain a healthy sleep-wake cycle. ***Exercise:*** Aerobic exercise combined with resistance training is an important part of maintaining health. It can also promote high-quality sleep. Nonrapid eye movement (NREM) and rapid eye movement (REM) sleep are increased when a person is fatigued and relaxed from having performed physical activities. High-intensity, vigorous exercise should be performed in the morning or late afternoon, at least 2 hours before bedtime.Relaxing exercise like yoga and stretching can be done within the hours prior to bed. This will help initiate a healthy night's sleep. ***Diet:*** Food and beverage choices can have a great effect on sleep.Large, heavy, or spicy meals late in the evening can interfere with falling asleep and staying asleep. Conversely, going to bed hungry can make falling asleep difficult. Complex carbohydrates and foods containing tryptophan can promote sleep.Caffeine and nicotine consumed too close to bedtime will cause problems falling asleep. Alcohol can make falling asleep easier but will interfere with the sleep cycle. Excessive fluids consumed too close to bedtime may cause a person to wake up to urinate. Therefore fluid consumption should be limited late in the evening. *Sleep Environment:* ***A comfortable and safe sleep environment promotes sleep.*** Most people prefer a dark and quiet room. However, infants and older adults may prefer a small night-light. Temperature preferences vary for each individual, and extra bedding or blankets should be provided to facilitate the desires of the patient.The bed should provide support, and linens should allow freedom of movement. Body alignment while sleeping should prevent muscle strain and discomfort. A bed should be used for sleep and sex only. Watching television, listening to the radio, using a mobile device, etc. should not be done in bed. ***Bedtime:*** Almost everyone has a bedtime routine that helps facilitate relaxation and mental preparedness for sleep. Bedtime routines for children may include bathing, story time, music, snuggles, and the presence of a specific toy or comforting blanket. Helpful and relaxing activities before bed may include reading, taking a warm bath, eating a light snack, aromatherapy, or music. **2. Insomnia** Chapter 43 "Sleep" Fundamentals ebook page 1113 Insomnia is a symptom that patients experience when they have chronic difficulty in falling asleep, frequent awakenings from sleep, and/or a short sleep or nonrestorative sleep (Kryger et al., 2017). It is the most common sleep-related complaint, with up to 30% of adults suffering from the problem (American Sleep Association, 2020). It is commonly experienced by individuals diagnosed with depression (Hedges and Gotelli, 2019). People with insomnia experience EDS and insufficient sleep quantity and quality. However, frequently a patient gets more sleep than is realized. Insomnia often signals an underlying physical or psychological disorder. It occurs more frequently in and is the most common sleep problem for women. People experience transient insomnia because of situational stresses such as family, work, or school problems; jet lag; illness; or loss of a loved one. Insomnia sometimes recurs, but between episodes a patient is able to sleep well. However, a temporary case of insomnia caused by a stressful situation can lead to chronic difficulty in getting enough sleep, perhaps because of the worry and anxiety that develop about getting sleep. Insomnia is often associated with poor sleep hygiene, or practices that a patient associates with sleep (Hedges and Gotelli, 2019). If the condition continues, the fear of not being able to sleep is enough to cause wakefulness. During the day people with chronic insomnia feel sleepy, fatigued, depressed, and anxious. Treatment is symptomatic, including improved sleep-hygiene measures, biofeedback, cognitive techniques, and relaxation techniques (Hedges and Gotelli, 2019; Rash et al., 2019). Behavioral and cognitive therapies have few adverse effects and show evidence of sustained improvement in sleep over time (Haynes et al., 2018). **3. RN interventions to promoting rest and sleep** From Sherpath " Sleep: Implement and Take Action; Evaluate / Nonpharmacologic Sleep Interventions and Evaluation" 1\) Routine : Cluster care activities together to allow for 90 to 120 minutes of uninterrupted sleep for the patient. This allows the patient time to complete a full sleep cycle. 2\) Noise: The nurse can reduce noise for the patient by: Drawing curtains and closing doors Negotiating times to mute televisions and radios Limiting overhead pages Lowering the volume of phone ringtones Limiting staff conversations in the hallway Conducting shift reports outside of the patient room, unless the facility requires bedside reports Moving equipment quietly, paying attention to avoid other objects Monitoring equipment frequently to prevent alarms. 3\) Evening Care: Evening care, often referred to as *h.s. ("hour of sleep") care,* is important in an inpatient facility. This helps establish and maintain the bedtime routine for the patient. Evening care may include: Oral care Partial bathing Skin care Backrub Linen maintenance Toileting Snacks or fluids Promoting Sleep BOX 43.8 " FOCUSED ON EARLY ADULTS" from fundamentals book page 1127 Sleep-wake pattern Maintain a regular bedtime and wake-up schedule (Hedges and Gotelli, 2019). Eliminate naps unless they are a routine part of the schedule. If naps are taken, limit to 30 minutes and time them early in the day (Morris et al., 2021). Go to bed when sleepy. Use warm bath and relaxation techniques (Touhy and Jett, 2020). If unable to sleep in 15 to 30 minutes, do a relaxing activity such as reading (Haynes et al., 2018). Avoid stimulating activities such as exercise or watching television before bedtime (Morris et al., 2021). Environment Sleep where you sleep best. Keep noise to a minimum; use soft music to mask it if necessary. Use night-light and keep path to bathroom free of obstacles. Set room temperature to preference; use socks to promote warmth. Listen to relaxing music (Touhy and Jett, 2020). Sit in natural sunlight upon awakening if possible (Morris et al., 2021). Medications Use sedatives and hypnotics with caution as last resort and then only short term if necessary (Hedges and Gotelli, 2019). Adjust medications being taken for other conditions and assess for drug interactions that may cause insomnia or excessive daytime sleepiness. Diet Limit caffeine and nicotine in late afternoon and evening (Hedges and Gotelli, 2019). Avoid large meals and alcohol close to bedtime (Hedges and Gotelli, 2019) Consume carbohydrates or milk as a light snack before bedtime (Touhy and Jett, 2020). Decrease fluids 2 to 4 hours before sleep (Touhy and Jett, 2020). Physiological/illness factors Elevate head of bed and provide extra pillows as preferred. Use analgesics 30 minutes before bed to ease aches and pains. Use therapeutics to control symptoms of chronic conditions as prescribed (Morris et al., 2021). **4. Promote sleep in a school-age children** School-age children. The amount of sleep needed varies during the school years. A 6-year-old averages 11 to 12 hours of sleep nightly, whereas an 11-year-old sleeps about 9 to 10 hours (Hockenberry et al., 2019). The 6- or 7-year-old usually goes to bed with some encouragement or by doing quiet activities. The older child often resists sleeping because the child is unaware of fatigue or has a need to be independent. When children experience sleep problems, it often causes sleep disruption in parents (Meltzer and Pugliese, 2017). Fundamentals ebook page 1113 **5. obstructive sleep apnea** (OSA) Fundamentals ebook page 1113 Sleep apnea. Following paragraph is to give context for Sleep Apnea. Sleep apnea is a disorder in which an individual is unable to breathe and sleep at the same time. There is a lack of airflow through the nose and mouth for periods from 10 seconds to 1 to 2 minutes in length. There are three types of sleep apnea: obstructive; central; and mixed apnea, which has both an obstructive and a central component. The most common form is obstructive sleep apnea (OSA), which is a cessation or stopping of airflow despite the effort to breathe. It occurs when muscles or soft structures of the oral cavity or throat relax during sleep. The upper airway becomes partially or completely blocked, and nasal airflow diminishes (hypopnea) or stops (apnea). The person tries to breathe because chest and abdominal movements continue, which often results in loud snoring sounds. When breathing is partially or completely diminished, the person becomes sufficiently hypoxic and must awaken to breathe. Structural abnormalities such as a deviated septum, nasal polyps, narrow lower jaw, or enlarged tonsils sometimes predispose a patient to OSA. It is estimated that 9% to 21% of women and 24% to 31% of men in the United States are affected by OSA (American Sleep Association, 2020). However, a large majority of people are undiagnosed and untreated (Kryger et al., 2017). Obesity and hypertension are major factors in OSA. Smoking, increasing age (greater than 65 years old), heart failure, alcohol, nasopharyngeal structural abnormalities, large neck circumferences, and menopause are increased risks for OSA (American Thoracic Society, 2017; Chaiard and Weaver, 2019a). Some research indicates that there may be a link between OSA and occupations in which the individual is exposed to and breathes in solvents (Schwartz et al., 2017). Central sleep apnea (CSA) involves dysfunction in the respiratory control center of the brain. The impulse to breathe fails temporarily, and nasal airflow and chest wall movement cease. The oxygen saturation of the blood falls. The condition is common in patients with brainstem injury, stroke, obesity, muscular dystrophy, and encephalitis. Less than 10% of sleep apnea is predominantly central in origin. People with CSA tend to awaken during sleep and therefore complain of insomnia and EDS. Mild and intermittent snoring is also present. Excessive daytime sleepiness (EDS) is a common complaint in people experiencing OSA and CSA. Other common symptoms of OSA include fatigue, morning headaches, irritability, depression, difficulty in concentrating, and a decrease in sex drive (Kryger et al., 2017). Untreated sleep apnea increases the risk of hypertension, diabetes mellitus, heart disease, and heart failure. Lifestyle changes, including a weight-reduction program in people who are obese, improved sleep hygiene, bilevel positive airway pressure (BPAP or BiPAP), continuous positive airway pressure (CPAP), surgery, hypoglossal nerve stimulation, and oral repositioning devices for the jaw and tongue, are treatment options for OSA (Chaiard and Weaver, 2019a). OSA causes a serious decline in arterial oxygen saturation level. Patients are at risk for cardiac dysrhythmias, right-sided heart failure, pulmonary hypertension, angina attacks, stroke, and hypertension. Patients with sleep apnea rarely achieve deep sleep. OSA affects quality-of-life issues such as concentration, social interactions, libido, and sexual activity and often is an embarrassment to a patient (Chaiard and Weaver, 2019a). Treatment includes therapy for underlying cardiac or respiratory complications and any emotional problems that occur because of the symptoms of this disorder. **From Sherpath** Implement and Take Action Evaluate: "Nonpharmacologic Interventions for Sleep Disorders" Obstructive Sleep Apnea (OSA) OSA treatments include improving sleep hygiene and weight-loss efforts. A continuous positive airway pressure (CPAP) device may be prescribed by a polysomnographic specialist. It has a specialized mask that is worn during sleep that helps maintain pressure on the airway to keep it open. Patients may report skin irritation, discomfort, or a claustrophobic sensation when using the CPAP machine, but use should still be encouraged. **From Sherpath Sleep: Assess and Recognize Cues / Assessment Techniques Related to Sleep** **Polysomnography, also called a *sleep study,* is the diagnostic testing for sleep disorders. In polysomnography, the brain waves, oxygen level, heart rate, and breathing, as well as eye and leg movements, are recorded while the patient is asleep.** **The following scale is used for diagnosing a potential case of OSA:** **\30 indicates severe OSA** **6. education on sleep medications** From Sherpath Sleep: Implement and Take Action; Evaluate / Pharmacologic Sleep Interventions and Evaluation Common Categories of Sleep Medications ====================================== In cases where nonpharmacologic methods have not been effective in providing the patient with high-quality sleep, medications may be prescribed or recommended. Education for the patient is extremely important when pharmacologic sleep aids are used. There are four common categories of sleep medication: sedative-hypnotics, benzodiazepines, melatonin receptor agonists, and antidepressants. +-----------------+-----------------+-----------------+-----------------+ | Medication | Action | Side Effects | Examples | | Class | | and | | | | | Considerations | | +=================+=================+=================+=================+ | **Sedative-Hypn | Sedative-hypnot | Sedative-hypnot | Zolpidem | | otics** | ics | ics | (Ambien, | | | work as | have a related | Intermezzo) | | | facilitators | risk for abuse | | | | against gamma | and dependence. | Zaleplon | | | aminobutyric | As such, they | (Sonata) | | | acid (GABA) | are listed as | | | | receptors to | controlled | Eszopiclone | | | inhibit brain | substances. | (Lunesta) | | | activity. They | | | | | help improve | ***Side | | | | the onset and | Effects:*** | | | | duration of | | | | | sleep. | - | | +-----------------+-----------------+-----------------+-----------------+ | **Benzodiazepin | Benzodiazepines | Long-term use | Alprazolam | | es** | act as a | of | (Xanax) | | | central nervous | benzodiazepine | | | | system | medications | Lorazepam | | | depressant by | further | (Ativan) | | | increasing the | disrupts sleep | | | | effect of GABA | and may cause | Oxazepam | | | to reduce brain | additional | | | | activity. | problems. | Temazepam | | | | | (Restoril) | | | | The use of | | | | | benzodiazepines | | | | | must be tapered | | | | | off to limit | | | | | dangerous | | | | | withdrawal | | | | | symptoms. | | +-----------------+-----------------+-----------------+-----------------+ | **Melatonin | Melatonin | Melatonin | Ramelteon | | Receptor | receptor | receptor | (Rozerem) | | Agonists** | agonists | agonists show | | | | increase the | no evidence of | Tasimelteon | | | body's uptake | abuse, | (Hetlioz) | | | of melatonin. | dependence, or | | | | They mimic | withdrawal and | Agomelatine | | | melatonin, | have been | (Valdoxan, | | | which is a | approved for | Melitor, | | | naturally | long-term use | Thymanax) | | | occurring | in adults. | | | | hormone | | | | | produced by the | | | | | pineal gland. | | | +-----------------+-----------------+-----------------+-----------------+ | **Antidepressan | Antidepressants | The use of | Doxepin | | ts** | can affect | antidepressants | (Silenor) | | | either the | as a sleep aid | | | | histamine or | is an | Trazodone | | | serotonin | "off-label" | (Oleptro) | | | receptors to | use; that is, | | | | cause a | the medication | Mirtazapine | | | sedative | is being used | (Remeron) | | | effect. | in a manner | | | | | that has not | Amitriptyline | | | | been given Food | | | | | and Drug | Imipramine | | | | Administration | | | | | (FDA) approval. | | | | | When prescribed | | | | | as a sleep aid, | | | | | antidepressants | | | | | are prescribed | | | | | at a lower | | | | | dose. One of | | | | | the main side | | | | | effects of | | | | | certain | | | | | antidepressant | | | | | medications is | | | | | drowsiness. | | | | | Other side | | | | | effects | | | | | include: | | | | | headache, | | | | | nervousness, | | | | | and decreased | | | | | sexual desire. | | | | | These side | | | | | effects usually | | | | | subside within | | | | | a few weeks. | | +-----------------+-----------------+-----------------+-----------------+ **7. Sleep Deprivation:** From Sherpath Sleep: Assess and Recognize Cues / Assessment Techniques Related to Sleep Behaviors of Sleep Deprivation ============================== Observe the patient for irritability, disorientation, and slurred speech. These behaviors may be the result of sleep deprivation. The patient may or may not be aware that sleep is affecting his or her behavior.Paranoia and delusions may result from long-term sleep deprivation. ===================================================================================================================================================================================================================================================================================== From Fundamentals ebook page 1113 Sleep Deprivation Many patients experience sleep deprivation because of a sleep disorder. It can be acute or chronic and results from insufficient or disrupted sleep. Causes include illness (e.g., fever, difficulty breathing, or pain), emotional stress, medications, environmental disturbances (e.g., frequent interruptions in sleep during nursing care, noisy neighbors or pets), and variability in the timing of sleep as a result of shift work. Sleep disorders such as sleep apnea or insomnia can cause sleep deprivation. With sleep deprivation, there is a decrease in the quantity or quality of sleep and/or an inconsistency in the timing of sleep. When sleep becomes interrupted or fragmented, changes in the normal sequencing of the sleep cycles occur. Cumulative sleep deprivation develops over time. Individuals respond to sleep deprivation differently. Patients experience a variety of physiological and psychological symptoms (Box 43.3). The severity of symptoms is often related to the duration of sleep deprivation. The most effective treatment for sleep deprivation is to eliminate or correct the environmental factors and patient care activities that disrupt the sleep pattern. Nurses play an important role in identifying treatable sleep-deprivation problems. Evidence suggests that both chronic sleep deprivation and long sleep duration are associated with obesity, type 2 diabetes mellitus, poor memory, depression, digestive problems, and the development of cardiovascular disease (Jike et al., 2018). From Sleep Powerpoints slide \#12 Sleep Disorders Sleep deprivation: Patient experiences sleep deprivation due to sleep disorders. Acute or chronic, results from insufficient or disrupted sleep. From Sleep Powerpoints slide \#21 Sleep History **vBehaviors of sleep deprivation Observe for behaviors indicating sleep deprivation, e.g., irritability, disorientation (\~drunken state), frequent yawning, slurred speech; chronic s/s è psychotic behavior such as delusions & paranoia** **8. NI,N2, N3, REM** Sherpath Overview of Sleep / Circadian Rhythms and Sleep Cycles ![](media/image2.png) There are two main cycles of sleep: nonrapid eye movement (NREM) and rapid eye movement (REM). NREM has three stages. NREM and REM sleep typically alternate in 90-minute intervals, with the normal sleep pattern being 3 to 5 cycles NREM 1 ====== - NREM 2 ====== - NREM 3 ====== - REM === - **9. Medications to prevent narcolepsy to prevent sleep attacks** Fundamentals ebook Chapter 43 " Sleep" page 1113 Patients diagnosed with narcolepsy(Excessive daytime sleepiness is the most common complaint associated with this disorder) are treated with stimulants or wakefulness-promoting agents such as modafinil, armodafinil, methylphenidate, or sodium oxybate, which only partially increase wakefulness and reduce sleep attacks (Chaiard and Weaver, 2019b; Maski and Owens, 2018). Patients also receive antidepressant medications that suppress cataplexy(sudden muscle weakness) and the other REM-related symptoms. Brief daytime naps no longer than 20 minutes help reduce subjective feelings of sleepiness. Other management methods that help are following a regular exercise program, practicing good sleep habits, avoiding shifts in sleep, strategically timing daytime naps if possible, eating light meals high in protein, practicing deep breathing, chewing gum, and taking vitamins (Kryger et al., 2017). Patients with narcolepsy need to avoid factors that increase drowsiness (e.g., alcohol, heavy meals, exhausting activities, long-distance driving, and long periods of sitting in hot, stuffy rooms). **10. Hours of sleep required for infants, children, adults, school age** Powerpoints "Sleep" " Normal Sleep Requirements & Patterns" Slide \#13 Neonates: 16 hours of sleep Infants: 15 hours total with naps Toddlers: 12 hours total with a nap Preschoolers; 12 hours per night School-age: varies; 9-12 hours Fundamentals ebook "Nursing Knowledge Base " Chapter 43 " Sleep" A 6-year-old averages 11 to 12 hours of sleep nightly, whereas an 11-year-old sleeps about 9 to 10 hours Adolescents: 8-10 hours recommended Young adults: 6-8.5 hours per night Middle adults: 7-9 hours per night Older adults: varies; many have sleep problems **11. Side effects of antidepressants and anticonvulsants** BOX 43.4 Fundamentals ebook Drugs and Their Effects on Sleep Anticonvulsants Decrease REM sleep time Cause daytime drowsiness Antidepressants and Stimulants Suppress REM sleep Decrease total sleep time From Sherpath AI Pharmacology ebook ------- -------- ------------------------------------------------------------------------------------------------------- p 266 Ch 16: 16: Psychotherapeutic DrugsPsychotic Disorders; Nursing Processs - Anxiolytic Drugs - Antidepressants ------- -------- ------------------------------------------------------------------------------------------------------- Side effects of antidepressants can include nausea, increased appetite and weight gain, loss of sexual desire, fatigue, dizziness, dry mouth, insomnia, and constipation. Anticonvulsants used for conditions like epilepsy can cause drowsiness, dizziness, headaches, nausea, blurred vision, and unsteadiness. Both antidepressants and anticonvulsants may increase the risk of suicidal thoughts and behaviors, especially in young adults. Close monitoring is required when starting these medications. See video for anticonvulsants / Go to Sherpat ATI and type " Anticonvulsant therapy video" **From Sherpath Sleep: Implement and Take Action; Evaluate / Pharmacologic Sleep Interventions and Evaluation** Antidepressants: One of the main side effects of certain antidepressant medications is drowsiness. Other side effects include: headache, nervousness, and decreased sexual desire. These side effects usually subside within a few weeks. **12. benzodiazepines, class, indication, side effects, etc** ***(pharmacology ebook pg 249)*** Benzodiazepines are the largest and most commonly prescribed ***anxiolytic drug class*** and used to treat anxiety. ***TABLE 16.2 ( pharmacology ebook)*** ***Adverse Effects of Selected Anxiolytic Drugs: Benzodiazepines Side effects: Amnesia, anorexia, sedation, lethargy, fatigue, confusion, drowsiness, dizziness, ataxia, headache, slurred speech, visual changes, hypotension, weight gain or loss, nausea, weakness.*** Powerpoints " Depressant and Muscle Relaxants" Slide \#12 Benzodiazepines Adverse Effects: Mild and Infrequent: Headache , drowsiness, dizziness, Cognitive Impairment,Vertigo, Lethargy, Fall hazard for older adults, " Hangover" effect or daytime sleepiness. **13. spiritual distress related to grief** Fundamentals ebook Chapter 35 " Spiritual Health" pg 766 same as slide \#7 from powerpoints "Spiritual Health" When illness, loss, grief, or a major life change occurs, people often use spiritual resources to help them cope and search for meaning. Spiritual needs and concerns usually develop when people fail to use their spiritual resources during these times. Spiritual distress is "a disruption in the life principle that pervades a person's entire being and transcends the person's biologic and psychosocial nature" (Andrews and Boyle, 2016). It causes people to question their identities and to feel doubt, lose faith, and feel alone or abandoned. Individuals often question their spiritual values or the meaning of life, raising questions about their way of life, purpose for living, and source of meaning (Connerton and Moe, 2018). Spiritual distress also occurs when there is conflict between a patient's beliefs and prescribed health regimens or when patients face the inability to practice usual rituals. An example is the experiences many individuals felt during the COVID-19 pandemic when churches and other religious and community settings were closed. Sherpath Spirituality and Spiritually Sensitive Nursing Care / Spiritually Sensitive Nursing Assessment Research has shown that religious and spiritual identities of health care providers can be influential in patient care encounters (Pesut, 2009). Therefore it is imperative when providing nursing care that the nurse maintains spiritual sensitivity and is observant of any spiritual or religious needs of the patient. Spiritual distress can occur during times of impaired health or when learning of a life-changing health diagnosis. The patient may be experiencing a "why me?" moment and could be facing extreme changes and difficulties in his or her life. This spiritual distress may be expressed as pain, insomnia, anger, depression, stoicism, sadness, or even the need for excessive attention. During times of spiritual distress, an individual will reflect on his or her spirituality and turn toward the things in life that provide peace, hope, and strength. Or sometimes, those without a spiritual source or inner connectedness may begin to feel hopeless or saddened or may even sink into a severe depressive state. As a nurse, being cognizant of spiritual distress and being present when a patient exhibits a spiritual need will strengthen the nurse-patient relationship. Sometimes, observation of the patient's surroundings can provide clues to his or her spirituality such as scriptures, religious jewelry, prayer objects, or even recognizing in day-to-day conversations where the pat**ient** may have expressed spiritual beliefs. **14. dimensions of spirituality** Fundamentals ebook " Spiritual Health" pg 764 Self-transcendence---a sense of authentically connecting to one's inner self. This contrasts with transcendence, the belief that a force outside of and greater than the person exists beyond the material world (Rochat et al., 2019). Self-transcendence is a positive force. It allows people to have new experiences and develop new perspectives that are beyond ordinary physical boundaries. Examples of transcendent moments include the feeling of awe when holding a new baby or looking at a beautiful sunset. Connectedness---being intrapersonally connected within oneself, interpersonally connected with others and the environment, and transpersonally connected with God or an unseen higher power. Through connectedness patients move beyond the stressors of everyday life and find comfort, faith, hope, and empowerment (Hakanson and Ohlen, 2016). =================================================================================================================================================================================================================================================================================================================================================== Faith and hope---Faith allows people to have firm beliefs despite lack of physical evidence and enables people to believe in and establish transpersonal connections. Although many people associate faith with religious beliefs, it also exists without them (Christman and Mueller, 2017). For example, one might have faith that all people are good, without being a practitioner of a religion. Hope has several meanings, which vary on the basis of how it is being experienced; it usually refers to an energizing source that has an orientation to future goals and outcomes (Griggs and Walker, 2016). ==================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================== Inner strength and peace---Spirituality gives people the ability to find a dynamic and creative sense of inner strength to use when making difficult decisions. This source of energy helps people stay open to change and life challenges, provides confidence in decision making, and promotes connections with others and a positive outlook on life (Boman et al., 2017). Inner peace fosters calm, positive, and peaceful feelings despite life experiences of chaos, fear, and uncertainty. These feelings help people feel comforted, even in times of great distress. =============================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================== Meaning and purpose in life---Spirituality also helps people find meaning and purpose in both positive and negative life events (Dobratz, 2016; Rochat et al., 2019). ======================================================================================================================================================================= **15. CONCEPTS OF SPIRITUALITY** Fundamentals ebook pg 765 Spiritual well-being. The concept of spiritual well-being is defined as feelings of contentment coming from the inner self and has been shown to be related to quality of life (Phenwan et al., 2019). Spiritual well-being includes four dimensions: meaning and purpose of one's own life, interpersonal relationships with others, a sense of unity with the environment, and a connectedness with God or a higher power (Phenwan et al., 2019). Those who experience spiritual well-being feel connected to others and can find meaning or purpose in their lives. Those who are spiritually healthy experience joy, can forgive themselves and others, accept hardship and mortality, and report an enhanced quality of life (Cottrell, 2016; Khahi et al., 2017). Spiritual well-being shows the positive aspects of spirituality and is associated with positive health outcomes of decreased pain, stress, and negative emotions; lower risk of depression and suicide; and improved tolerance of the physical and emotional stressors of disease and illness (Harrad et al., 2019). Faith. In addition to being a component of spirituality, the concept of faith has other definitions. It can be described as a cultural or institutional religion such as Judaism, Buddhism, Islam, or Christianity. It is also a relationship with a divinity, higher power, or spirit that incorporates a reasoning faith (belief) and a trusting faith (action). Reasoning faith provides confidence in something for which there is no proof. It is an acceptance of what reasoning cannot explain. Sometimes faith involves a belief in a higher power, spirit guide, God, or Allah. It is also the way a person chooses to live. It gives purpose and meaning to an individual's life, allowing for action. Religion. Religion is associated with the "state of doing," or a specific system of practices associated with a particular denomination, sect, or form of worship. It is a system of organized beliefs and worship that a person practices to outwardly express spirituality. Many people practice a faith or belief in the doctrines and expressions of a specific religion or sect, such as the Lutheran church or Judaism. People from different religions also view spirituality differently. For example, a Buddhist believes in Four Noble Truths: 1\. Life is suffering. 2\. Suffering is caused by karma and disturbing emotions. 3\. Suffering can be eliminated by eliminating karma and disturbing emotions. 4\. To eliminate karma, disturbing emotions, and suffering, one follows an eightfold path (i.e., right understanding, intention, speech, action, livelihood, effort, mindfulness, and concentration) (Rinpoche, 2017). A Buddhist turns inward, valuing self-control, whereas a Christian looks to the love of God to provide enlightenment and direction in life. When providing spiritual care, it is important to understand the differences between religion and spirituality. Many people tend to use the terms interchangeably. Although closely associated, they are not synonymous. Religious practices encompass spirituality, but spirituality does not need to include religious practice. Religious care helps patients maintain their faithfulness to their belief systems and worship practices. Spiritual care helps people identify meaning and purpose in life, look beyond the present, and maintain personal relationships and a relationship with a higher being or life force. Hope. A spiritual person's faith brings hope. When a person has the attitude of something to live for and look forward to, hope is present. It is a multidimensional concept that provides comfort while people endure life-threatening situations, hardships, and other personal challenges. Hope is closely associated with faith; it is energizing and motivates people to achieve goals, such as adopting healthy behaviors. People express hope in all aspects of their lives to help them deal with life stressors. It is a valuable personal resource whenever someone is facing a loss (see Chapter 36) or a difficult challenge (Griggs and Walker, 2016). **16. bilirubin** Sherpath Laboratory Tests Performed on Blood and Body Fluids / Laboratory Tests Performed on Blood: Blood Chemistries To screen for or monitor liver disease: ======================================= Levels of albumin and bilirubin indicate how well the liver is making protein and clearing bilirubin, which is a waste product. The enzyme levels are measures of liver disease because the enzymes are released from damaged liver cells. ========================================================================================================================================================================================================================================== Bilirubin Expected Lab Value → **0.3--1.0 mg/dL** **17. Coagulation test and which drugs they are used to check therapeutic ranges for** From Sherpath Laboratory Tests Performed on Blood and Body Fluids / Laboratory Tests Performed on Blood: Complete Blood Count and Coagulation Studies There are five diagnostic measures related to coagulation. Each one assesses a different part of the hemostasis process. The five diagnostic tests are: ======================================================================================================================================================= - Platelet count ============== Prothrombin time (PT) ===================== International normalized ratio (INR) ==================================== Activated partial thromboplastin time (aPTT) ============================================ Fibrinogen ========== These tests are done on a sample of venous blood. ================================================= Prothrombin Time and International Normalized Ratio =================================================== Prothrombin time (PT) and the international normalized ratio (INR) are used to evaluate the time required for blood clotting. The INR is calculated from the result of a PT test. ================================================================================================================================================================================= Prothrombin Time ================ PT is a measure of how long it takes the blood to clot. Prothrombin is one of the clotting factors made by the liver. The PT test checks for the presence of five different clotting factors (factors I, II, V, VII, and X). ============================================================================================================================================================================================================================ Reasons for Prescribing ----------------------- - To detect bleeding disorders caused by abnormalities of the extrinsic clotting pathway ====================================================================================== To monitor and titrate warfarin therapy ======================================= Expected Value Range -------------------- - The normal PT value is 11 to 12.5 seconds. The therapeutic level for anticoagulant therapy is 1.5 to 2.0 times the control value of 11 to 12.5 seconds. ======================================================================================================================================================= A higher level means that the blood takes longer to clot; therefore a person on anticoagulant therapy would have a higher PT. ============================================================================================================================= Reason for Prescribing ---------------------- Use of the INR makes results of PT testing comparable, regardless of which laboratory or method of testing is used. =================================================================================================================== Expected Value Range -------------------- The normal INR is 0.8 to 1.1 for a patient who is not on anticoagulant therapy and 2 to 3 for patients prescribed prophylactic measures or undergoing treatment of venous thrombosis with anticoagulant therapy. ================================================================================================================================================================================================================ The activated partial thromboplastin time (aPTT) is a measure of the function of the intrinsic clotting system and the time required for blood to clot. ======================================================================================================================================================= The aPTT measures the same clotting functions as a partial thromboplastin time (PTT), but it has an activator added to speed up the process so the reference range is narrower. The aPTT is considered more sensitive than a PTT. ================================================================================================================================================================================================================================= Reasons for Prescribing ----------------------- - To detect bleeding disorders caused by abnormalities of the intrinsic clotting pathway ====================================================================================== To monitor and titrate heparin therapy ====================================== Expected Value Range -------------------- The normal value for aPTT is 30 to 40 seconds. The therapeutic level for anticoagulant therapy is 1.5 to 2.5 times the control value or normal range. ===================================================================================================================================================== Interpretation of Abnormal Values --------------------------------- A high PT or aPTT is abnormal, and it can indicate a problem such as liver disease. An elevated PT or aPTT is desirable when a patient is on anticoagulant therapy because it means the anticoagulant is working. The normal range for PT and aPTT is unique in that it is referred to as a control. PT and aPTT relate to time, not number, proportion, or function of individual cells as with other blood tests. *While PT reflects the function of the extrinsic clotting system, the aPTT reflects the function of the intrinsic clotting system.* ======================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================================= **18. cardiac markers, what do they mean/indicate?** Sherpath Oxygenation and Perfusion: Assess and Recognize Cues / Laboratory Studies Related to Oxygenation and Perfusion The nurse is responsible for understanding the results of different diagnostic tests and how they affect the patient care plan in relation to oxygenation and perfusion. ======================================================================================================================================================================== Injured and dying cardiac cells release specific enzymes (such as troponins) into the bloodstream that are measured to determine the extent of myocardial injury. Other laboratory and diagnostic tests help identify chemical imbalances and the presence of abnormal substances in the blood, and they determine the function and structure of heart and lung tissues. ======================================================================================================================================================================================================================================================================================================================================================================== Cardiac Enzymes =============== What It Is ========== Cardiac enzymes and proteins are released when myocardial necrosis (death of heart muscle cells) occurs. When a patient has chest pain or related signs and symptoms of cardiac muscle hypoxia, cardiac enzyme levels are evaluated to determine if damage to the heart has occurred. ===================================================================================================================================================================================================================================================================================== What It Is Used For =================== Used to assess for elevated levels of creatine phosphokinase-MB, troponin T, troponin I, and myoglobin. Cardiac troponin T and I proteins are the most ====================================================================================================================================================== helpful biomarkers for determining cardiac tissue damage. ========================================================= **19. Culture and sensitivity** Laboratory Tests Performed on Blood and Body Fluids / Laboratory Tests Performed on Body Fluids sherpath Cultures are laboratory tests to detect infection and identify the infecting organism. A sterile swab can be used to sample body fluid or any area of the body. The sample is placed on a culture medium and incubated at body temperature. If microorganisms grow, the culture is positive. Common sources of culture specimens are blood, throat, sputum, stool, urine, and wounds. Sensitivity tests guide the selection of an effective antibiotic to treat a patient's infection. The sensitivity test exposes the positive culture to multiple antibiotics. Sensitivity is found when a specific antibiotic kills or inhibits growth. The "sensitive" antibiotic is then given to the patient to fight the infection. Reason for Prescribing ---------------------- Cultures and sensitivity tests identify organisms causing infection and the antiinfectives that will eliminate them. Some microorganisms that cause infections are resistant to certain antibiotics. This means that the antibiotic does not kill them or stop them from growing. When an infecting microorganism is killed or stopped from growing by an antibiotic, the microorganism is said to be susceptible to it. **20. Side effects of suctioning to often** ( Chapter 41 p972) Suctioning too frequently can lead to several side effects and complications: \- Trauma and bleeding of the airway mucosa \- Hypoxemia (low oxygen levels) from interrupted ventilation \- Increased risk of arrhythmias and cardiovascular instability \- Atelectasis (collapsed lung segments) if too much air is removed \- Increased risk of infection from repeated mucosal trauma \- Patient discomfort, anxiety, and fatigue \- Increased intracranial pressure in patients with head injuries ### To minimize harm, suctioning should only be performed when clinically indicated, using proper technique, limiting duration, and closely monitoring the patient\'s response. Routine, unnecessary suctioning should be avoided. To help remember the side effects of suctioning too frequently, try using the mnemonic \"HABITS\": H - Hypoxemia (low oxygen levels) A - Airway trauma B - Bleeding I - Increased infection risk T - Tachycardia (fast heart rate) S - Stimulation of vagus nerve (can cause arrhythmias, increased ICP) **21. Oxygen mask** Potter and perry page page 1005 **[Simple Mask: ]** **An oxygen mask is a plastic device that fits snugly over the mouth and nose and is secured in place with a strap. It delivers oxygen as the patient breathes through either the mouth or nose by way of a plastic tubing at the base of the mask that is attached to an oxygen source. An adjustable elastic band is attached to either side of the mask that slides over the head to above the ears to hold the mask in place. There are two primary types of oxygen masks: those delivering low concentrations of oxygen and those delivering high concentrations.** **The simple face mask is used for short-term oxygen therapy. It fits loosely and delivers oxygen concentrations from 6 to 12 L/min (35% to 50% oxygen). The mask is contraindicated for patients with carbon dioxide retention because retention can be worsened, leading to decreased levels of consciousness. Flow rates should be 6 L or more to avoid rebreathing exhaled carbon dioxide retained in the mask. Be alert to skin breakdown under the mask with long-term use (Hartjes, 2018).** **Partial rebreather and nonrebreather masks are simple masks with a reservoir bag that are capable of delivering higher concentrations of oxygen for a short period of time (60% to 90% oxygen at a flow rate of 10 to 15 L/min). Frequently inspect the reservoir bag to make sure that it is inflated. If it is deflated, the patient is breathing large amounts of exhaled carbon dioxide. (Hartjes, 2018; Harding et al., 2020).** **The Venturi mask delivers high-flow, more precise oxygen concentrations of 24% to 60% and usually requires oxygen flow rates of 4 to** **12 L/min, depending on the flow-control meter selected. Its use is typically reserved for patients with COPD who need low, constant oxygen concentrations (Hartjes, 2018;.** from sherpath Oxygen masks. Face Masks Mask delivery systems deliver a higher percentage of O2 than a nasal cannula because they gather and store O2 between patient breaths. Partial **rebreather** and nonrebreather masks have a flexible 1-L reservoir bag with an O2 inlet. They are referred to as *reservoir masks* because they have a valve system and can deliver higher levels of inspired O2. Simple Face Mask ================ - - Partial Rebreather Mask ======================= - - Nonrebreather Mask ================== - - Venturi Mask - - **[Simple Mask:]** **🡪 6 - 10 L/ Min** **1 L increase = approx. 5% FiO2** **i.e. 6L/min = approx. 45% FiO2** **Nonrebreathing mask** ![](media/image7.png) **22. Humidification and oxygen** Watch the video Overview of Oxygenation and Perfusion ### Sherpath AI ### Humidification is the process of adding moisture to oxygen gas to prevent drying of the airways and mucous membranes. It is necessary for patients receiving high-flow oxygen therapy, typically over 4 L/minute. Oxygen can be humidified by bubbling it through sterile water in a humidifier bottle or via a nebulizer that produces a mist. Humidification helps improve mucociliary clearance and secretion removal, especially for pediatric patients with smaller airways. It is important to monitor water levels, change humidifier solutions per protocol, and drain any condensation that accumulates in the tubing to prevent infection risks. **23. Oxygenation and tracheostomy** (chapter 41 p 972 , watch Osmosis video Tracheostomy) ### In a patient with a tracheostomy, oxygenation is facilitated by the direct access to the airway through the tracheostomy tube. The tracheostomy bypasses the upper airway, allowing air to flow directly into the trachea and lungs. This can improve oxygenation in patients who have difficulty breathing through their nose or mouth due to an obstructed upper airway or inability to protect their airway. However, proper humidification and suctioning of the tracheostomy tube is important to prevent mucus plugging and maintain effective gas exchange. With a tracheostomy in place, the patient\'s oxygenation status should be closely monitored through assessment of respiratory rate, work of breathing, oxygen saturation levels, and arterial blood gasses as needed. **24. Effects of smoking** Potter and perry book pg 979 Cigarette smoking and secondhand smoke are associated with a number of diseases, including heart disease, COPD, and lung cancer. Cigarette smoking worsens peripheral vascular and coronary artery diseases. Inhaled nicotine causes vasoconstriction of peripheral and coronary blood vessels, increasing blood pressure and decreasing blood flow to peripheral vessels (McCance and Huether, 2019). Women who take birth control pills and smoke cigarettes have an increased risk for thrombophlebitis and pulmonary emboli. Smoking during pregnancy can result in low-birth-weight babies, preterm delivery, and babies with reduced lung function (CDC, 2020a). Smoking accounts for approximately 30% of all cancer deaths in the United States, including 80% of all lung cancer deaths. Smoking has been linked to the development of other cancers, including cancers of the mouth, esophagus, liver, bladder, kidney, and cervix, and myeloid leukemia (ACS, 2020a). Nicotine patches, gum, and lozenges are available over the counter, and nicotine nasal spray and inhalers can be obtained by prescription. Prescription drugs such as bupropion and varenicline are also available to help people quit smoking (ACS, 2020b). Exposure to environmental tobacco smoke (secondhand smoke) increases the risk of lung cancer and cardiovascular disease in the non-smoker. Children with parents who smoke have a higher incidence of asthma, pneumonia, and ear infections. Infants exposed to secondhand smoke are at higher risk for sudden infant death syndrome (NCI, 2018). Potter and Perry Pg book 983 Smoking. It is important to determine a patient\'s direct and secondary exposure to tobacco. Ask about any history of smoking; include the number of years smoked and the number of packages smoked per day. This is recorded as pack-year history (packages per day X years smoked). For example, if a patient smoked two packs a day for 20 years, the patient has a 40 pack-year history. Determine exposure to secondhand smoke, because any form of tobacco exposure increases a patient\'s risk for cardiopulmonary diseases (American Lung Association \[ALA), 2020a). Skin and Aging: Smoking accelerates skin aging and leads to a dull complexion and increased wrinkles. Immune System: Smoking weakens the immune system, making individuals more susceptible to infections. **25. Muslim culture** (Chapter 35 p777) Followers of Islam practice Salah, the second of the Five Pillars of Islam, requiring all Muslims who have reached puberty to worship five times daily, facing the holy city of Mecca. Consumption of pork and alcohol is haram (forbidden). Use of caffeine is makrooh (doubtful). Followers fast during the month of Ramadan. A patient who is a follower of Islam will want to say daily prayers (Salah) five times a day. **26. Spiritual health concepts** Potter and perry book pg 764 Current Concepts in Spiritual Health Spiritual health involves finding a balance between one\'s val and beliefs and one\'s relationships within the self and with caber. lua a healthy way of expressing and experiencing one\'s spiritato Throughout life our spirituality often grows as we become imctemn aware of the meaning, purpose, and values of life, In times of stee illness, loss, or recovery, a person who is spiritually healthy will him find ways of responding or adjusting to a it uation. Often these coping styles lie within a person\'s spiritual beliefs. Spiritual beliefs change as patients grow and develop, pontemalay developing their spirituality as well (Table 35.1). Spirituality begine as children learn about themselves and their relationships with others, including a higher power. As children mature into adulthod, they experience spiritual growth by entering lifelong relationships unti people who share similar values and beliefs. Beliefs among people vary based on cultural factors such as gender, past experience, religion, ethnicity, and economic status. For example. spiritual health in older adults gives peace and acceptance of the welf and is often the result of a lifelong connection with a higher power. Illness and loss sometimes threaten and challenge an individuals spiritual development. Older adults often express their spirituality turning to important relationships and giving of themselves to others (louhy and Jett, 2020). A variety of concepts describing spiritual health are a part of nursing science and professional nursing practice. To provide meaningful and supportive spiritual care, it is important to understand the concepts of spirituality, spiritual well-being, faith, religion, and hope. Each concept offers direction in how to assess patient needs and understand the views that individuals have of life and its value. This level of understanding aids in making clinical judgments about patient needs. ### Sherpath AI ### answered: Spiritual health involves finding meaning, purpose, and balance in one\'s values, beliefs, and relationships with self and others. Key spiritual health concepts include: Spirituality - An awareness of one\'s inner self and connection to something greater, providing energy to cope with difficulties. Spiritual well-being - Feeling connected, finding meaning in life, and experiencing an enhanced quality of life. Faith - A belief system that provides hope, meaning, and purpose. Religion - An organized system of beliefs, practices, and worship. Hope - An optimistic attitude of mind based on expecting positive outcomes. ### Spiritual health aids in adjusting to stressful situations through coping mechanisms rooted in spiritual beliefs. Assessing and understanding these concepts guides clinical judgments about meeting patients\' spiritual needs. **27. Meds for anxiety** [**[Chapter\_012 CNS Depressant and Muscle Relaxants.pptx]**](https://ilearn.laccd.edu/courses/288412/modules/items/20153259) Go to PPT slide [**[CNS Depressant]**](https://ilearn.laccd.edu/courses/288412/modules/items/20153259) ### The main medications used for anxiety disorders are: ### ### Benzodiazepines: ### - Alprazolam (Xanax) ### - Lorazepam (Ativan) ### - Clonazepam (Klonopin) ### - Diazepam (Valium) ### ### Non-benzodiazepine: ### - Buspirone (BuSpar) ### Antidepressants like SSRIs are also sometimes prescribed off-label for anxiety. ### Buspirone (BuSpar) is the main non-benzodiazepine medication used for anxiety disorders. It is an azapirone anxiolytic that works differently than benzodiazepines, with a lower risk of dependence and sedation. However, it may take several weeks to take full effect compared to the more rapid onset of benzodiazepines. Benzodiazepines A chemical category of drugs most frequently prescribed as anxiolytic drugs and less frequently as sedative-hypnotic agents ### Sherpath AI ### answered: ### The main medications used for treating anxiety disorders are benzodiazepines like alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin). These work by increasing the effects of the inhibitory neurotransmitter GABA in the brain. Other anti-anxiety drugs include buspirone (BuSpar), a non-benzodiazepine anxiolytic. Benzodiazepines provide faster relief but carry risks of dependence and withdrawal effects with long-term use. They are typically prescribed short-term while buspirone is preferred for chronic anxiety management due to a lower dependence risk. Antidepressants like SSRIs are also sometimes used off-label for anxiety disorders. https://student-study.elsevier.com/\#/ai-chat:\~:text=Antianxiety%20Drug%20Therapy **28. Barbiturates** [**[Chapter\_012 CNS Depressant and Muscle Relaxants.pptx]**](https://ilearn.laccd.edu/courses/288412/modules/items/20153259) Go on the power points slide 21-34.Like benzodiazepines, barbiturates can also have varied uses, including preoperative sedation, anesthesia adjunct, and anticonvulsant therapy. All barbiturates are controlled substances, but not all are on the same schedule, as illustrated in Table 12.7. Dosage information appears in the dosages table for barbiturates. pentobarbital Pentobarbital (Nembutal) is a short-acting barbiturate. Formerly prescribed as a sedative-hypnotic for insomnia, pentobarbital is now principally used preoperatively to relieve anxiety and provide sedation. In addition, it is used occasionally to control status epilepticus. Pentobarbital also may be used to treat withdrawal symptoms in patients who are physically dependent on barbiturates or nonbarbiturate hypnotics. It is available in oral, injectable, and rectal dosage forms. ### Sherpath AI ### ### answered: ### The few barbiturates still used clinically include phenobarbital (for seizures and neonatal hyperbilirubinemia), pentobarbital (for pre-operative sedation), and secobarbital (for insomnia). Phenobarbital is considered the prototypical long-acting barbiturate still commonly prescribed. Most other barbiturates have been replaced by benzodiazepines due to the narrow therapeutic window and risk of dependence with barbiturates. ### Answered: ### Barbiturates are a class of sedative-hypnotic drugs derived from barbituric acid. They were widely used in the past for insomnia and sedation, but have largely been replaced by benzodiazepines due to their narrow therapeutic window and risk of dependence. Phenobarbital is one of the few barbiturates still used clinically, primarily as an anticonvulsant for preventing seizures. Barbiturates depress the central nervous system by enhancing GABA neurotransmission. While effective, they can cause respiratory depression, tolerance, and difficult withdrawal symptoms with long-term use. Their use is now limited due to safer alternatives. **29. Malignant hyperthermia** Malignant hyperthermia is an uncommon but potentially fatal, genetically linked adverse metabolic reaction to general anesthesia. It is classically associated with the use of volatile inhalational anesthetics as well as the depolarizing NMBD succinylcholine. Signs include a rapid rise in body temperature, tachycardia, tachypnea, and muscular rigidity.Also ( unstable blood pressure). Patients known to be at greater risk for malignant hyperthermia include children, adolescents, and individuals with muscular and/or skeletal abnormalities. Malignant hyperthermia is treated with cardiorespiratory supportive care as needed to stabilize heart and lung function, along with the skeletal muscle relaxant dantrolene (see Chapter 12). In fact, by law, all health care institutions that provide general anesthesia must keep a certain amount of dantrolene on hand in the event that a case of malignant hyperthermia should occur. IV dantrolene used for malignant hyperthermia 7\. During a patient's recovery from a lengthy surgery, the nurse monitors for signs of malignant hyperthermia. In addition to a rapid rise in body temperature, which assessment findings would indicate the possible presence of this condition? (Select all that apply.) b\. Tachypnea c\. Tachycardia e\. Muscle rigidity **30. Antidotes for drugs covered** Benzodiazepines toxicity and overdose antidote Narcan - Naloxone antidote for Opiods **31. CHF** Congested heart failure, also known as congestive heart failure, occurs when the heart is unable to effectively pump blood throughout the body. This leads to a buildup of fluid in various tissues and organs, resulting in congestion. Left-sided or left ventricular heart failure often causes pulmonary edema (fluid buildup in the lungs), leading to coughing, shortness of breath, and difficulty breathing. Right-sided or right ventricular heart failure typically involves systemic venous congestion, causing swelling in the legs and feet (pedal edema), distended neck veins, abdominal swelling (ascites), and liver congestion. Both left and right heart failure stem from increased pressure within the ventricles, which forces fluid back into the pulmonary and systemic circulation. The underlying cause is often a reduced ejection fraction, which is the proportion of blood pumped out of the ventricle with each contraction. **32. Anticholinergic drugs class, indication, side effects, MOA (watch Osmosis cholinergic therapy** **Some common anticholinergic drugs include:** **- Atropine- It blocks the action of acetylcholine at muscarinic receptors, inhibiting the parasympathetic nervous system. Atropine is used to treat bradycardia, asystole during cardiac arrest** **- Scopolamine - is an anticholinergic drug used primarily as an antiemetic (anti-nausea medication)** **- Ipratropium (Atrovent) - is an inhaled anticholinergic bronchodilator used in the management of chronic obstructive pulmonary disease (COPD) and asthma** **- Tiotropium (Spiriva)** **- Glycopyrrolate** **- Oxybutynin (Ditropan)** **- Tolterodine (Detrol)** **- Solifenacin (Vesicare)** **- Darifenacin (Enablex)** **- Trospium (Sanctura)** **- Benztropine (Cogentin)** **- Biperiden** **- Procyclidine** Anticholinergic drugs are a class of medications that block the action of the neurotransmitter acetylcholine at muscarinic receptors in the parasympathetic nervous system. Indications: Parkinson\'s disease, drug-induced extrapyramidal reactions, chronic obstructive pulmonary disease, asthma, chronic bronchitis, exercise-induced bronchospasm, cardiovascular disorders like bradycardia. Mechanism of Action: They competitively inhibit acetylcholine from binding to muscarinic receptors, preventing parasympathetic nerve impulses from being transmitted to effector organs like smooth muscles and glands. ### Side Effects: Dry mouth, constipation, urinary retention, blurred vision, increased heart rate, confusion, drowsiness, dizziness. ![](media/image8.png) **33. Metered Dose Inhaler** **Sherpath AI** ### Sherpath AI ### answered: ### MDIs, or metered dose inhalers, are devices that deliver medication as a fine liquid spray or aerosol. They require a propellant to form the aerosol and can be used with or without a spacer device. MDIs allow drugs like bronchodilators and corticosteroids to be delivered directly to the lungs for treating respiratory conditions like asthma and COPD. Proper inhalation technique is important to ensure the medication reaches the lower airways effectively. Sherpath Drugs Used in the Management of Asthma and COPD / Pharmacokinetics and Pharmacodynamics of Drugs Used in the Management of Asthma and COPD Albuterol has an immediate onset of action when inhaled, peaking 10 to 25 minutes after administration. It lasts for 3 to 4 hours and has a plasma half-life of 3 to 4 hours. As such, it is generally dosed as needed based on symptoms. Salmeterol's onset of action and peak plasma concentration depend on if the patient has asthma or COPD. In asthma, it begins working in 5 to 48 minutes, peaking in 2 to 4 hours. In COPD, the onset of action is a bit more delayed at 2 hours, peaking in 3 to 4.5 hours. Salmeterol's plasma half-life is 5.5 hours, and it lasts for 12 hours, allowing for twice-daily dosing. To provide quick relief, beta2-adrenergic agonists must be administered by inhalation. Three types of devices may be used: MDIs, DPIs, and nebulizers. **Administration** For certain patients, nebulizers may be superior to inhalers. Some patients who have developed a tolerance to a beta2-adrenergic agonist delivered with an inhaler may respond to the same drug when it is given with a nebulizer. The nebulizer delivers the dose slowly (over several minutes); as the bronchi gradually dilate, the drug gains deeper and deeper access to the lungs. **Dosage** - **Administration** Five inhaled LABAs are approved for treatment of asthma: salmeterol, formoterol, arformoterol, indacaterol, and olodaterol. Vilanterol is another LABA that is available only in combination with a glucocorticoid or long-acting muscarinic drug (fluticasone/vilanterol and umeclidinium/vilanterol). **Dosage** LABAs have a long duration of action, and they are designed for maintenance therapy, not acute relief. Dosing is either every 12 or 24 hours depending on the drug. LABAs are not first-choice agents for long-term control, and they should not be used alone. Rather, they should always be combined with an inhaled glucocorticoid, preferably in the same inhaler device. Inhaled Preparations: Short Acting ================================== **Side effects:** Inhaled SABAs are generally well tolerated. Common side effects include tremors, anxiety, restlessness, dizziness, headache, palpitations, tachycardia, angina, coughing, wheezing, dizziness, and dry throat. **Adverse effects:** Sympathomimetic stimulation from beta2-adrenergic agonists may cause palpitations, ectopy, tachycardia, chest pain, and changes in blood pressure. Excessively using beta2-adrenergic agonists can lead to reduced bronchodilating effects and subsequent paradoxical bronchoconstriction. Inhaled Preparations: Long Acting Inhaled LABAs may increase the risk of severe asthma and asthma-related death when used as monotherapy for long-term control. To minimize risk, LABAs should be used only in patients taking a recommended medication for long-term control, and only if that medication has been inadequate by itself. LABAs should never be used as first-line therapy for prolonged control and should never be used alone. **Side effects:** Common side effects include tremors, anxiety, restlessness, dizziness, headache, palpitations, tachycardia, angina, cough, and bronchospasms. **Adverse effects:** Beta2-adrenergic agonists may prolong the QT interval and cause ventricular arrhythmias. Other adverse effects include hypokalemia and hyperglycemia. As the selectivity of beta2-adrenergic agonists is relative, oral administration can lead to activation of the beta receptors in the heart. **Side effects:** Common side effects include tremors, anxiety, restlessness, dizziness, headache, palpitations, tachycardia, and angina. **Adverse effects:** Beta2-adrenergic agonists may prolong QT interval and can cause ventricular arrhythmias. Pre-Administration Assessment for Anticholinergics ================================================== For patients taking anticholinergics, a nurse should assess for the following: - Contraindications and Drug Interactions with Anticholinergics ============================================================= Patients with a known drug allergy, including an allergy to atropine, should not use anticholinergics. Because of the propellant that was once used, patients with an allergy to soy or peanuts were advised to avoid anticholinergics; however, hydrofluoroalkane (HFA) inhalers do not carry this concern and can safely be used by these patients. Patients with acute narrow-angle glaucoma and men with benign prostatic hyperplasia should cautiously use anticholinergics because they can worsen these conditions (Lilley, 2017). Additionally, anticholinergics should be used cautiously, if at all, during pregnancy and breastfeeding. Potential drug interactions with anticholinergics include the following: - - Ipratropium Solution 500 mcg 3 to 4 times daily via nebulizer ------------- ---------- ---------------------------------------------------------------- MDI Two inhalations 4 times daily (maximum of 12 inhalations/24 h) **34. Corticosteroids** Chapter 37 sherpath Respiratory Drugs ===================================== Drugs Used in the Management of Asthma and COPD =============================================== https://youtu.be/9nmcY0ySip8?si=5STYnESNCIaUVLKi The classes of drugs that will likely be prescribed for patients with asthma and COPD include glucocorticoids serving as the antiinflammatory drugs +-----------------------+-----------------------+-----------------------+ | Drug Class | Action and Uses | Examples | +=======================+=======================+=======================+ | Glucocorticoids | Antiinflammatory | - | | | drugs used for | | | | long-term control of | | | | asthma and COPD | | | | | | | | Suppress inflammation | | | | to decrease | | | | hyperreactivity and | | | | overproduction of | | | | mucus in the airways | | +-----------------------+-----------------------+-----------------------+ Glucocorticoids are primarily administered by inhalation for respiratory treatment, but some may be administered orally. If necessary, they may be given by the intravenous (IV) or intramuscular (IM) route. **Absorption** The rate of absorption of a glucocorticoid depends on the route of administration (e.g., inhaled, oral, IM, or IV). Inhaled glucocorticoids are intended to exert localized effects in the lungs. However, some of the drug gets swallowed with administration and can cause systemic effects. Therefore it is ideal for a glucocorticoid to have minimum oral bioavailability of 1%. Fluticasone propionate has an oral bioavailability of less than 1%, budesonide 11%, and flunisolide 20% (Derendorf et al., 1998). With oral administration, absorption of all glucocorticoids is rapid and nearly complete. After IM injection, absorption is dependent on the type of glucocorticoid, with some having immediate absorption and some requiring a longer time for absorption. These rates are dependent on the type of salt with which the medication is combined. ------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Distribution** Glucocorticoids are generally highly protein bound, but the level depends on the specific drug. **Metabolism** Glucocorticoids are metabolized primarily by the liver; the resulting metabolites are inactive. **Excretion** Excretion of glucocorticoid metabolites is renal. Pharmacodynamics of Glucocorticoids =================================== Glucocorticoids, which are also known as *corticosteroids*, are drugs that are usedGlucocorticoids exert antiinflammatory actions to decrease asthma symptoms. Mechanism of Action They work to reduce the production and block the release of leukotrienes, histamine, and prostaglandins. They also block the activity and infiltration of eosinophils and leukocytes, important mediators in the inflammatory process. Glucocorticoids reduce vascular permeability to yield a reduction in edema in the airways. They also reduce hyperreactivity and mucus production in the airways. as antiinflammatory agents in the treatment of pulmonary diseases. Duration of Action ================== The duration of action depends on the dosage, the route, and the drug solubility. For glucocorticoids that are administered orally or intravenously, the duration is mostly determined by half-life. With IM administration, the duration is a function of water solubility. Highly soluble preparations have a shorter duration than less soluble preparations. For locally administered glucocorticoids, the duration is determined by solubility and by the specific site of administration. For example, inhaled fluticasone propionate terminal half-life has been reported to range from 7.8 hours to over 10 hours (Derendorf et al., 1998). Its onset of action and time to peak plasma concentration are unknown, but it has a duration of action of 24 hours (Lilley, 2017). Best Practice Pearls In asthma, glucocorticoids affect disease progression and should be given on a daily basis to modify the disease state. Glucocorticoids are an effective treatment for patients with asthma; however, these drugs should be taken as a scheduled regimen and are not appropriate for use when a patient is actively experiencing an acute attack. Additionally, because glucocorticoids can worsen some conditions such as hypertension and diabetes, patients should be carefully monitored. Establish Therapeutic Goal ========================== Glucocorticoids are used on a fixed schedule to suppress inflammation. They are not used to abort an acute attack. Determine Baseline Data ======================= A baseline assessment of vital signs, breath sounds, and heart sounds should be performed (Lilley, 2017). The patient should be assessed for any adrenal dysfunction because of the risk for adrenal suppression with these drugs. The use of corticosteroids in pediatric patients should be carefully considered because they can potentially suppress growth with chronic use and/or use of high dosage amounts (Lilley, 2017). Patients receiving larger systemic dosages are more likely to experience adrenal suppression as opposed to those receiving inhaled corticosteroids and those receiving corticosteroids over prolonged periods of time (Lilley, 2017). It is important to determine the forced expiratory volume (FEV1) to assess improvements or worsening in lung function. Additionally, the frequency and severity of asthma attacks should be documented along with potential triggers Sherpath Question Which class of drugs used in the management of pulmonary diseases decreases the production of and inhibits the release of leukotrienes, histamine, and prostaglandins; inhibits the activity of eosinophils and leukocytes; and decreases vascular permeability to decrease airway edema? AI Sherpath ### Corticosteroids, also known as glucocorticoids, are a class of steroid hormones that are either naturally occurring or synthetic. They have potent anti-inflammatory and immunosuppressive effects. Corticosteroids mimic the actions of the body\'s natural hormone cortisol. They are used to treat various inflammatory and autoimmune conditions like asthma, COPD, rheumatoid arthritis, and inflammatory bowel disease. Corticosteroids can be administered orally, intravenously, topically, or by inhalation. Inhaled corticosteroids like fluticasone and budesonide are commonly used for long-term control of persistent asthma by reducing airway inflammation. ![](media/image5.png) **35. COPD** Chronic Obstructive Pulmonary Disease COPD is a lung disease depicted by chronic obstruction of lung airflow that interferes with normal breathing. COPD is not fully reversible. The terms chronic bronchitis and emphysema are no longer used but are now included within the COPD diagnosis. Chronic bronchitis is a continuous inflammation and low-grade infection of the bronchi. Inflammation in the associated bronchioles (smaller bronchi) is responsible for most of the airflow obstruction. It involves the excessive secretion of mucus and certain pathologic changes in the bronchial structure. It is usually precipitated by prolonged exposure to bronchial irritants, the most common being cigarette smoke. Some patients acquire the disease because of other predisposing factors such as viral or bacterial pulmonary infections during childhood. Other causes include impairment of the ability to inactivate proteolytic (protein-destroying) enzymes, which then damage the airway mucosal tissues. Unknown genetic characteristics may be responsible as well. Emphysema is a condition in which the air spaces enlarge as a result of the destruction of the alveolar walls. Emphysema is no longer used as a term, but is included in COPD. This appears to be caused by the effect of proteolytic enzymes released from leukocytes in response to alveolar inflammation. Because the alveolar walls are partially destroyed, the surface area available for oxygen and carbon dioxide exchange is reduced, which impairs effective respiration. As with chronic bronchitis, cigarette smoke appears to be the primary irritant responsible for the development of emphysema. There is also an associated genetic deficiency of the enzyme alpha1-antitrypsin. Treatment of Diseases of the Lower Respiratory Tract In the past, the treatment of asthma and other COPDs was focused primarily on the use of drugs that cause the airways to dilate. The emphasis of research has shifted from the bronchoconstriction component of the disease to the inflammatory component. This is reflected in the various medication classes used to treat COPD, although bronchodilators still play an important role. Bronchodilators Bronchodilators are an important part of the pharmacotherapy for all respiratory diseases. These drugs relax bronchial smooth muscle, which causes dilation of the bronchi and bronchioles that are narrowed as a result of the disease process. There are three classes of drugs that cause bronchodilation: beta-adrenergic agonists, anticholinergics, and xanthine derivatives. Beta-Adrenergic Agonists The beta-adrenergic agonists are a group of drugs that are commonly used during the acute phase of an asthmatic attack to quickly reduce airway constriction and restore airflow. They are agonists of the adrenergic receptors in the sympathetic nervous system. Beta- and alpha-adrenergic receptors are discussed in Chapters 18 and 19. The beta agonists imitate the effects of norepinephrine on beta receptors. For this reason, they are also called sympathomimetic bronchodilators. The beta agonists are categorized by their onset of action. Short-acting beta agonist (SABA) inhalers include albuterol (Ventolin, ProAir, others), levalbuterol (Xopenex), terbutaline (Brethine), and metaproterenol (Alupent). Long-acting beta agonist (LABA) inhalers include arformoterol (Brovana), formoterol (Foradil, Perforomist), salmeterol (Serevent), olodaterol (Striverdi), vilanterol in conjunction with fluticasone (Breo Ellipta), formoterol in conjunction with budesonide and glycopyrrolate (Breztri), vilanterol in combination with fluticasone and umbeclidium (Trelegy Ellipta), and vilanterol in conjunction with the anticholinergic umeclidinium (Anoro Ellipta). The term Ellipta refers to a new delivery system. Because the LABAs have a longer onset of action, they must never be used for acute treatment. Patients must be taught to use the SABA for rescue. TABLE 37.2 Mechanisms of Antiasthmatic Drug Action Antiasthmatic Mechanism in Asthma Relief Anticholinergics Block cholinergic receptors, thus preventing the binding of cholinergic substances that cause bronchoconstriction and increase secretions. Leukotriene receptor antagonists Modify or inhibit the activity of leukotrienes, which decreases arachidonic acid--induced inflammation and allergen-induced bronchoconstriction. Beta agonists and xanthine derivatives Raise intracellular levels of cyclic adenosine monophosphate, which in turn produces smooth muscle relaxation, and relaxes and dilates the constricted bronchi and bronchioles. Corticosteroids Prevent the inflammation commonly provoked by the substances released from mast cells. Mast cell stabilizers (cromolyn and nedocromil) Stabilize the cell membranes of the mast cells in which the antigen-antibody reactions take place, thereby preventing the release of substances such as histamine that cause constriction. chapter 37 Drugs Used in the Management of Asthma and COPD / Introduction Introduction ============ COPD is most commonly caused by cigarette smoking, can be debilitating, and is largely irreversible. Although drug therapy is highly effective in reversing the airway inflammation of asthma, it is minimally effective in managing COPD because most of the airway damage is irreversible. Drug therapy for COPD is generally associated with symptom improvement as opposed to affecting disease progression. **36. Albuterol** The short-acting beta2-adrenergic agonists are commonly used during the acute phase of an asthmatic attack to quickly reduce airway constriction and restore airflow. Long-acting beta2-adrenergic agonists are used in the chronic management of airway symptoms. They are agonists of the adrenergic receptors in the sympathetic nervous system. The pharmacodynamics of the beta2-adrenergic agonists will differ based on whether they are short-acting or long-acting. Albuterol ========= Albuterol has an immediate onset of action when inhaled, peaking 10 to 25 minutes after administration. It lasts for 3 to 4 hours and has a plasma half-life of 3 to 4 hours. As such, it is generally dosed as needed based on symptoms. ========================================================================================================================================================================================================================================= In case she asks ================ Salmeterol ========== Salmeterol's onset of action and peak plasma concentration depend on if the patient has asthma or COPD. In asthma, it begins working in 5 to 48 minutes, peaking in 2 to 4 hours. In COPD, the onset of action is a bit more delayed at 2 hours, peaking in 3 to 4.5 hours. Salmeterol's plasma half-life is 5.5 hours, and it lasts for 12 hours, allowing for twice-daily dosing. =================================================================================================================================================================================================================================================================================================================================================================================== Best Practice Pearls Short-acting beta2-agonists are like "band-aids" in that they only help the symptoms of asthma; they do not manage the disease state process. Which statement describes a pharmacodynamic difference between albuterol and salmeterol?

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