Rest/Sleep/Comfort/Hygiene
What year did the APS encourage healthcare to include pain assessment as the fifth vital sign?
1995
What percentage of US adults report insufficient sleep?
25% report insufficient rest or sleep 15 out of 30 days
How many stages of NREM are there, and what percentage of sleep do they typically consist of?
4 Stages Stage I and II - 5% to 50 % of sleep, light sleep Stage III and IV - 10 % of sleep, deep sleep (delta)
During a lecture on pain management, the nursing instructor informs the group of nursing students that the primary treatment measure for pain is which of the following? A - Analgesics B - Relaxation techniques C - Surgery D - Cutaneous stimulation
A - Analgesics
Which assessment finding is consistent with the presence of pain? A -Restlessness B - Euphoria C - Decreased BP D - Decreased pulse
A -Restlessness
Common sleep disorders
Insomnia Narcolepsy Sleep apnea RLS (Restless Leg Syndrome) Sleep deprivation Parasomnias
What is the purpose of Hygiene (specifically relating to clinical setting)?
Maintain skin integrity Reduce occurrence of infection Promote comfort and self-esteem
Opioid
More correct term for narcotic analgesics, since these drugs act by binding to opiate receptor sites in the central nervous system
NSAIDS
Nonsteroidal anti-inflammatory drugs
Adderall
Not only used to treat ADHD, but also to treat narcolepsy
How do you provide proper eye care for an unconscious patient?
Nursing measures include normal saline or artificial tears, based on medical orders, to lubricate the eye and a protective eye shield to keep the eyes closed
Analgesic Drug
Pharmaceutical agent used to relieve pain; It helps reduce the person's perception of pain and to alter the person's response to dicomfort
Implementing a Healthy Sleep Cycle
Preparing restful environment Promoting bedtime rituals Offering appropriate bedtime snacks and beverages Promoting relaxation Promoting comfort
What is an appropriate bedtime snack?
Protein and carbohydrates
What is the most important stage of sleep?
REM (Rapid Eye Movement)
What is the difference between rest and sleep?
Rest is a decreased state of activity Sleep is a state of rest accomplished by altered consciousness and relative inactivity
What are the first interventions a Nurse should try when a patient is having trouble sleeping
START WITH THE SIMPLE THINGS: Dim lights, straighten bed linens, back massage, turn down tv volume, etc
What are contributing factors in diagnosing pain?
Type of pain/discomfort Duration Contribution Physiological responses
What order are the stages of sleep?
Wakefulness - NREM Stage I - NREM Stage II - NREM Stage III - NREM Stage IV - NREM Stage III - NREM Stage II - REM - NREM Stage II 1, 2, 3, 4, 3, 2, Rem, 2
What are some of the pain distress scales used when assessing a patient's pain?
Wong-Baker Faces Pain Rating Scale 0-10 Numeric Rating CRIES pain scale
Various studies have confirmed that improved personal hygiene practices...
reduce illness rates
What are some of the factors included in the Planning step of the Nursing Process in regards to Hygiene?
Ability to perform ADL without assistance Maintain skin integrity Demonstrate signs of healing in existing lesions Remain free of infection
How much sleep is enough
Adults 7-8 Newborns 16-18 Infants 14-20 Preschool 10-12 School-aged and Teen 9+
Which natural chemical does the body produce at night to decrease wakefulness and promote sleep? A - Serotonin B - Melatonin C - Endorphins D - Dopamine
B - Melatonin
*Know this for the test* Sleep timing and duration affect a number of endocrine, metabolic, and neurological functions that are critical to the maintenance of individual health. If left untreated, sleep disorders and chronic short sleep are associated with and increased risk of:
Heart disease High blood pressure Obesity Diabetes All-cause mortality
When documenting a patient's pain what should be documented?
Both the level of pain that the patient states, as well as what you observe
A postoperative patient who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. What drug has the potential to reverse the respiratory-depressant effect of an opiod? A - Altropine B - Deiphenhydramine C - Epinephrine D - Naloxone
D - Naloxone
The nurse has entered the room of a newly admitted patient and observed a continuous positive airway pressure (CPAP) on the patient's bedside table. The nurse would recognize this patient likely has a history of what condition? A - Insomnia B - Narcolepsy C - Somnambulism D - Obstructive sleep apnea
D - Obstructive sleep apnea
What steps are used in the planning stage of the Nursing Process in regards to a patient's pain?
Developing effective comfort management strategies by determining if the pain is acute or chronic and creating a plan to control the pain
What steps are used in the Implementing stage of the Nursing Process in regards to a patient's pain?
Establish a trusting nurse-patient relationship Identify affecting factors Initiate non-pharmacologic and pharmacologic pain relief Reassess Educate the patient
Self-care deficits address (4) activities necessary to meet daily needs:
Feeding Bathing/hygiene Dressing/grooming Toileting
Why is adequate sleep necessary?
Fights off infection Supports the metabolism of sugar to prevent diabetes (spike in glucose reading) Improved performance, effectiveness and safety
What are some parasomnias
Sleep walking, Sleep talking, Bed Wetting, Bruxism (grinding/clenching teeth while sleeping), Nocturnal erections
