Nursing 104 Exam 3 - Exam Study Guide - Comfort

Nursing 104 Fundamentals of Nursing Study Guide Comfort Class: 3.5 hours Instructor: S. Weiser Required Readings: Treas and Wilkinson Chapter 22 (Hygiene); Chapt...

Nursing 104 Fundamentals of Nursing Study Guide Comfort Class: 3.5 hours Instructor: S. Weiser Required Readings: Treas and Wilkinson Chapter 22 (Hygiene); Chapter 28 (Pain); Chapter 31 (Sleep). Chapter 32 (Skin Integrity). Required Article: Color Awareness: A Must for Patient Assessment (posted on BB) Required Videos: Treas and Wilkinson-Chapter 22- Hygiene video FA Davis Quiz: Comfort due 10/13/24 Behavioral Outcomes: Upon completion of this assignment, the student will be able to: 1. Review major complications of wound healing. Recall wounds heal by moving through phases of inflammation, proliferation, and maturation; at times, process is interrupted by complications, namely hemorrhage, infection, dehiscence, evisceration, and fistulas A. Hemorrhage - implies profuse or rapid blood loss; whenever capillary network is interrupted or blood vessel is severed, bleeding occurs; hemostasis (cessation of bleeding) usually occurs within minutes of injury; hemostasis can delay when large vessels are injured, clotting disorder exists, or patient is on anticoagulant therapy; if bleeding begins again after initial hemostasis, something is probably wrong; possible causes include slipped suture, erosion of blood vessel, dislodged clot, or infection a. KEY POINT: risk of hemorrhage (both internal and external bleeding) is greatest in first 24-48 hrs following surgery or injury b. Internal hemorrhage - swelling of affected body part, pain, and changes in vital signs (i.e., decreased bp, elevated pulse) may indicate internal bleeding, specifically a hematoma, red-blue collection of blood under skin, forms because bleeding can’t escape to surface; a large hematoma causes pressure on surrounding tissues; if hematoma is located near major artery or vein, may impede blood flow c. External hemorrhage - relatively easy to recognize; will see bloody drainage on dressings and in wound drainage devices; if there’s a brisk hemorrhage, blood often pools underneath patient as dressings become saturated; to be aware of full extent of bleeding, remember to look underneath patient B. Infection - microorganisms can be introduced to wound during injury, surgery, or after surgery a. Suspect infection if wound fails to heal; other symptoms suggesting infection: i. localized swelling ii. redness iii. heat iv. pain v. fever (temperatures higher than 38°C [100.4°F]) vi. foul-smelling or purulent drainage vii. change in the color of drainage  b. In contaminated or traumatic wound, symptoms are likely within 2-3 days c. In clean surgical wound, will usually not see signs and symptoms of infection until the 4th or 5th postoperative day C. Dehiscence - rupture (separation) of one or more layers of wound = dehiscence; most likely to occur in inflammatory phase of healing, before large amounts of collagen have deposited in wound to strengthen it; increased risk occurs from incisions that begin draining within 5-7 days post surgery a. Common causes: i. poor nutritional status ii. inadequate closure of muscles iii. wound infection iv. increased tension on suture line (e.g. coughing, lifting an object) v. obesity - more likely to experience dehiscence because fatty tissue doen’t heal readily; increased tissue mass puts additional strain on suture line b. Usually associated with abdominal wounds; patients often report feeling “pop” or tear, especially with sudden straining from coughing, vomiting, changing positions in bed, or standing; usually there is immediate increase in serosanguineous drainage nursing interventions include the following: i. maintaining bedrest with head of bed elevated at 20° and knees flexed ii. applying binder, if necessary, to prevent evisceration iii. notifying provider of dehiscence stat D. Evisceration - total separation of layers of a wound with internal viscera protruding through incision a. KEY POINT: rare complication is surgical emergency b. Immediately cover wound with sterile towels or dressings soaked in sterile saline solution to prevent organs from drying out and becoming contaminated with environmental bacteria c. Have patient stay in bed with knees bent to minimize strain on incision d. Do not put binder on patient e. Notify surgeon and ready patient for surgery E. Fistulas - abnormal passage connecting two body cavities or a cavity and skin; often result from infection or debris left in wound; abscess forms, which breaks down surrounding tissue and creates abnormal passageway; chronic drainage from fistula may lead to skin breakdown and delayed wound healing; most common sites of formation are GI and genitourinary tracts. 2. Explain factors involved in development of pressure injuries/ulcers A. Immobility - healthy people move and shift positions unconsciously when sensing pressure or discomfort; patients with degree of immobility are at higher risk and should be closely monitored to detect early signs; for people unable to move independently, body weight on bed or chair causes increase in pressure that can lead to skin tissue injury B. Impaired sensation/cognition - patients with peripheral vascular disease, spinal cord injury, diabetes, cerebrovascular accident, trauma, or fractures often have diminished tactile sense therefore more prone to skin breakdown a. patients with diminished sensation - are less able to sense hot surface and would likely suffer burn; cut or wound in area with limited sensation may go unnoticed and therefore untreated; also unable to feel pressure in affected area; result = may not shift position to relieve pressure over bony prominences or be aware that footwear/clothing is constricting b. patients with impaired cognition - (i.e., Alzheimer disease, dementia, altered level of consciousness) at higher risk for pressure injury, because aren’t aware of need to reposition, cognitive impairment can be subtle and difficult to recognize; talk to patients’ families/caregivers and review patient’s health history so that plan of care can be adjusted C. Poor nutrition - adequate protein, cholesterol, calories, fluid, vitamin C, and minerals are essential for maintaining healthy skin and promoting tissue repair; malnourished individuals have thinner, more fragile skin and are less able to heal after minor injuries, increasing susceptibility to pressure ulcers a. Protein - healthy skin depends on adequate protein levels to maintain skin, repair minor defects, and preserve intravascular volume; as protein levels decline: i. skin injury is slow to heal, and minor defects can’t be repaired ii. fluid leaks from vascular compartment of dependent areas and edema (excess fluid in the tissues) develops iii. edema decreases skin elasticity and interferes with diffusion of oxygen to cells, therefore, the skin becomes prone to breakdown. b. Cholesterol - Low cholesterol levels predispose patients to skin breakdown and inhibit wound healing; patients on low-fat tube feedings may experience deficiencies in cholesterol, fatty acids, and linoleic acid; together, these fats aid in providing fuel for wound healing and maintain a waterproof barrier in stratum corneum i. Calorie Intake - if calorie intake is inadequate, body uses proteins for energy (catabolism); they’re then unavailable for building and maintenance functions (anabolism); with prolonged malnutrition, person experiences weight loss, loss of subcutaneous tissue, and muscle atrophy; resulting in padding between skin and bones decreases, predisposing skin to pressure injury ii. Ascorbic Acid, Zinc, and Copper - vitamin C (ascorbic acid), zinc, and copper are involved in formation and maintenance of collagen; deficiency of any of these elements can delay wound healing iii. Hydration - poor skin turgor may occur as a result of dehydration, whereas edema may result from overhydration; both dry, dehydrated skin and edematous, overhydrated skin are prone to injury, especially when exposed to pressure, shearing, friction, and moisture c. Dehydration - dehydrated skin is more prone to breakdown and less resilient to pressure; sufficient hydration is critical for maintaining skin elasticity and integrity  D. Aging - elderly individuals are more vulnerable due to thinning skin, decreased elasticity, and reduced tissue regeneration capabilities; may have decreased mobility and circulation, further compounding risk E. Fever - leads to sweating, which can cause maceration F. Infection - implies microorganisms are causing harm by releasing toxins, invading body tissues, and increasing metabolic demand of tissue; makes skin more vulnerable to breakdown and impedes healing of open wounds G. Edema - swelling from fluid retention can stretch and weaken skin, increasing risk; edematous tissues are less oxygenated and more vulnerable to damage from pressure and shear forces H. Circulation a. Impaired venous circulation - results in engorged tissues containing high levels of metabolic waste products that make tissue susceptible to edema, ulceration, and breakdown I. Friction - damages outer protective epidermal layer, decreasing amount of pressure needed to develop skin lesions J. Pressure - pressure injury most commonly develops over bony prominences but can occur under casts, splints, or other assistive devices; skin is compressed between bone and hard surface of bed or chair, reducing blood flow to area; when patient is supine, pressure points are: occiput, scapulae, elbows, sacrum, and heels K. Shearing - occurs when epidermal layer slides over dermis, causing damage to vascular bed; most commonly occurs when head of the bed is elevated and patient slides downward, causing shear to develop in sacral area L. Moisture - especially in form of urine or feces, macerates skin and also decreases amount of pressure required to produce ulceration 3. Assess and categorize pressure ulcers based on the pressure ulcer staging system Staging Pressure Injury A. Stage 1 a. localized area of intact skin with nonblanchable redness (does not become pale under applied light pressure), usually over bony prominence, but not maroon or purple discoloration b. area may be painful, firm, soft, or warmer or cooler as compared with adjacent tissue c. discoloration will remain for more than 30 min after pressure relieved d. dark skin may not have visible blanching (becomes pale when light pressure is applied); its color may differ from that of surrounding area; stage 1 may be difficult to detect B. Stage 2 a. involves partial-thickness loss of dermis b. is open but shallow and with red-pink wound bed c. no slough (tan, yellow, gray, green, or brown necrotic tissue) d. may also be intact or open/ruptured serum-filled blister, or shiny or dry shallow ulcer without slough or bruising  e. don’t use stage to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation f. don’t mistake moisture-associated skin damage or fungal infections for stage 2 g. doesn’t involve sloughing or bruising C. Stage 3 a. deep crater characterized by full-thickness skin loss with damage or necrosis of subcutaneous tissue; adipose is visible b. may extend down to, but not through, underlying fascia c. undermining (deeper-level damage under boggy superficial layers) of adjacent tissue may be present d. bone/tendon is not visible or directly palpable e. some can be extremely deep when located in area with significant adipose layers D. Stage 4 a. involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures b. exposed bone/tendon is visible or directly palpable c. slough or eschar (tan, black, or brown leathery necrotic tissue) may be present d. ebole (rolled edges), undermining, and sinus tracts (blind tracts underneath epidermis) are common e. depth varies by location, can be shallow on bridge of nose, ear, occiput, and malleolus because areas don’t have subcutaneous tissue f. can extend into muscle and supporting structures (e.g. fascia, tendon, or joint capsule) g. often requires full year to heal; even healed, site remains at risk for future injury because scar tissue isn’t as strong as original tissue E. Deep Tissue Pressure Injury (DTI) a. an area of skin is intact but persistently discolored; might be purplish or deep red, painful, or boggy, or have blister; pain and temperature change often come before skin color changes b. occurs owing to damage of underlying soft tissue from pressure or shear c. findings can be subtle enough that often DTI isn’t recognized until after severe tissue damage has occurred d. may heal or evolve further and become covered by thin eschar, rapidly exposing additional layers of tissue even with optimal treatment e. iIn darker pigmented individuals, discoloration might go undetected F. Unstageable Pressure Injury a. involves full-thickness skin loss b. base of wound is obscured by slough (tan, yellow, gray, green, or brown necrotic tissue) or eschar (tan, black, or brown leathery necrotic tissue) c. until enough slough and/or eschar is removed to expose base of wound, true depth, and therefore stage, can’t be determined d. stable eschar is dry, adherent, and intact without erythema or fluctuance; don’t remove or soften a stable eschar, serves as “body’s natural cover” G. PUSH tool - for evaluation of pressure injury 4. Describe nursing care for clients with various types of wounds. A. Types of Wounds - classified according to length of time existed, and condition (e.g. contamination, severity) a. Skin integrity - simplest wound classification system is based on integrity of skin i. Closed wound - exists when there are no breaks in skin; contusions (bruises) or tissue swelling from fractures are common closed wounds  ii. Open wound - occurs when there is break in skin or mucous membranes; include abrasions, lacerations, puncture wounds, and surgical incisions; compound fracture may also lead to open wound caused by projection of bone through skin b. Length of time for healing - varies according to skin integrity and factors affecting i. Acute wounds - expected to be of short duration; in healthy person, heal spontaneously without complications through three phases of wound healing (inflammation, proliferation, and maturation ii. Chronic wounds - exceed expected length of recovery, usually because natural healing progression has been interrupted or stalled because of infection, continued trauma, ischemia, or edema; include pressure injury, or arterial, venous, and diabetic ulcers; frequently colonized with several types of bacteria, and healing is slow due to underlying disease process; unless type of wound is properly diagnosed and underlying disease process treated, may linger for months or years c. Level of contamination i. Clean wounds - uninfected wounds with minimal inflammation; may be open or closed and don’t involve the GI, respiratory, or genitourinary tracts (systems frequently harbor microorganisms); very little risk of infection ii. Clean-contaminated wounds - surgical incisions that enter GI, respiratory, or genitourinary tracts; increased risk of infection, but there no obvious infection iii. Contaminated wounds - open, traumatic wounds or surgical incisions in which major break in asepsis occurred; risk of infection is high iv. Infected wounds - bacteria in wound are above 100,000 organisms per gram of tissue 1. KEY POINT: presence of beta-hemolytic streptococci is considered infection; signs of wound infection: erythema and swelling around wound, fever, foul odor, severe or increasing pain, large amount of drainage, or warmth of surrounding soft tissue d. Depth and location - major determinant of healing time e. KEY POINT: deeper wound = longer healing time; wounds located at points of pressure or movement = slower healing; wound healing is more difficult in areas of poor circulation (e.g. feet of diabetic or individual with congestive heart failure) i. Superficial wounds - only epidermal layer of skin; injury is usually result of friction, shearing, or burning ii. Partial-thickness wounds - extend through the epidermis but not dermis iii. Full-thickness wounds - extend into subcutaneous tissue and beyond; the descriptor penetrating sometimes added to indicate wound involves internal organs B. Wound Closures - wounds healed by primary and tertiary intention may be closed in several ways a. Adhesive strips - a.k.a. steri-strips are used to: i. close superficial low-tension wounds: skin tears or lacerations ii. close skin on wound closed subcutaneously to aid in healing and reduce scarring iii. give additional support after sutures or staples have been removed iv. stay in place until self-separation from skin on their own occurs b. Sutures - traditional wound closures (“stitches”); creates small puncture wounds along track of laceration or incision; several types available i. Absorbent sutures - used deep in tissues i.e., to close organ or anastomose (connective) tissue; because made of gradually dissolving material, no need to remove ii. Nonabsorbent sutures - placed in superficial tissues and require removal, usually by nurse c. Surgical staples - made of lightweight titanium, provide fast, easy way to close incision; associated with lower risk of infection and tissue reaction compared to sutures; downside is some wound edges more difficult to align; most common sites for wound stapling: arms, legs, abdomen, back, scalp, or bowel i. KEY POINT: wounds on hands, feet, neck, or face shouldn’t be stapled d. Surgical glue - safe for use in clean, low-tension wounds; ideal wound closure method for skin tears C. Collaborative Wound Treatments - necessary for wounds not healing despite aggressive care; such treatments include following: a. Surgical options - extensive débridement, skin grafts, secondary closure of wound, and flap techniques (partially detached tissue placed over a wound) for complicated wounds b. Hyperbaric oxygen therapy (HBOT) - administration of 100% oxygen under pressure to wound site; increases oxygen concentration in tissue, stimulates growth of new blood vessels, and enhances WBC action; promotes development of fibroblasts for wound healing c. Platelet-derived growth factor - augments inflammatory phase of wound healing and accelerates collagen formation in wound 5. Identify factors that influence rest and sleep A. Biorhythms - “biological clocks” controlled within body and synchronized with environmental factors a. e.g. of environmental factors - gravity, electromagnetic forces, light, and darkness b. e.g. of biorhythms - body temperature is typically lowest when someone wakes up in the morning; female menstruation follows approx. 28-day cycle, like the lunar cycle calendar months are based on c. influence many physical and mental functions B. Circadian Rhythm - a biorhythm based on day-night pattern in a 24-hour cycle; is regulated by a cluster of cells hypothalamus of brainstem that respond to changing levels of light a. e.g. most people have higher energy level in the daytime and less energy at night; however, some people are more alert and active in morning, and others function at higher level in the afternoon/evening b. People who work evening and night shifts - can suffer significant sleep deprivation until bodies adjust to new pattern c. Changing time zones - can disrupt sleep-wake cycles and can thus be troublesome for people who travel frequently d. Hospitalization - noises, lights, waking patient for vital signs/medications, altered normal bedtime rituals, absence or presence of family, homesickness, recent losses, worry, fear of unknown, and pain may compromise patient’s quality of sleep and ability to fall and stay asleep C. Age - an important factor affecting duration and patterns of sleep a. Toddlers and preschoolers - often have trouble falling asleep, frequent awakenings, nightmares, and heavy snoring; may have difficulty “winding down” after hectic activities in late afternoon and early evening hrs b. School-age children and adolescents - may suffer sleep disturbances related to stress, excitement, or social concerns e.g. anticipating school event or sports competition c. Adolescents - may not sleep well because of: i. normal shifts in circadian rhythms that occur with puberty ii. increased demands at school, or staying up late to complete assignments iii. evening use of electronics or sleep with smartphones near beds; light produced devices disrupts circadian rhythms and suppresses naturally occurring melatonin; results in difficulty falling asleep iv. Caffeine, alcohol, nicotine, or drugs d. College students - may stay up all night to study for exams or experience difficulty falling/staying asleep because of stress about grades or future career choices; many have a preference for a late-night schedule, yet have schedules requiring them to attend early class e. Young adults - may: i. drive themselves too hard to succeed, prompting late work nights or sleep loss due to hectic travel schedules or work-related stress ii. not obtain enough sleep because of social and personal entertainment  iii. work an evening or night shift f. Parents of young children - often experience sleep interruptions; toddler parents often wake to care for child having a nightmare, is ill, or needs to use bathroom g. Middle-aged adults - may experience sleep difficulties because of depression, anxiety, and tension resulting from stress and competing demands on time, such as: i. work or family ii. the need to care for parent(s) iii. marital discord iv. worry about children v. financial problems vi. lack of sleep compounds the problem, leading to reduced ability to cope and further difficulty achieving quality sleep h. Menopausal women - may experience difficulty falling and staying asleep because of hormonal fluctuations; obstructive sleep apnea (OSA) also plays role in insufficient sleep i. Older adults - may suffer sleep disturbances because of: i. side effects of medications ii. underlying illnesses iii. depression iv. discomfort v. nocturia vi. pain vii. declining melatonin levels (common for stage) D. Lifestyle Factors - influencing sleep include work, exercise, nutrition, and medications/drugs; e.g. people who cross time zones frequently for travel may experience difficulty falling asleep, early wakening, or daytime fatigue a. Physical activity - exercise at least 2 hours before bedtime promotes sleep; fatigue from normal physically active day promotes restful night’s sleep; however, the more tired a person is, the shorter first period of REM sleep will be; also, sedentary lifestyle is a factor for sleep disorder b. Diet - foods can either promote or interfere with sleep i. meal high in saturated fat near bedtime may interfere with sleep ii. dietary L-tryptophan and adenosine are essential amino acids (bc body does not produce its own) found in milk, cheese, and animal products that may induce sleep by converting into serotonin iii. carbohydrates seem to promote relaxation through effects on brain serotonin levels; generally, satiation induces sleep, ]many people, especially infants and children, have difficulty falling asleep when hungry c. Nicotine and caffeine - CNS stimulants interfere with sleep i. nicotine - smokers have more difficulty falling asleep and more easily roused than nonsmokers; people who quit often experience temporary sleep disturbances during withdrawal period  ii. caffeine - blocks adenosine thereby inhibits sleep; however, individuals vary greatly in caffeine sensitivity d. Alcohol i. disrupts REM - may hasten the sleep onset; however, disrupts REM/SWS and may cause spontaneous awakenings with difficulty returning to sleep ii. vivid dreams in REM - for some, heavy alcohol consumption can prompt dreams that lead to awakening during REM iii. nocturia - alcohol = diuretic, thus sleep interrupter e. Medications - many people take cause sleeplessness or excessive grogginess and sedation; medications to induce sleep (i.e. hypnotics) tend to increase amount of sleep while decreasing quality i. Zolpidem tartrate (Ambien) promotes normal REM sleep and appears to influence sleep quality less than other hypnotics ii. Amphetamines, tranquilizers, and antidepressants reduce amount of REM sleep; barbiturates, interfere with NREM sleep iii. Opioids, like morphine, suppress REM sleep and cause frequent awakening iv. Beta blockers can cause sleep disorders and nightmares E. Illness - increases need for sleep/rest; concurrently, its associated mental and physical distress can cause sleep problems a. Disease symptoms, fever, pain, nausea, and respiratory conditions (e.g. SOB, dyspnea, sinus congestion), can interfere with sleep b. Specific disease conditions altering quality of sleep include allergies, hyperthyroidism, and Parkinson's disease. c. Anxiety increases gastric secretions, intestinal motility, heart rate, and respirations, all contribute to restless nights; stimulates the sympathetic nervous system, increasing level of norepinephrine, which decreases stage III and REM sleep leading to more awakenings d. Depression may be associated with too much sleep or difficulty sleeping e. Fear of the unknown outcome of illness and role changes associated with hospitalization can cause anxiety and interfere with falling/staying asleep F. Environmental Factors - can promote or inhibit sleep; some need cool room, whereas others need warmth; some prefer heavy blankets, others like light sheet a. Noise - can inhibit sleep, but person can become habituated to noise over time and be less affected; any change in usual environmental stimuli can affect sleep i. some routinely fall asleep to music or listening to radio or television ii. loud noises may be needed to awaken person in NREM stages III and REM iii. equipment noise, muffled sounds of busy medical-surgical unit, or labored breathing or snoring of roommate can interfere with patient’s sleep b. Light - when people accustomed to sleeping in dark room are hospitalized, they may have trouble falling asleep because of light outside window or filtering into room from hallway; however, light can be therapeutic for those suffering from  sleep problems; exposure to bright light can alter circadian rhythms in some adults c. Noxious odor d. Comfort of bedding 6. Plan, implement, and evaluate nursing care related to specific nursing diagnosis addressing sleep problems. A. Common Sleep Disorders a. Insomnia - the predominant complaint of dissatisfaction with sleep quantity, associated with inability to fall asleep, remain asleep, or go back to sleep b. Sleep-wake schedule (circadian) disorders - abnormalities in sleep-wake schedules c. Restless Leg Syndrome (RLS) - disorder of central nervous system characterized by strong and often overwhelming urge to move legs while resting or before sleep onset d. Sleep deprivation - not actually a sleep disorder, but in NANDA-I terms, human response to prolonged sleep disturbances (e.g. insomnia and parasomnias) involving NREM or REM deprivation, or both e. Hyperinsomnia - excessive sleeping, especially in daytime f. Sleep apnea - sleep with numerous pauses in breathing and frequent awakenings g. Narcolepsy - chronic disorder caused by brain’s inability to regulate sleep-wake cycles normally; uncontrollable episodes of sleep during the day even with adequate sleep at night; episodes can last from secs to mins h. Parasomnias i. Sleepwalking - a.k.a. somnambulism, occurs during stage III of NREM sleep, usually 1 to 2 hours after person falls asleep; sleeper leaves bed and walks about, with little awareness of surroundings; may perform what appear to be conscious motor activities but don’t wake up; aren’t aware of occurrences and don’t remember when awake ii. Sleeptalking - occurs during NREM sleep, just before REM stage; speech is often disorganized/hard to understand; does not usually interfere with person’s rest but may be disturbing to others iii. Bruxism - grinding and clenching of the teeth iv. Night Terrors - sudden arousals in which person (often a child) is physically active, often hallucinatory, and expresses a strong emotion such as terror; unlike nightmares (unpleasant, frightening dreams), which occur during REM sleep, night terrors occur during stage III (deep NREM) sleep v. REM Sleep Behavior Disorders - associated with REM (or dreaming period) sleep, where sleeper violently acts out dream; people have actually injured themselves or others without waking vi. Nocturnal Enuresis - a.k.a. bedwetting nighttime incontinence past stage toilet training was well established B. Assessment - it’s important to assess usual sleep patterns and rituals for all patients being admitted to hospital or seeking help for a sleep problem; a brief assessment for all patients should include questions about the following: a. Usual sleeping pattern i. When do you go to sleep and wake up? ii. How many hours do you sleep? iii. Do you have a regular sleep schedule? iv. How would you rate the quality of your sleep on a scale of 1 to 10, with 10 meaning “great”? v. Do you take a nap? If you do, for how long? vi. How often do you waken during sleep, for example, to go to the bathroom? vii. Do you feel adequately rested when you wake up? b. Sleeping environment i. Would you like a night-light? ii. What room temperature do you prefer? iii. What noise level do you prefer (e.g., radio, television, absolute quiet)? c. Bedtime routines/rituals i. What do you typically do in the hour before bedtime? ii. What do you do to help you fall asleep? d. Sleep aids i. Do you need a special pillow or positioning aid? ii. Do you take any sleep medications or other drugs, natural sleep aids, or homeopathic remedies that may affect sleep? e. Sleep changes or problems i. Have your sleep patterns changed? If so, how? ii. How often do you experience difficulty falling asleep? Staying asleep? iii. Do you currently, or have you in the past, ever experienced a sleep disorder (e.g., narcolepsy, insomnia)? iv. Do you remember your dreams after you wake? Do you ever have night terrors? Do you sleepwalk? v. Do you ever experience an unpleasant creeping feeling, crawling, or tingling, relieved only by moving the legs at night? vi. Do you snore? Does your own snoring or grunting ever wake you or anyone in the room? vii. Do you wear a cap at night? Do you require oxygen at night? Do you require any other medical aid or therapy while you sleep? viii. Do you grind your teeth while you sleep? Do you wear a dental appliance to prevent grinding? ix. Do you experience any kind of pain that makes it difficult for you to fall asleep or stay asleep? x. Is there anything that I have not asked that might help you sleep while you are in the hospital (having surgery, receiving home care)?  xi. If the client reports experiencing satisfactory sleep, that is an adequate assessment, and you merely need to support their usual sleep patterns and rituals; when you suspect a sleep problem, you will perform a more in-depth assessment, such as a detailed sleep history or sleep diary. f. KEY POINT: conduct more in-depth sleep assessment for patients who wake up at least three times a night; those who take more than 30 minutes to fall asleep; and if difficulty falling or staying asleep has been going on for more than 30 days; a sleep study is recommended for unexplained daytime sleepiness g. Sleep history (self-report) - includes in-depth questions about person’s usual times for sleep, any preparation, preferences and routines, quality of sleep, napping habits (if any), and whether they wake early and cannot return to sleep h. Sleep log - provides specific information on patient’s patterns of sleep; allows for identifying trends in sleep/wakefulness and identify any relationship with sleep habits; usually ask patient to keep log for 14 days; remind them it’s important to be diligent in maintaining it i. Social history - can reveal habits that can affect sleep quality: use of tobacco, caffeinated products, and recreational drugs; prescription and nonprescription medication can also interfere with sleep (e.g., beta blockers, clonidine, theophylline, certain antidepressants [fluoxetine], and decongestants). j. Actigraph - an application on mobile device that estimates person’s sleep and wake patterns, including time spent in various sleep stages k. Sleep study - test observing what happens in body during sleep; most useful in detecting sleep apnea, narcolepsy, night terrors, and periodic limb movement disorder l. Polysomnography - one of the most common sleep studies performed in sleep laboratory, records brain wave activity, eye movement, oxygen and carbon dioxide levels, vital signs, and body movements during sleep phases; The American College of Physicians recommends polysomnography for anyone suspected to have obstructive sleep apnea C. Diagnosis - it’s important to determine whether lack of sleep is a problem, is a symptom of a problem, or is contributing to (etiology of) a different problem; for health promotion applications, use NANDA-I diagnosis Readiness for Enhanced Sleep when client has no particular sleep problem but wishes to move to higher level of functioning in area of sleep a. Sleep as the Problem - when wishing to focus on interventions to promote sleep, use the following NANDA-I labels on the problem side of the nursing diagnosis: i. Insomnia - use for patients who have a disruption in the amount of quality of sleep to the extent that it impairs functioning ii. Sleep deprivation - use when patient’s amount, consistency, or quality of sleep is decreased over prolonged periods of time; defining characteristics are more severe than those for disturbed sleep pattern, so nursing activities may focus as much on relieving symptoms (e.g. confusion, paranoia) as on sleep promotion  iii. Disturbed sleep pattern - use when assessment data point to a time-limited sleep problem due to external factors (e.g. inability to sleep in the unfamiliar hospital environment) D. Plan a. NOC standardized outcomes linked to the NANDA-I sleep labels are as follows: i. For disturbed sleep pattern: rest, sleep, and personal well-being ii. For sleep deprivation: rest, sleep, and symptom severity iii. For insomnia: concentration, endurance, fatigue level, mood equilibrium, personal health status, personal well-being, quality of life, rest, and sleep b. Individualized goals/outcome statements you might use to evaluate success of interventions for sleep enhancement include: i. verbalizes feeling rested/feeling less fatigue ii. falls asleep within 30 minutes; sleeps 6 hours without awakening iii. maintains sleep-wake pattern that provides sufficient energy for day’s tasks iv. demonstrates self-care behaviors that provide healthy balance between rest and activity v. identifies stress-relieving rituals that enable falling asleep more easily vi. demonstrates decreased signs of sleep deprivation vii. verbalizes feeling less fatigued and more in control of life activities E. Implement - NIC standardized interventions for sleep deprivation and sleep pattern disturbance include: coping enhancement, energy management, environmental management: comfort, relaxation therapy, and sleep enhancement; linkages haven’t yet been established for insomnia a. Schedule nursing care to avoid interrupting sleep - use nursing judgment to decide when procedure must be done and when it’s more important for patient to sleep; healthcare routines usually allow time for rest periods; consider the following caring interventions: i. some patients need to rest after procedure or after meals ii. give prescribed sleeping pill when providing care to avoid waking them later in evening iii. can often alter routines; for example, allow patient to sleep as long as they can in morning and bring breakfast later iv. cluster care to avoid unnecessary interruptions in sleep; unless patient is critically ill, don’t wake them for morning vital signs if asleep v. keep noise level to a minimum; be aware that activities, conversation, and equipment, even outside patient’s room, can disrupt sleep b. Create a restful environment - many people find it difficult to sleep in a strange bed, even a comfortable on; hospital beds are not noted for their luxury, but can be made more comfortable i. be sure the bed linens are tight on bottom and loose on top, allows movement ii. keep linens clean, dry, and free of irritants, perspiration on hospital gown or linens can lead to chill  iii. good body alignment also facilitates relaxation; use extra pillows, blanket from home, or any other item that may help patient rest iv. keep the room dark and quiet, unless patient prefers a light v. as much as possible, control temperature of room and provide good ventilation c. Promote comfort - pain, itching, and nausea may all be deterrents to rest and sleep in ill person; offer pain medications at their scheduled times, and before patient’s sleep time; provide aforementioned restful environment, offer fluids, cool cloths, or massage/back rub d. Support bedtime rituals and routine - most have some kind of routine before bed, be it reading, watching TV, drinking warm milk, praying, or meditating, to allow them to prepare for sleep; for children, favorite stuffed animal, blanket, bedtime story, and brushing teeth and hair, may enhance sleepiness; include any routines or rituals in nursing plan of care to ensure continuity; advise patients who smoke not to smoke after evening meal, or at all e. Offer appropriate bedtime snacks or beverages i. complex carbohydrates (e.g., bread, cereal) seem to help most people sleep, they likely increase level of sleep-inducing tryptophan in blood ii. small amount of protein (e.g., milk, cheese) with snack reduces sugar boost and keeps blood glucose more stable, however, high protein intake may be more difficult to digest iii. advise the client to avoid alcohol, especially in evening; although it may induce sleepiness at first, alcohol interferes with deep sleep cycle iv. client should avoid consuming caffeine-containing foods and beverages (e.g., tea, coffee, energy drinks, chocolate, colas) after evening meal v. advise client to drink plenty of fluids during the day but restrict fluids close to bedtime vi. avoid nicotine is stimulant f. Promote relaxation - base choice of relaxation strategies on repertoire of techniques and patient preference; relaxation strategies may include massage, warm bath, or one of the following: i. guided imagery can be used to help your patient move their mind to a safe place, where relaxation is possible. You may ask the patient what type of place will soothe them and “guide” them there through visualization. See Chapter 8 if you need to review. ii. progressive muscle relaxation - relaxing each muscle independently and progressing from head-toe, may help promote sleep iii. music therapy - has shown to be effective in promoting relaxation; some patients respond well and can put away troubles while listening to music, whereas others find music irritating; slow, quiet music or recording of forest or ocean sounds may be soothing g. Teach about sleep hygiene - most with sleep problems manage at home by creating restful environment, relaxing, avoiding distractions, and trying various sleep strategies without using sleep-inducing medication  To do: i. use your bedroom only for sleep; do not turn your bedroom into family room ii. follow a regular routine for bedtime and morning awakenings iii. go to bed each night at same time, even on days off work iv. keep bedroom as dark, cool, and quiet as possible 1. ideal temperature for most is 65°- 69° 2. even an illuminated clock is distracting light source; replace clock or block light with something 3. use earplugs to block noise, if necessary v. try weighted blanket; most manufacturers recommend using blanket that is 10% of user’s weight vi. if can’t fall asleep in 30 minutes, get up and do something nonstimulating, but avoid electronics with illuminated screens; when feeling sleepy, go back to bed; wavelengths of blue light emitted from screen arouse brain into wakeful state vii. use relaxation methods; read book, pray, or meditate; try closing eyes and visualizing something peaceful when trying to sleep; imaging favorite, relaxing place where there’s comfort or familiarity viii. use aromatherapy to relax; essential oil diffuser may help induce sleep; lavender scent, e.g., slows HR and lowers BP ix. try progressive relaxation to fall asleep; follow recorded instructions directing in sequence of relaxing certain muscle groups x. exercise at right time, ideally, >3 hours before bedtime; exercise stimulates hormone that makes one more alert (cortisol); for some, evening exercise isn’t associated with worse sleep xi. nap right amount and at right time; short (20-minute) nap can recharge battery, but longer naps can leave one feeling groggy and make it difficult to fall asleep at night; naps later in day disrupt sleep routine xii. if one takes prescription drugs, ask prescriber or pharmacist about side effects. xiii. consider taking melatonin supplement; although doesn’t induce sleep, it has calming effect xiv. take warm, not hot, bath just before sleep; will raise body temperature and relax one to help fall asleep more easily xv. find best sleep position, perhaps with pillow under or between knees; side-lying position is best for someone who snores or has sleep apnea; using pillow between knees keeps spine in better alignment; side-lying position also relieves back compression, helping prevent lower backache; sleeping on left side is better than right side if experiencing heartburn from acid reflux xvi. try using sleep tracker; to get feel for how much movement made while asleep; even though sleep trackers don’t record actual sleep, can indicate restlessness, which reveals sleep quality  To avoid: xvii. don’t try to “catch up” on sleep; rise at regular time, even if bedtime later than usual xviii. limit screen time before going to sleep; too much “blue light” given off by cell phone, computer, or tablet can interfere with sleep quality xix. don’t depend on sleeping aids; be aware of potential dangers of sleeping medications xx. avoid cold medications that contain stimulant ingredients (e.g., pseudoephedrine). xxi. avoid caffeine, alcohol, tobacco products, and heavy meals before sleep; some beverages and foods, like black tea, chocolate, and soda, contain caffeine, tobacco is also stimulant; alcohol interferes with transition to deeper sleep phases; heavy alcohol consumption can contribute to breathing impairment during night xxii. avoid eating carbohydrates (e.g., crackers, cereal, or bread) before bed; boost blood glucose levels, so few hours later, rapid drop will awaken one xxiii. don’t overhydrate before bedtime; although awakening thirsty isn’t ideal, too much water can cause awakening to empty bladder during night xxiv. avoid going to bed angry or frustrated; stay clear of emotional discussions bed h. Administer and teach about sleep medications i. Prescription sleep medications - should be familiar with prescription and nonprescription sleep medications patients are taking; are typically classified into the following five categories 1. Nonbenzodiazepines - sedative-hypnotics have short half-life, meaning are eliminated from body quickly and don’t cause daytime sleepiness; e.g. zolpidem tartrate and zaleplon a. nonbenzodiazepines are selective, meaning they target specific receptors thought to be associated with sleep rather than depressing entire CNS b. general side effects - drowsiness, dizziness, fatigue, headache, and unpleasant taste c. long-term effects - not yet known, although increased risk of fatal overdose has been reported 2. Benzodiazepines - class of sedative-hypnotics is first-line treatment for insomnia; have the following characteristics: a. may be long-acting or short-acting b. long-acting ones linger in body and potentially cause daytime drowsiness; older adults are particularly at risk for daytime sleepiness and dizziness c. carry greater risk for rebound insomnia, dependency, and tolerance, especially older adults d. potentially dangerous when combined with alcohol and some medications  e. many originally formulated to treat anxiety; e.g. diazepam, alprazolam, flurazepam, lorazepam, and triazolam 3. Selective melatonin agonists - class regulates sleep-wake cycle by targeting melatonin receptors; ramelteon used to treat insomnia associated with difficulty falling asleep; is not designated as controlled substance 4. Barbiturates - sedative-hypnotics and anticonvulsants rarely prescribed for insomnia due to risk of addiction, abuse, and overdose; amobarbital (e.g. amytal), pentobarbital (e.g. nembutal), and secobarbital (e.g. seconal) 5. Tricyclic antidepressants - at times, primary care providers prescribe antidepressants to promote sleep; show clinical benefit for some people with insomnia who also suffer with depression; amitriptyline (e.g. elavil), doxepin (e.g. sinequan), imipramine (e.g. tofranil), and nortriptyline (e.g. aventyl, pamelor) ii. Nonprescription sleep medications - can be helpful to induce restfulness or initiate sleep, when used over long period of time can lose effectiveness; usually contain an antihistamine 1. Antihistamines - diphenhydramine (benadryl) may induce drowsiness, although due to the long half-life of the drug, grogginess commonly lasts into the next day. a. important to check ingredient label of any over-the-counter (OTC) medication to see if it contains an antihistamine b. advise clients that OTC sleep medications can interact with other medicines, so consult prescriber or pharmacist before using c. diphenhydramine can cause constipation, urinary retention, and impair memory over time iii. Natural sleep aids 1. Melatonin - natural hormone produced by pineal gland to modulate sleep, although generally safe short-term, is unregulated and varies in strength and purity across manufacturers, may interfere with anticoagulants, birth control pills, antidiabetic medication, and other drugs suppressing immune system 2. Herbal remedies - produce calming effect can help with relaxation and falling asleep a. KEY POINT: haven’t undergone extensive testing for benefits and safety and haven’t been proven effective sleep aids; examples include: b. Chamomile relaxes muscles for transitioning to sleep c. Valerian root (a.k.a. “poor man’s Valium”) reduces time takes to fall asleep; also improves sleep quality d. Hops have aromatic quality that help with relaxation leading to sleep e. Passionflower known for calming properties because contains GABA, chemical in brain that affects mood and sleep f. Kava plant used to ease insomnia caused by stress; however, has been linked to liver damage g. Magnolia bark has compound, called hohkiol, keeps body from releasing stress hormone, adrenaline h. Cannabidiol (CBD) oil extracted from marijuana and hemp plants; can help induce sleep by taking edge off of tension and anxiety at sleep time