foundations exam 3 part two

family and ethnic background

A child's parents play a key role in the development of the child's spirituality. What parents explicitly teach a child about spirituality and religion is generally less important than what the child learns about spirituality, life, and self from the parents' behavior. Ethnic background Religious traditions differ among ethnic groups. There are clear distinctions between Eastern and Western spiritual traditions as well as among those of individual ethnic groups, such as Native Americans. A person's culture and formal religion significantly affect whether the person's approach to religion is doing something, being someone, or continually striving for harmony.

intimacy and spiritual needs

ADDRESSING NEEDS FOR INTIMACY Terminally ill patients and their sexual partners may feel uncomfortable discussing their needs for intimacy. Partners may wish to be physically intimate with the dying person but are afraid of "hurting" him or her and may also be afraid that an open expression of sexuality is somehow "inappropriate" when someone is dying. Encourage discussion and suggest ways to be physically intimate that will meet the needs of both partners. A loving foot massage or a tender, cradling body embrace may be exactly what a dying person needs in his or her last moments. ADDRESSING SPIRITUAL NEEDS Although not all patients follow specific spiritual or religious beliefs, most require some form of spiritual care. Many terminally ill patients find great comfort in the support they receive from their religious faith. Help obtain the services of clergy or pastoral care workers as the situation indicates. Most patients need to feel that their lives have meaning; many feel a need for hope in the face of death. Spiritual needs are discussed more fully in Chapter 46.

burnout

Activities and situations identified as highly stressful include the following: Assuming responsibilities for which you are not prepared Working with unqualified personnel Working in an environment in which supervisors and administrators are not supportive Experiencing conflict with a peer Caring for a patient who is suffering, and caring for the patient's family Caring for a patient during a cardiac arrest or for a patient who is dying Providing care to a patient who is disengaged, nonadherent, or lacks the resources to participate in his or her care Knowing the correct, right, or ethical course of action in a situation, but being unable to take that action (moral distress) · Most nurses and student nurses enjoy their education and work, coping with physical and emotional demands effectively. · Some, however, become overwhelmed and develop symptoms of stress, or a complex of behaviors called burnout. Burnout can be compared with the exhaustion stage of anxiety and is characterized by a wide range of behaviors. S · ome nurses try to become "supernurses," expecting perfection in themselves and others. Some withdraw and do only minimal work, while still others resort to drugs or alcohol. Many nurses who cannot handle the stress leave the profession. Refer to the Research in Nursing box for a study of stress resiliency practices in emergency department nurses. · What can graduate and student nurses do to help reduce stress and prevent burnout? The first step in preventing a stress level high enough to cause burnout is to identify and accept the stress. The same stress reduction techniques that are used for patients have positive benefits for nurses as well (see Encouraging Use of Stress Management Techniques in the Nursing Process section). Nurses must accept that they have the same needs and are as individual as their patients. Dickerson (2013) has developed a tool, the Stress Management Algorithm, to help nurses assess and cope with various stressors in their daily practice (see https://www.americannursetoday.com/an-algorithm-to-help-you-manage-your-stress). The guide includes taking steps to: (a) identify the stressor, (b) identify your personal feelings regarding the stressor, (c) decide if you want to change the situation causing the stress, (d) consider whether you can change the dynamics of the situation, (e) identify the plan of action, (f) involve key outside parties (as needed), (g) take action, and (h) evaluate the outcomes (Dickerson). By recognizing the early signs of stress and taking steps to reduce it, nurses can continue to be effective, productive, and satisfied in the profession

Physical Activity and Exercise

Activity and exercise increase fatigue and, in many instances, promote relaxation that is followed by sleep. It appears that physical activity increases both REM and NREM sleep. Moderate exercise is a healthy way to promote sleep, but exercise that occurs within a 3-hour interval before normal bedtime can hinder sleep. The fatigue that results from normal work activities or exercise is believed to contribute to a restful sleep, whereas excessive exercise or exhaustion can decrease the quality of sleep.

preceptorship

An alternative model for leadership training is preceptorship. The preceptor (experienced nurse) is selected (and generally paid) to introduce an employee to new responsibilities through teaching and guidance. This orientation ensures that the new RN gains the appropriate knowledge, skills, and support to care for patients safely and efficiently. Preceptors also assist new RNs to learn the policies and procedures of a new facility, and can serve as a mentor by modeling excellent nursing practice. The relationship is limited by the new employee's needs. When you are ready to select your first professional nursing position you will want to carefully evaluate how different institutions orient new nurses. You may also find it helpful to explore student internships in a setting or specialty of interest (Fig. 10-4).

Ethical and Professional Boundaries

Before exploring spiritual care strategies, remind yourself of the importance of discussing spiritual concerns in a respectful manner and as directed by patients. While the PEW landmark religion survey shows the importance of religion to many Americans, it is also true that religion means very different things to different people. A nurse's offer to pray for a patient may be received gratefully by one person and dismissed angrily by another who associates prayer with a "last resort" intervention when everything else has failed. The fact that some health care professionals confuse spiritual care with proselytizing (trying to convert others to his or her own religion) is another source of concern. Puchalski (2006) offers the following hints about professional boundaries: Keep the spiritual history patient centered. Recognize pastoral care professionals as experts in this field and consult them appropriately. Proselytizing is never acceptable in professional settings. Addressing spiritual issues should not be coercive. More in-depth spiritual counseling should be under the direction of chaplains and other spiritual leaders. Praying with patients should not be initiated by the nurse unless there is no pastoral care available and the patient requests it, or in situations in which the nurse and patient have a long-standing relationship or share a similar belief system. The nurse can stand in silence as the patient prays in her or his tradition. The nurse can always make a referral to pastoral care for chaplain-led prayer.

life events

Both positive and negative life experiences can influence spirituality, and they in turn are influenced by the meaning a person's spiritual beliefs attribute to them. For example, if two women who believe in a loving God both lose a child in a car accident, one may bitterly deny God's existence, whereas the other may spend more time in prayer, asking God to help her. Similarly, a chain of successful life experiences (marriage, promotion) may cause one person to assume success and experience no need for God, whereas for another it occasions deep gratitude and rejoicing.

Developmental Stress

Developmental stress occurs as a person progresses through the normal stages of growth and development from birth to old age (described in Chapters 21, 22, and 23). Within each stage, certain tasks must be resolved to reduce the stress. Examples of stages of growth and development associated with developmental stress include the following: The infant learning to trust others The toddler learning to control elimination The school-aged child socializing with peers The adolescent striving for independence The middle-aged adult accepting physical signs of aging The older adult reflecting on past life experiences with satisfaction

signs of impending death

Difficulty talking or swallowing Nausea, flatus, abdominal distention Urinary or bowel incontinence or constipation Loss of movement, sensation, and reflexes Decreasing body temperature with cold or clammy skin Weak, slow, or irregular pulse Decreasing blood pressure Noisy, irregular, or Cheyne-Stokes respirations Restlessness or agitation Cooling, mottling, and cyanosis of the extremities and dependent areas · As death nears, the patient may have a decreased level of consciousness or agitated delirium. · Although decreased consciousness and agitation are both normal at the end of life, they are very distressing to the patient's family. It is important for nurses to prepare family members when death is imminent and to determine if they are more comfortable being alone with a dying loved one or supported by a nurse or other member of the professional caregiving team.

formal religion

Each of the major religious groups discussed earlier in this chapter shares several characteristics: Basis of authority or source of power Scripture or sacred word An ethical code that defines right and wrong A psychology and identity, so that its adherents fit into a group, and the world is defined by the religion Aspirations or expectations Ideas about what follows death

love

Earlier, we noted that people express and experience spirituality in and through connectedness with other people. There is a basic human need to love and be loved, and we cannot be spiritually whole, spiritually healthy, unless this need is met.

effect on family

Effect on the Family · Whenever possible, with the patient's permission, encourage the family and significant others of terminally ill patients to participate in planning the patient's care. · Health care personnel should be available to discuss the patient's condition with family members and should offer support and care as the family begins the grieving process (Fig. 43-2). · The family may want to make arrangements with the patient for funeral or memorial services, depending on which stage of grief both the patient and the family members are in. · Palliative care involves taking care of the whole person—body, mind, and spirit, heart and soul. It views dying as something natural and personal. · The goal of palliative care is to give patients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms. In January 2016, The American Nurses Association (ANA) and the Hospice and Palliative Nurses Association (HPNA) partnered to develop Call for Action: Nurses Lead and Transform Palliative Care. They concluded that seriously ill and injured patients, families, and communities should receive quality palliative care in all care settings. This was to be achieved by the delivery of primary palliative care nursing by every nurse regardless of setting. · As you begin your clinical practice, you will want to be intentional about developing the knowledge, skills, and attitudes necessary to provide excellent palliative care. Be sure to check out the Clinical Practice Guidelines for Quality Palliative Care, published by the National Consensus Project for Quality Palliative Care, available online at http://keyweb24.com/nchpc/wp-content/uploads/2017/04/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf. Also of interest, in 2017, the ANA issued a call for public comment on a position statement, The Ethical Responsibility to Manage Pain and Suffering. See Chapter 35 for further information. · Hospice care is care provided for people with limited life expectancy, often in the home. When considering whether a patient is a candidate for hospice care, ask yourself, "Would I be surprised if this person died within the next 6 months?" Indicators for hospice referral (Puffenbarger, 2014) include: Poor performance status Declining cognitive status Advanced age Poor nutritional intake Pressure injuries Comorbidities Previous hospital admissions for acute decompensation · While hospice care focuses on the needs of the dying, palliative care is appropriate across the spectrum of disease and illness. Both palliative care and hospice care are discussed in Chapter 11. Established in 1986, the HPNA (www.hpna.org) is the nation's largest and oldest professional organization dedicated to promoting excellence in palliative nursing care. Among its aims are assisting members of the nursing team with ensuring quality nursing care delivery, managing complex symptoms along with grief and bereavement, and having difficult conversations.

Support systems

Families and support groups provide emotional support that can help a person identify and verbalize feelings associated with stress. In addition, families and support groups provide an accepting environment, allowing the person to explore problem-solving methods and try out new coping skills. Support groups, aside from providing information and services, may help a person maintain a positive self-concept and establish an avenue for new relationships and social roles. There are support groups for almost every situation; Alcoholics Anonymous Assertiveness training groups Child abuse support groups Ostomy clubs Overeaters Anonymous Parents Without Partners Reach to Recovery (cancer) Stroke clubs Sudden infant death support groups Weight Watchers

guided imagery and biofeedback

GUIDED IMAGERY In guided imagery, a person creates a mental image, concentrates on the image, and becomes less responsive to other stimuli (including pain). The nurse sits by the patient and reads a description of a scene or an experience that the patient has described as happy, pleasant, or peaceful. The patient is then "guided" through the image. For example, using a soothing, soft voice, the nurse might start as follows: "You are floating in your swimming pool. The water is cool and comfortable. Birds are singing in the trees. The roses are perfuming the air." As the patient becomes more and more focused on the scene, the nurse needs only to verbally "paint the picture" at intervals. BIOFEEDBACK Biofeedback is a method of gaining mental control of the autonomic nervous system and thus regulating body responses, such as blood pressure, heart rate, and headaches. A measurement device (e.g., skin temperature sensors) is used, and the patient tries to control the readings through relaxation and conscious thought. Over a period of time, the feedback of the change in readings teaches the person to control physiologic functions that normally are considered involuntary responses.

gender

Gender is not the same as biological sex or sexual orientation; they are distinct concepts. · Gender identity is the inner sense a person has of being male or female (or other), which may be the same as or different from that person's biological sex. · Gender nonconformity is behaving and appearing in ways that are considered sociologically or psychologically atypical for a person's gender. · People who experience discomfort or distress because their biological sex at birth is contrary to the gender they identify with are diagnosed with gender dysphoria (World Professional Association for Transgender Health [WPATH], 2011). · Gender role behavior is the behavior a person exhibits in relation to being male or female, which, again, may or may not be the same as biological sex or gender identity. · Cisgender refers to a gender identity or role performance that matches society's expectations based on biological sex. For example, a woman who identifies as cisgender would have a vagina and clitoris (biologically female), and would identify as female (gender).

Addressing Spiritual Distress

Goals and expected outcomes for patients in spiritual distress need to be individualized and may include a patient achieving some of the following: Exploring the origin of spiritual beliefs and practices Identifying factors in life that challenge spiritual beliefs Exploring alternatives given these challenges: denying, modifying, or reaffirming beliefs; developing new beliefs Identifying spiritual supports (e.g., spiritual reading, faith, community) Reporting or demonstrating a decrease in spiritual distress after successful intervention

Spirituality, Health, and Illness

Guide to Daily Living Habits Certain practices generally associated with health care may have religious significance for a patient. For example, many religions have dietary requirements and restrictions. Acceptable birth-control practices are determined by some religious faiths, as are some types of medical treatments Source of Support Many people seek support from their religious faith during times of stress. This support is often vital to the acceptance of an illness, especially if the illness brings with it a prolonged period of convalescence or may lead to a questionable outcome. Prayer, devotional reading, and other religious practices often do for the person spiritually what protective exercises do for the body physically. Source of Strength and Healing The value of religious faith cannot be enumerated or evaluated easily. However, the effects attributable to faith are constantly in evidence to health care workers. People have been known to endure extreme physical distress because of strong faith. Patients' families have taken on almost unbelievable rehabilitative tasks because they had faith in the eventual positive results of their effort. In the Through the Eyes of a Patient box on page 1800, a woman facing life-threatening events describes what she means by healing. Source of Conflict · Sometimes religious beliefs conflict with prevalent health care practices (see Table 46-1 on pages 1796-1797). For example, the doctrine of the Jehovah's Witnesses prohibits blood transfusions. Some Navajos use a lengthy religious ceremony to cure certain diseases, such as tuberculosis. For some people, illness is viewed as punishment for sin and is therefore inevitable. · Such beliefs may require the health care worker to modify a treatment plan to accommodate the person's religion. In some instances, acknowledgment of the patient's religious convictions and efforts by health practitioners to accommodate the patient's beliefs can result in quality health care without violating the person's religious practices. In other situations, an objective explanation of alternative treatments and the predicted consequences of each may help the patient choose acceptable therapy. Whatever the person's decision about health care, remember that each person is unique and has a right to pursue his or her own convictions, even though they may differ from those of the health care provider. · Health care professionals can reduce conflict by attempting to understand how a particular religious culture influences people's thinking about basic questions of biology and ethics. Some of the major questions that religious beliefs, attitudes, and values can affect include: What is the meaning of suffering? How should we regard the physical body and its functions? What are the meaning and role of biological sex differences, sexuality, and reproduction? How are we to understand and respond to birth, aging, and death? What constitutes the self, and how is selfhood assessed? How are sin and moral culpability understood? What makes something sinful, and how is sin relieved or absolved? What are the tradition's specific bioethical teachings?

hypertension and MI

HYPERTENSION · The most significant difficulty a person diagnosed with hypertension faces regarding sexuality is that the medication used to control the disease frequently causes a change in sexual functioning. · These sexual dysfunctions may be relieved by modifying the dose of the medication or switching to a different medication. MYOCARDIAL INFARCTION · The primary goal after a myocardial infarction (MI), or heart attack, is to allow the heart ample time to heal. · Activities of daily living, including sexual activity, should be resumed gradually, and stressors such as overexertion, alcohol consumption, and emotional upheavals should be avoided. · After an uncomplicated MI, sexual activity may begin at about the third week of recovery, beginning with masturbation to partial erection in the male. Generally, this activity is gradually increased until 3 months after the MI, when sexual intercourse may be resumed. A comfortable position that places the least stress on the affected partner should be used.

Resistance to Change

If you find yourself in a clinical setting undergoing small or big change, it can be helpful to ask yourself the following questions: How patient am I with myself and with others? Am I open to new experiences and to growth? Do I believe that good will come of the change? Hope is that human excellence that allows us to envision a positive future and work to bring it into being. Am I a positive influence on others and on our institution? People may resist change for various reasons. You may find it helpful to locate yourself on the Fisher change curve in Figure 10-1. One nurse in the early days of orienting to a new electronic medical record shared that she found herself in all of the places on any given day! The nurse manager/leader must identify if any resistance is present in order to determine which techniques are needed to overcome it. Change alters the balance of a group, and resistance is an expected accompaniment to change. People resist change for a number of reasons, as noted below:

illness

Illness, a physiologic as well as a psychological stressor, influences sleep. Certain illnesses are more closely related to sleep disturbances than others. For example: Gastric secretions increase during REM sleep. Many people with gastroesophageal reflux disease (GERD) awaken at night with heartburn or pain. They find that using antacids to neutralize stomach acidity often relieves discomfort and promotes sleep. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep. Epilepsy seizures are most likely to occur during NREM sleep and appear to be depressed by REM sleep. Liver failure and encephalitis tend to cause a reversal in day-night sleeping habits. Hypothyroidism tends to decrease the amount of NREM sleep, especially stages II and IV, while hyperthyroidism may result in difficulty falling asleep. End-stage renal disease (ESRD) disrupts nocturnal sleep and leads to excessive daytime sleepiness. Patients with ESRD who receive dialysis also have a higher incidence of RLS (discussed later in the chapter), which possibly is related to the iron deficiency common in ESRD.

developmental

Infancy: Birth to 18 months • Needs affection and tactile stimulation • Boys have penile erections, and girls have orgasmic potential • Gradually can differentiate self from others • Obtains pleasure from touching genitals • Dressed according to biological sex • Avoid early weaning to prevent oral deprivation. • Encourage parents to provide ample physical touch, deprivation of which may cause physical and mental underdevelopment. • Self-manipulation of genitals is normal behavior; avoid denoting this as "bad." Toddler: Age 1-3 years • Establishes control over bowels and bladder • Both sexes enjoy fondling genitals • Able to identify own gender • Develops vocabulary related to anatomy • Allow toddler to designate his or her readiness to toilet training. Strict measures may lead to compulsive behaviors later. • Punishment of genital fondling may lead to guilt and shame regarding sexual behavior later in life. • Use proper terms for body parts. Preschooler: Age 4-6 years • Becomes increasingly aware of self • Enjoys exploring body parts of self and playmates • Engages in masturbation • Gender identity is formed • Parents may cause anxiety in the child by intolerance of inconsistency of sex-role behavior. • Negative overreaction by parents to child's masturbating behavior can lead to a belief that the genitals and sex are bad and dirty. School-aged: Age 6-10 years • Attachment to the parent of the opposite sex • Tendency toward having same-sex friends • Curiosity about sex and sharing of fears • Increasing self-awareness • Same-sex preference for relationships is not related to heterosexual or homosexual tendencies. • Give child the information (intercourse, abstinence, STI prevention, pregnancy) in a clear, factual form. May look to peers for information that may be incorrect. Preadolescence: Age 10-13 years • Puberty begins for most boys and girls with development of secondary sex characteristics • Menarche takes place • May test behavioral limits • Information is necessary regarding body changes to alleviate fears. This information should be given to the young person before pubertal changes begin. • Parents need to find a satisfactory middle ground for rule setting. Rules that are either too rigid or too lenient can interfere with the development of self-confidence and an internal value system. • Treat body image changes with a positive attitude to prevent poor self-image. Adolescence: Age 13-19 years • Primary and secondary sex characteristics develop • Sexual fantasies are common • Masturbation is common • May begin to partake in sexual activity ranging from light to heavy petting to full genital intercourse • May experiment with same-sex relationships • At risk for pregnancy and sexually transmitted infections • Gender expression and identification is often solidified during adolescence • Parents share their beliefs and moral value systems with their children. • Teenagers may share their feelings with parents. Not taking them seriously may lead to lack of trust and a communication gap. • Teens need information regarding contraceptive measures and the potential for contracting sexually transmitted infections. Young adulthood: Age 20-35 years • Premarital sex is common • Knowledge regarding sexual response and activity increases pleasure of relationship • May experiment with various sexual expressions • Develops own value system and respects values of other people • Many couples share financial responsibilities as well as household tasks • Encourage communication between partners regarding sexual needs and differences. • Reinforce the use of abstinence and contraceptive measures to prevent unwanted pregnancies. • Counsel against promiscuous behavior to guard against sexually transmitted infections and loss of trust of partner. • Daily communication is necessary to vent stresses and work out difficulties. Adulthood: Age 35-55 years • Bodily changes as a result of menopause • Couples focus on quality rather than quantity of sexual experiences • Divorce is common • Grown children begin their own lives and sexual experiences • Sexual satisfaction may actually increase because of loss of fear of pregnancy • Both men and women need positive reinforcement of what is good about themselves and their relationships. • Teach parents that empty nest syndrome (feelings of loss caused by children leaving) is common. Accentuate positive aspects of this situation. • Encourage couple to use this period as one of renewal for themselves. Late adulthood: Age 55 years and older • Orgasms may become shorter and less intense in both men and women • Vaginal secretions decrease, and period of resolution in men lengthens • May feel need to conform to stereotypes regarding the aging process, and cease sexual activity • Fear of loss of sexual abilities • Sexual activity need not be hindered by age. • Teach couples that adaptation to bodily changes is possible with use of comfortable positions for intercourse and increased time for stimulation. • Teach alternatives to coitus, such as caressing, hugging, and stroking, when coitus is impossible because of illness or disability. • Couples who have been consistently sexually active throughout their lives may continue their intimate relationship for as long as they desire.

Developing a Positive Body Image

Interventions for body image disturbances vary according to the nature of the disturbance. Interventions may include a combination of the following: Express interest in and acceptance of the patient through verbal and nonverbal expression. Allow the patient to share his or her feelings openly. Sitting quietly by the patient for a few minutes, with a few words such as, "How are things?" or "Tell me what's going on with you" communicates to the patient your willingness and readiness to share the patient's experience. Explore with the patient his or her feelings about altered body image and the patient's perceptions about the meaning and consequences of such alteration. Support the patient through the various stages of loss, grief, and mourning (shock, disbelief, denial, anger, guilt, acceptance), remembering that there is no one right way to proceed through these stages. Rather, patients may move fluidly in and out of various stages, sometimes returning to earlier stages. Some patients may need to learn that it is okay to cry, to be angry, or to feel depressed. Use play therapy with children so that they can describe their feelings and work through their grief using the nonthreatening medium of dolls or animals. Use self-reflection to gain awareness of your attitudes and feelings toward the patient. Be careful not to let facial expressions, words, or body positioning communicate to the patient disgust, fear, or rejection. While communicating support to the patient who is slow to develop and use appropriate self-care behaviors, firmly insist that the patient participate in his or her care to the extent that the patient is able. Whenever possible, provide the patient with honest answers to questions or put the patient in touch with the appropriate person to give the answers. Strengthen the patient's decision-making ability by honestly exploring alternatives; help the patient to imagine living with the consequences of different courses of action. Reinforce the patient's personal strengths and help the patient and family to identify all possible resources. Assess the response of the patient's significant others and intervene if they negatively influence the patient.

joints and mobility

Joint diseases and disorders affect young and old people. Pain, fatigue, stiffness, and loss of range of motion can accompany any of the dozens of known diseases of the joints. The disease itself does not affect sexual functioning, although the manifestation of it can cause discomfort and anxiety.

types of anxiety

MILD ANXIETY Mild anxiety is present in day-to-day living. It increases alertness and perceptual fields (e.g., vision and hearing) and motivates learning and growth. Although mild anxiety may interfere with sleep, it also facilitates problem solving. Mild anxiety is often manifested by restlessness and increased questioning. MODERATE ANXIETY Moderate anxiety narrows a person's perceptual fields so that the focus is on immediate concerns, with inattention to other communications and details. Moderate anxiety is manifested by a quavering voice, tremors, increased muscle tension, a complaint of "butterflies in the stomach," and slight increases in respirations and pulse. SEVERE ANXIETY Severe anxiety creates a very narrow focus on specific details, causing all behavior to be geared toward getting relief. The person has impaired learning ability and is easily distracted. Severe anxiety is characterized by extreme fear of a danger that is not real, by emotional distress that interferes with everyday life, and by avoiding situations that cause anxiety. It is manifested by difficulty communicating verbally, increased motor activity, a fearful facial expression, headache, nausea, dizziness, tachycardia, and hyperventilation. At this point, anxiety is no longer functioning as a signal for danger or motivation for a needed change, but instead results in maladaptive behaviors and emotional disability that signal the presence of an anxiety disorder. PANIC Panic causes the person to lose control and experience dread and terror. The resulting disorganized state is characterized by increased physical activity, distorted perception of events, and loss of rational thought. Panic is manifested by difficulty communicating verbally, agitation, trembling, poor motor control, sensory changes, sweating, tachycardia, hyperventilation, dyspnea, palpitations, a choking sensation, and sensations of chest pain or pressure. The person is unable to learn, concentrates only on the present situation, and often experiences feelings of impending doom. This level of anxiety can lead to exhaustion and death. ANXIETY DISORDERS Anxiety disorders are a group of conditions where excessive anxiety is the key feature. This type of anxiety is persistent and affects responses from a cognitive, behavioral, emotional, and physiologic perspective (Videbeck, 2017). Based on an analysis of data collected from national surveys in the early 2000s, 31.6% of those aged 13 and older report an anxiety disorder at some point in their lives; 22.2% of those aged 13 and older report an anxiety disorder in the last 12 months. The highest prevalence is reported by adolescents and the lowest prevalence by older adults. Anxiety disorders include panic disorder, generalized anxiety disorder (GAD), phobias (agoraphobia, social phobia, specific phobia), separation anxiety disorder, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder

fear of increased responsibility

Many people are worried about having to take on more complex responsibilities, especially if they feel unprepared for the planned changes. The changes may seem overwhelming, so they naturally resist them.

continuing education

Many programs for developing leadership, managerial, and administrative skills are available to nurses. Courses can be taken by correspondence or over the Internet. Periodicals and books also provide continuing education for emerging leaders. Many continuing education programs are available to prepare nurses before they assume higher levels of leadership; some are geared to nurses already in such positions. Nurses should choose a program that matches their learning needs. Many State Boards of Nursing require evidence of continuing education credits prior to renewal of RN licenses.

meditation

Meditation has four components: quiet surroundings, a passive attitude, a comfortable position, and a word or mental image on which to focus. A person practicing meditation sits comfortably with closed eyes, relaxes the major muscle groups, and repeats the selected word silently with each exhalation. Alternatively, a person may focus on a pleasant scene and mentally place oneself in it while breathing slowly in and out. This exercise should be performed for 20 to 30 minutes twice a day.

ethical and legal dimension

Multiple treatment options and sophisticated life support technologies may make it difficult to draw the line between promoting life and needlessly prolonging the dying process. This complicates health care decision making for patients and health care professionals alike. Patients have a legally and morally protected right to consent to or refuse medical therapies. Legal foundations for the patient's freedom to choose include the common law right of self-determination and the constitutionally supported right of privacy (discussed in Chapters 6 and 7). Discussions about legalizing physician-assisted suicide and physician-administered lethal injections ("aid in dying") pose new ethical challenges. As patients and families struggle with end-of-life treatment decisions, they are increasingly looking to nurses for information, advice, and support. It is important for you to clarify you own beliefs about suicide and euthanasia before attempting to counsel patients and the public. Take time to work through your answers to the questions in Box 43-4 on page 1696.

Counseling in Cases of Abusive Relationships and Rape

Nurses encounter children, adolescents, women, and sometimes men who have experienced sexual abuse or rape. Sexual violence (rape, forced sodomy, sexual child abuse, incest, fondling, sexual harassment, or any unwanted sexual contact) is NOT about love or sex; it is about power, violence, and control. The Rape, Abuse & Incest National Network (RAINN, 2016) reports that: One out of every six American women has been a victim of an attempted or completed rape in her lifetime (14.8% completed rape; 2.8% attempted rape). About 3% of American men—or 1 in 33—have experienced an attempted or completed rape in their lifetime. Every 98 seconds, an American is sexually assaulted. 15% of victims of sexual assault and rape are age 12 to 17; 54% are age 18 to 34. The majority of sexual assaults occur at or near the victim's home; 48% of victims were sleeping or at home doing something else when the crime occurred. 21% of transgender college students have been sexually assaulted (compared to 18% of nontransgender females and 4% of nontransgender males). Sexual violence has fallen by more than 50% since 1993. · Date rape occurs when there is forced or coerced sex within a dating relationship. With acquaintance rape, the act is committed by someone known to the victim. Nearly two thirds of all victims between the ages of 18 and 29 report that they had a prior relationship with their attacker. Over 13% of college women report they have been forced to have sex while in a dating situation (Center for Family Justice, 2017). · Victims of sexual assault are 3 times more likely to suffer from depression, 6 times more likely to suffer from posttraumatic stress disorder, 13 times more likely to abuse alcohol, 26 times more likely to abuse drugs, and 4 times more likely to contemplate suicide. Clearly, nurses need to be alert to evidence of sexual abuse while taking the history and conducting physical examinations. Abuse crosses all socioeconomic and ethnic groups. Become familiar with your legal and clinical responsibilities when a victim is identified. The first priority is getting the victim into a safe environment and mobilizing support for the victim and family. Multiple parties may need therapy. Be familiar with local resources and make appropriate referrals. The National Sexual Assault Online Hotline is a free, confidential, secure service that provides live help over the RAINN website (https://www.rainn.org/get-help).

defense mechanisms

Other unconscious reactions to stressors, called defense mechanisms, often occur. These mechanisms protect a person's self-esteem and are useful in mild to moderate anxiety. When extreme, however, they distort reality and create problems with relationships. At that point, the mechanisms become maladaptive instead of adaptive. Compensation A person attempts to overcome a perceived weakness by emphasizing a more desirable trait or overachieving in a more comfortable area. A student who has difficulty with academics may excel in sports. Denial A person refuses to acknowledge the presence of a condition that is disturbing. Despite finding a lump in her breast, a woman does not seek medical treatment. Displacement A person transfers (displaces) an emotional reaction from one object or person to another object or person. An employee who is angry with a coworker kicks a chair. Dissociation A person subconsciously protects him- or herself from the memories of a horrific or painful event by allowing the mind to forget the incident. An adult cannot recall childhood memories surrounding the traumatic death of a sibling. Introjection A person incorporates qualities or values of another person into his or her own ego structure. This mechanism is important in the formation of conscience during childhood. An older sibling tells his preschool sister not to talk to strangers, expressing his parents' values to his younger sister. Projection A person attributes thoughts or impulses to someone else. A person who denies any sexual feelings for a coworker accuses him of sexual harassment. Rationalization A person tries to give a logical or socially acceptable explanation for questionable behavior ("behavior justification"). A patient who forgot to keep a health care appointment says, "If patients didn't have to wait 3 months to get an appointment, they wouldn't forget them." Reaction formation A person develops conscious attitudes and behavior patterns that are opposite to what he or she would really like to do. A married woman is attracted to her husband's best friend but is constantly rude to him. Regression A person returns to an earlier method of behaving. Children often regress to soiling diapers or demanding a bottle when they are ill. Repression A person voluntarily excludes an anxiety-producing event from conscious awareness. A father may not remember shaking his crying baby. Sublimation A person substitutes a socially acceptable goal for one whose normal channel of expression is blocked. A person who is aggressive toward others may become a star football player. Undoing A person uses an act or communication to negate a previous act or communication. A husband who was physically abusive to his wife may bring her an expensive present the next day.

threat to self

People generally view change in terms of how they are affected personally. Personal threats may include a loss of self-esteem, a belief that more work will be required, or a belief that social relationships will be disrupted. For example, when hospitals began to use more unlicensed assistive personnel (UAP) for routine nursing care, many nurses resisted, not only because of quality concerns but also because they found themselves legally and professionally responsible for supervising the care given by these aides. There was also concern that some professional nurses would be replaced by UAP.

Effects of Stress on Basic Human Needs

Physiologic Needs Change in appetite, activity, or sleep Change in elimination patterns Increased pulse, respirations, blood pressure Safety and Security Feels threatened or nervous Uses ineffective coping mechanisms Is inattentive Love and Belonging Is withdrawn and isolated Blames others for own faults Demonstrates aggressive behaviors Becomes overly dependent on others Self-Esteem Becomes a workaholic Exhibits attention-seeking behaviors Self-Actualization Refuses to accept reality Centers on own problems Demonstrates lack of control

1. Describe the responsibilities and structures of nursing management and how they relate to leadership.

Planning: identifying problems and developing goals, objectives, and related strategies to meet the demands of the clinical arena Organizing: acquiring, managing, and mobilizing resources to meet both clinical and financial objectives Staffing: hiring, orienting, scheduling to facilitate team building; also includes staff development Directing: leading others in achieving goals within the constraints of the current fiscal and workforce shortage scenarios, a demanding task for managers and staff alike Controlling: implementing mechanisms for ongoing evaluation, particularly in areas of clinical quality and financial accountability

psychological stress

Psychological stress, such as from illness and various life situations, tends to disturb sleep. In general, psychological stress affects sleep in two ways: (1) the person experiencing stress may find it difficult to obtain the amount of sleep needed; and (2) REM sleep decreases in amount, which tends to add to anxiety and stress.

adaptive and maladaptive responses to body image

RESPONSE TO DEFORMITY OR LIMITATION Adaptive responses: Patient exhibits signs of grief and mourning (shock, disbelief, denial, anger, guilt, acceptance). Maladaptive responses: Patient continues to deny and to avoid dealing with the deformity or limitation, engages in self-destructive behavior, talks about feelings of worthlessness or insecurity, equates deformity or limitation with whole person, shows a change in ability to estimate relationship of body to environment. NDEPENDENCE-DEPENDENCE PATTERNS Adaptive responses: Patient assumes responsibility for care (makes decisions), develops new self-care behaviors, uses available resources, interacts in a mutually supportive way with family. Maladaptive responses: Patient assigns responsibility for his or her care to others, becomes increasingly dependent, or stubbornly refuses necessary help.

Overcoming Resistance to Change

Resistance can be subtle or distinct, gentle or aggressive. Responding to resistance is both a leadership responsibility and a challenge in which the leader uses leadership qualities, leadership style, and knowledge of group dynamics to influence others toward a desired outcome. Nurses acting as change agents find the following guidelines helpful for overcoming resistance to change: Explain the proposed change to all affected people in simple, concise language. List the advantages of the proposed change, both for the individual and for members of the group. Relate the proposed change to the person's or group's existing beliefs and values. Help overcome resistance by providing opportunities for open communication and feedback. Indicate clearly how the change will be evaluated. If possible, introduce change gradually. Involve everyone affected by the change in the design and implementation of the process. Provide incentives for commitment to change, such as money, status, time off, or a better working environment.

disagreements about the benefits of change

Resistance may occur when the change agent and those resisting change have different information. If the information known by the people resisting change is more accurate and relevant than the change agent's information, resistance may be beneficial. For example, the supervisor of community health services proposes to implement, in a low-income neighborhood, a home health care plan that has been effective in a middle-class section of the city. The nurse in charge of the health program in the low-income area resists, believing that the same plan would not be successful in a financially and educationally disadvantaged neighborhood.

goals

Rest and sleep are essential components of well-being. Planning for patient care, especially in a health care facility, involves planning with the patient suitable measures to promote rest and sleep. Whenever nurses care for a patient, nursing measures support the following expected patient outcomes: The patient will: Maintain a sleep-wake pattern that provides sufficient energy for the day's tasks Demonstrate self-care behaviors that provide a healthy balance between rest and activity Identify stress-relieving rituals that enable the patient to fall asleep more easily Demonstrate decreased signs of sleep deprivation Verbalize feeling less fatigued and more in control of life activities

rest and sleep

Rest and sleep help the body maintain homeostasis and restore energy levels. Adequate rest can provide insulation against stress, but stress may interfere with a person's ability to sleep. Each person has individual sleep needs, but 7 to 9 hours of sleep a day is the usual recommendation. Relaxation techniques can be used during both health and illness to facilitate rest and sleep. Hospitalized patients may require additional nursing interventions to relieve pain and promote comfort to get needed rest.

bases of self esteem

SOCIALIZATION AND COMMUNICATION Responses to socialization and communication may be adaptive or maladaptive: Adaptive responses: Maintains usual social patterns, communicates needs and accepts offers of help, serves as support for others. Maladaptive responses: Isolates self, exhibits superficial self-confidence, is unable to express needs (becomes hostile, ashamed, frustrated, depressed). To assess the quantity and quality of the patient's interpersonal relationships, which helps identify the person's level of social support and relatedness, you might ask: "Who do you feel is important to you?" "Is there anyone you feel you can depend on for help if you need it?" "How do you feel about your relationships?" "Tell me about changes you've noticed in your ways of meeting and interacting with others." "Many people have 'people' problems. Are your relationships causing you any problems right now?" SIGNIFICANCE To assess the patient's feelings of significance, you might ask: "Are there people in your life with whom you share a close relationship?" "To what extent do you feel loved and approved of by the key people in your life?" "Does it bother you when you feel unloved or when others fail to appreciate you?" "In what ways do you let family members and friends know that you like them or are proud of their accomplishments?" COMPETENCE To assess the patient's feelings of competence, you might ask: "What are the things you need to do to feel important?" "Is anything interfering with your ability to execute these tasks? How does this make you feel?" "How important to you is it to feel that others value your work?" VIRTUE To assess the patient's sense of virtue, you might ask: "Tell me something about the moral-ethical principles that govern your life." "How must you live to describe yourself as a 'good' person?" "Describe any difficulties you experience in living up to your moral principles that you would like to discuss." "In what ways can the nurses help you to live better according to your moral standards?" POWER To assess the patient's sense of power, you might ask: "How important is it to you to 'be in control' of your life (health)?" "To what extent did you feel 'in control' of your life (health) before this illness (trauma, crisis)?" "To what extent do you feel 'in control' of your life (health) currently?" "What is it that makes you feel not in control?" "How might you change this? How can nurses help you to develop and gain more control?"

self actualization, identity diffusion, depersonalization

Self-actualization · is the need for people to reach their full potential through development of their unique capabilities. Identity diffusion · Disturbances in self-concept may occur for a number of reasons. Identity diffusion is the failure to integrate various childhood identifications into a harmonious adult psychosocial identity, which can lead to disruptions in relationships and problems of intimacy. Depersonalization · a person's subjective experience of the partial or total disruption of the ego and the disintegration and disorganization of self-concept

Teaching Self-Compassion

Self-compassion is a powerful tool that nurses can use for themselves and for patients. When we see others who are suffering and feel their plight, when we are moved by the suffering of others and want to respond in a helpful way, we are being compassionate. Self-compassion scholar Dr. Kristin Neff writes that self-compassion involves acting the same way toward yourself when you are having a difficult time, fail, or notice something you don't like about yourself. "Instead of just ignoring your pain with a 'stiff upper lip' mentality, you stop and tell yourself, 'this is really difficult right now; how can I comfort and care for myself in this moment?'." Instead of mercilessly judging and criticizing yourself for various inadequacies or shortcoming, self-compassion means you are kind and understanding when confronted with personal failings—after all, who ever said you were supposed to be perfect?" You may want to try out the official self-compassion website (http://self-compassion.org) for helpful self-compassion practices (guided meditations and exercises).

Enhancing Spiritual Health

Show you value spiritual health by being sensitive to the role that spiritual beliefs play in influencing both a person's thoughts about self and the world and his or her interactions with the world. Your interactions with any patient who values spirituality support the following patient outcomes. The patient will: Identify spiritual beliefs that meet needs for meaning and purpose, love and relatedness, and forgiveness Derive from these beliefs strength, hope, and comfort when facing the challenge of illness, injury, or other life crisis Develop spiritual practices that nurture communion with inner self, with God or a higher power, and with the world Express satisfaction with the compatibility of spiritual beliefs and everyday living

situational stress

Situational stress is different from developmental stress. It does not occur in predictable patterns as a person progresses through life. Situational stress can occur at any time, although the person's ability to adapt may be strongly influenced by his or her developmental level. Examples of situational stress, which may be either positive or negative, include the following: Illness or traumatic injury Marriage or divorce Loss (of belongings, relationships, family member) New job Role change · Consider pregnancy as an example of a situational stress. A young married couple may be overjoyed at the prospect of becoming parents, whereas an unmarried adolescent may be panic-stricken when she discovers she is pregnant. The situations and the developmental levels of the young couple and the adolescent will have a major effect on the adaptations they will make. A person's physical and psychosocial capacities to cope with the situation depend not only on stage of maturation, but also on the support systems available.

older adults

Sleep Pattern · An average of 7 to 8 hours of sleep is usually adequate for this age group. · Sleep is less sound, and stage IV sleep is absent or considerably decreased. Periods of REM sleep shorten. · Older adults frequently have great difficulty falling asleep and have more complaints of problems sleeping. · Decline in physical health, psychological factors, effects of drug therapy (e.g., nocturia), or environmental factors may be implicated as causes of inability to sleep. Nursing Implications · A comprehensive nursing assessment and individualized interventions may be effective in the long-term care of this age group. · Emphasize concern for a safe environment because it is not uncommon for older adults to be temporarily confused and disoriented when they first awake. · Use sedatives with extreme caution because of declining physiologic function and concerns about polypharmacy. · Encourage older adults to discuss sleep concerns with their health care provider.

preschooler

Sleep Pattern · Children in this stage generally sleep 11 to 13 hours at night. · The REM sleep pattern is similar to that of an adult. · Daytime napping decreases during this period, and by the age of 5 years, most children no longer nap. · This age group may continue to resist going to bed at night. Nursing Implications · Encourage parents to continue bedtime routines. · Advise parents that waking from nightmares or night terrors (awakening screaming about 20 minutes after falling asleep) are common during this stage. Waking the child and comforting the child generally helps. Sometimes use of a night light is soothing.

toddlers

Sleep Pattern · Need for sleep declines as this stage progresses. May require two naps during the day and end this stage sleeping 11 to 14 hours a night and napping once during the day. · Toddlers may begin to resist naps and going to bed at night. · They may move from crib to youth bed or regular bed at around 2 years. Nursing Implications · Establish a regular bedtime routine (e.g., reading a story, singing a lullaby, saying prayers). · Advise parents of the value of a routine sleeping pattern with minimal variation. · Encourage attention to safety once child moves from crib to bed. If child attempts to wander out of room, a folding gate may be necessary across the door of the room.

newborns and infants

Sleep Pattern · Newborn: Sleeps an average of 16 hr/24 hr; averages about 4 hours at a time. · Each infant's sleep pattern is unique. On average, infants sleep 12 to 15 hours at night, with several naps during the day. · Usually by 8 to 16 weeks of age, an infant sleeps through the night. · REM sleep constitutes much of the sleep cycle of a young infant. Nursing Implications · Teach parents to position infant on the back. This is the only safe sleeping position for infants less than 1 year old. Sleeping in the prone position increases the risk for sudden infant death syndrome (SIDS). · Advise parents that eye movements, groaning, grimacing, and moving are normal activities at this age. · Encourage parents to have infant sleep in a separate area rather than their bed. · Caution parents about placing pillows, crib bumpers, quilts, stuffed animals, and so on in the crib because this may pose a suffocation risk.

teenagers

Sleep Pattern · Sleep needs of teenagers vary widely, but the average requirement is 8 to 10 hours. The growth spurt that normally occurs at this stage may necessitate the need for more sleep; however, the stresses of school, activities, and part-time employment may cause adolescents to have a restless sleep. Adolescents tend to go to bed later than younger children and adults, but early morning start times for high school frequently require an early awakening time. This can result in an average of only 7 to 7.5 hours of sleep a night. · Many adolescents do not get enough sleep. Nursing Implications · Advise parents that their adolescents' complaints of fatigue or inability to do well in school may be related to not enough sleep. Excessive daytime sleepiness (EDS) may also make the teenager more vulnerable to accidents and behavioral problems.

young adults

Sleep Pattern · The amount of sleep required is 7 to 9 hours. · Sleep is affected by many factors: physical health, type of occupation, exercise. Lifestyle demands may interfere with sleep patterns. · REM sleep averages about 20% of sleep. Nursing Implications · Reinforce that developing good sleep habits has a positive effect on health, particularly as a person ages. · If loss of sleep is a problem, explore lifestyle demands and stress as possible causes. · Suggest use of relaxation techniques and stress-reduction exercises rather than resorting to medication to induce sleep. Sleep medications decrease REM sleep, may be habit forming, and frequently lose their effectiveness over time.

middle aged adults

Sleep Pattern · Total sleep time decreases during these years, with a decrease in stage IV sleep. · The percentage of time spent awake in bed begins to increase. · People become more aware of sleep disturbances during this period. Nursing Implications · Encourage adults to investigate consistent sleep difficulties to exclude pathology or anxiety and depression as causes. · Encourage adults to avoid use of sleep-inducing medication on a regular basis.

school aged children

Sleep Pattern · Younger school-aged children may require 10 to 12 hours nightly, whereas older children in this stage may average 9 to 11 hours. · Sleep needs usually increase when physical growth peaks. Nursing Implications · Discuss the fact that the stress of beginning school may interrupt normal sleep patterns. · Advise that a relaxed bedtime routine is most helpful at this stage. · Inform parents about child's awareness of the concept of death possibly occurring at this stage. Encourage parental presence and support to help alleviate some of the child's concerns.

limited tolerance for change

Some people simply do not like to function in a state of flux or disequilibrium. A person may understand the need for change but may be unable to cope with it emotionally. For example, a nurse may resist change because of the temporary confusion the change is likely to cause.

lack of understanding

Someone who does not understand the nature of change is likely to resist. The people who will be affected by the change must become involved and educated if their resistance is to be overcome. For example, nurses who do not realize the effectiveness of using care plans tend to resist preparing them because they believe they are not beneficial for providing patient care.

assess

Spiritual beliefs "Are there particular spiritual or religious beliefs that are important to you? Have these beliefs changed recently? Is your illness challenging these beliefs? Do your religious beliefs in any way dictate a course of action that puts you in conflict with what your health care providers are recommending?" Spiritual practices "Describe your usual spiritual practices and anything interfering with your ability to perform them. Can I help in any way to secure the aids necessary for these practices (prayer shawl, Bible, crystals, amulets, beads, icons)?" Relation between spiritual beliefs and everyday living "Describe ways your spiritual beliefs affect everyday living (daily schedule, diet, hygiene, sense of self and the world, relationships). Do you find this influence to be healthy (life affirming) or destructive (life denying)?" Spiritual deficit or distress "Are your spiritual beliefs currently causing you any distress?" Spiritual needs "In what ways can I and the other nurses help you to meet your spiritual needs?" "Would you like me to contact your spiritual adviser or the hospital's pastoral care minister?" Need for meaning and purpose "In what ways do your religious beliefs help or hinder you to understand your current situation and face it with peace and courage?" Need for love and relatedness "In what ways do your religious beliefs help or hinder you to meet your need to love and be loved?" Need for forgiveness "In what ways do your religious beliefs help or hinder you to feel at peace?" Significant behavioral observations Be alert to sudden changes in spiritual practices, mood changes, sudden interest in spiritual matters, and sleep disturbances—any of which may point to unresolved spiritual needs.

Spirituality and Everyday Living

Spiritual beliefs and practices are associated with all aspects of a person's life, including health and illness. The major wisdom traditions address the invisible Spirit—a creative, mysterious guiding power—by creating principles and practices that: Cultivate love for ourselves, our neighbors, of a higher being, and of nature Cultivate wisdom that helps us find meaning in life; be in relationships with others; be true to ourselves; live in uncertainty and mystery; deal with suffering, sickness, and death; and honor life's transitions (birth, marriage, death) Cultivate awareness of the sacred dimension of life through practices such as worship, prayer, meditation, and singing Respect our connectedness as fellow human beings while acknowledging our differences Help us be generous in service to others. Religious influences may be life affirming or life denying. Life-affirming influences enhance life, give meaning and purpose to existence, strengthen a person's feelings of self-worth, encourage self-actualization, and are health giving and life sustaining. Life-denying influences restrict or enclose life patterns, limit experiences and associations, place burdens of guilt on people, encourage feelings of unworthiness, and are generally health denying and life inhibiting.

Servant

The Robert K. Greenleaf Center for Servant Leadership (https://www.greenleaf.org) defines servant leadership as a philosophy and set of practices that enriches the lives of individuals, builds better organizations, and ultimately creates a more just and caring world. It begins with the natural feeling that one wants to serve. Greenleaf recognized that, although some prize leadership because of their love for power and material possessions, others aspire to leadership because of wanting to serve. "The difference manifests itself in the care taken by the servant first to make sure that other people's highest priority needs are being served. The best test, and most difficult to administer, is: Do those served grow as people? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants? And what is the effect on the least privileged in society? Will they benefit or at least not be further deprived?" Relationships are the key to successful servant leadership. It is easy to see why many nurses find servant leadership a great fit with nursing values, roles, and responsibilities. Fahlberg and Toomey (2016) believe that many of the best nursing leaders practice servant leadership. "We lead, speak up, volunteer, and advocate because it is the right thing to do. We want to make something better. We see a wrong and we want to make it right, so we do something. Soon, others join in, becoming leaders as they learn and grow through their service" (p. 50). Box 10-4 presents five key practices for servant leaders.

nursing department

The nursing team can also be viewed in the broader context of the entire nursing department of a health care institution or facility. Nurses should have an interest in the functioning of the department. Using this knowledge, nurses can seek information or change through appropriate channels. The more nurses understand how the nursing department runs, the better able they are to work constructively to meet the department's objectives.

Counseling Patients Spiritually

The patient who feels that the nurse is sensitive to spiritual needs and comfortable with his or her own spirituality may choose to share spiritual concerns with the nurse rather than with a religious counselor. A nurse who feels competent to counsel the patient may assist the patient to accomplish the following: Articulate spiritual beliefs. Explore the origin of the patient's spiritual beliefs and practices. Identify life factors that challenge the patient's spiritual beliefs (cause spiritual distress). Explore alternatives given these challenges (e.g., modify lifestyle; deny, modify, or reaffirm beliefs; develop new beliefs). Develop spiritual beliefs that meet needs for meaning and purpose, care and relatedness, forgiveness. To be an effective spiritual counselor, the nurse must be open to different spiritual beliefs and forms of spiritual expression, and should be supportive of the patient's efforts to nurture spiritual growth.

outcomes related to promoting self-concept

The patient will: describe self realistically, identifying both strengths and deficiencies. verbalize realistic expectations for self, based on who the patient would like to be. verbalize that self is liked, or at least "OK." communicate feelings and needs in a way that is comfortable and effective in meeting needs. nurture relationships in which needs for love and worth are mutually met (significance). assume role-related responsibilities with confidence (competence). express satisfaction with ability to live according to his or her moral-ethical standards (virtue). demonstrate confidence in ability to accomplish what is desired (power). The following are sample outcomes for patients with specific disturbances in self-concept: The patient will: describe the relation between self-concept and behavior. identify faulty thinking that reinforces a negative self-concept (distortions and denials, faulty categorizing, inappropriate standards). integrate positive self-knowledge into self-concept. report feeling better about himself or herself.

ana standards - leadership

The registered nurse demonstrates leadership in the professional practice setting and the profession. Competencies The registered nurse: · Contributes to the establishment of an environment that supports and maintains respect, trust, and dignity. · Encourages innovation in practice and role performance to attain personal and professional plans, goals, and vision. · Communicates to manage change and address conflict. · Mentors colleagues for the advancement of nursing practice and the profession to enhance safe, quality health care. · Retains accountability for delegated nursing care. · Contributes to the evolution of the profession through participation in professional organizations. · Influences policy to promote health.

change theory

There are many theories of change, most based on the classic theory of change proposed by Lewin (1951). Lewin identified three stages of change: Unfreezing: The need for change is recognized. Moving: Change is initiated after a careful process of planning. Refreezing: Change becomes operational. · These three rather simplistic stages do not fully reveal the very dynamic and personal nature of change of any kind. In health care, we can find numerous examples of using change theory to transform practice. Not so long ago, childbirth in the United States was routinely "medicalized." Women came to the hospital to deliver their babies; pain medications that interfered with the natural process of labor were routinely administered, necessitating forceps and assisted deliveries; and husbands, partners, and siblings were banished from the delivery room. Nurse midwives and others recognized the need for change (unfreezing) and set about researching childbirth and ways to improve infant and family outcomes. After a careful process of planning (moving), multiple natural childbirth options in health care facilities and in the home were made available to women and couples; today they represent mainstream care (refreezing).

Facilitating the Practice of Religion

Ways that the nurse can help the patient continue normal spiritual practices in the unfamiliar environment of the hospital or care center are as follows: Familiarize the patient with the pastoral and religious services and materials available within the institution. Respect the patient's need for privacy or quiet during periods of prayer. Assist the patient to obtain devotional objects and protect them from loss or damage. Arrange for the patient wishing to receive the sacraments to do so. Attempt to meet the patient's religious dietary restrictions. Arrange for the patient's minister, priest, or rabbi to visit if the patient so wishes. If the patient has a conflict between spiritual beliefs and the proposed medical therapy, assist the patient in discussing this with the health care provider. For ill patients in the home who cannot attend services or meetings to which they are accustomed, help them find ways to meet their spiritual needs. · Nurturing Spirituality

post mortem care

When a patient dies, the nurse's responsibilities include caring for the patient's body, caring for the family, and discharging specific legal responsibilities. The last involves ensuring that a death certificate is issued and signed, labeling the body, and reviewing organ donation arrangements, if any. • Donor services• Notify coroner• Funeral home• Postmortem care• Body bag• Patient identification• Family support/notification• Patient belongings

Praying for Patients

With research suggesting links between prayer and physical, mental, and spiritual health, some have argued that health care professionals should pray for, as well as with, their patients. At the present time, no one is claiming that health care professionals are negligent if they fail to pray for patients. Prayer may, however, be an effective intervention strategy. At the very least, nurses ought to be mediators of the spiritual resources patients and their families need.

outcomes - stress

decrease the level of anxiety by verbalizing feelings and using support systems. develop effective methods of coping through problem-solving skills and anxiety-reducing techniques. describe a reduction in anxiety and an increase in comfort. identify three concrete stress-reduction techniques that are of interest. identify resources to manage moral distress (see Chapter 6) and spiritual distress.

parasomias

goalsParasomnias are patterns of waking behavior that appear during REM or NREM stages of sleep. They are more commonly seen in children. Although parasomnias are commonly outgrown before adulthood, safety and prevention of injury are paramount concerns. These sleep disorders can occur rarely or on a regular basis. Examples of parasomnias include: Somnambulism or sleepwalking may range from sitting up in bed to walking around the room or the house to walking outside the house. The sleepwalker is unaware of his environment. REM Sleep Behavior Disorder (RBD) is characterized by "acting out" dreams while asleep. While experiencing the dream episode, the sleeper can moan and thrash around in the bed, possibly causing harm to a bed partner or oneself (American Sleep Association, 2010). Sleep terrors are more common in children and occur during the deepest stages of sleep. Typical behavior involves waking up screaming and sitting up in bed. They may appear to be awake and reasonable but are unable to communicate when they awaken from a sleep terror. Nightmare disorder involves frightening dreams that are vivid and disturbing. They occur more frequently in children and represent a normal developmental process. Sleep enuresis is urinating during sleep or bedwetting. It occurs most commonly in males who are over 3 years of age. Sleep-related eating disorder occurs when a person eats while sleeping but has no recollection of eating in the morning. It can occur during sleepwalking and those affected can gain weight and experience injury either from cooking in their sleep or eating potentially dangerous raw food. They may also exhibit signs of sleep disruption during waking hours. Parasomnias may be treated by improving sleep habits, including maintaining a regular sleep schedule; good sleep hygiene, and obtaining an adequate amount of sleep. Medication may be used to control symptoms if the behaviors associated with the parasomnia cause a risk for injury to or disrupt the sleep of the patient or another person (NSF, n.d.h).

anxiety

o The most common human response to stress is anxiety. Anxiety is a vague, uneasy feeling of discomfort or dread, the source of which is often unknown or nonspecific. It is also a feeling of apprehension caused by anticipating a perceived danger. Anxiety is experienced at some time by all people and can involve a person's body, self-perceptions, and social relationships. Anxiety is a sign that alerts you to impending danger and enables you to take measures to manage a threat (North American Nursing Diagnosis Association [NANDA] International, 2018). In contrast, fear is a feeling of dread in response to a known threat. · Anxiety is often present before new experiences, such as starting college or beginning a new job, which may be perceived as a threat to a person's identity and self-esteem. The four levels of anxiety are mild, moderate, severe, and panic; each level has different effects. At a mild level, anxiety can have a positive effect; for example, mild anxiety about an upcoming examination can motivate a student to do the required reading and review. Anxiety beyond that level is generally negative and has unpleasant effects. In an attempt to neutralize, deny, or counteract the anxiety, the person develops individual patterns of coping.

suicide prevention

· A 2016 New York Times article (Tavernise, 2016) reported that the U.S. suicide rate surged to a 30-year high, with increases in every age group except older adults. The rise was particularly steep for women. It was also substantial among middle-aged Americans, sending a signal of deep anguish from a group whose suicide rates had been stable or falling since the 1950s. Causative factors linked to the increase in suicides include economic recession, increased drug addiction, "gray divorce," increased social isolation, and the rise of the Internet and social media. · What are our obligations to prevent suicide? It can be difficult for nurses to discern when someone is freely and knowingly choosing to end his or her life and when a genuine mental health crisis is operative. Mental Health First Aid USA teaches the risk factors and warning signs for mental health crises and discusses additional concerns and strategies for helping someone in both crisis and noncrisis situations. It focuses on a five-step action plan that you can remember with the acronym ALGEE: Assess for risk of suicide or harm Listen nonjudgmentally Give reassurance and information Encourage appropriate professional help Encourage self-help and other support strategies. · Visit the Mental Health First Aid USA website (https://www.mentalhealthfirstaid.org) to access valuable resources for frontline caregivers.

POLST

· A Physician Order for Life-Sustaining Treatment form, or POLST form, is a medical order indicating a patient's wishes regarding treatments commonly used in a medical crisis. Because it is a medical order, a POLST form must be completed and signed by a health care professional and cannot be filled out by a patient. These forms are always completed in close consultation with the patient to ensure that the patient's values and goals of care are accurately represented. These brightly colored forms (see the POLST website, www.polst.org) always remain with the patient, regardless of whether the patient is in the hospital, at home, or in a long-term care facility. See Box 43-3 for a description of the differences between an advance directive and POLST form. POLST forms are not available in every state. In some states, such as Maryland, they are called Medical Orders for Life-Sustaining Treatment forms, or MOLST forms. Advance Directive · For anyone 18 and older · Provides instructions for future treatment · Appoints a Health Care Representative · Does not guide Emergency Medical Personnel · Guides inpatient treatment decisions when made available Physician Order for Life-Sustaining Treatment (POLST) Form · For persons with serious illness—at any age · Provides medical orders for current treatment · Guides actions by Emergency Medical Personnel when made available · Guides inpatient treatment decisions when made available

socioeconomic

· A bereaved family may suffer more acutely if there is no health or life insurance or pension after the death of the family provider. Such families face not only the loss of a loved one, but also an economic loss that may further disrupt family life. · Older adults especially may be placed in a difficult position because the death of a spouse may result in the decrease or even elimination of a source of retirement income for the surviving spouse. This reduction in income may lead to loss of home, community, and support systems.

Preparing a Restful Environment

· A comfortable bed helps promote rest and sleep. The bottom linen should be tight and clean. The upper linen, while secure, should allow freedom of movement and should not exert pressure, especially over the legs and feet. Good body alignment is conducive to relaxation. For patients who must assume unusual positions because of their illness, ingenuity and skill are necessary to minimize muscle strain and discomfort. For example, patients who must sleep with their head and torso elevated to aid breathing should be well supported in a manner that relieves muscle strain. · A quiet and darkened room with privacy is relaxing for nearly everyone. In a strange environment, unfamiliar noises, such as people walking by or entering and leaving the room and the sounds of elevator doors, often bring complaints from patients in health care facilities. Although some of these sounds are difficult to control, make every effort to reduce disturbances and to promote relaxation and sleep. Many health care facilities have made attempts to transform their patient care areas into quieter settings that facilitate rest and sleep. Attention to design features with a focus on eliminating environmental noise, providing patients with private rooms, and formal quiet times on units all are aimed at creating a more supportive environment that is conducive to good sleep. · The temperature of the room, the amount of ventilation, and the amount of bed covering are matters of individual choice. Meet the patient's wishes when at all possible. Many older adults cannot sleep if they feel cold. Thermal blankets or comforters, insulated bed socks, cotton flannel sheets, leg warmers, long underwear, and a stockinette cap help patients stay warm and promote comfort and sleep. Refer to Focus on the Older Adult for additional suggestions.

Crisis

· A crisis is a disturbance caused by a precipitating event, such as a perceived loss, a threat of loss, or a challenge, that is perceived as a threat to self. · Crises may be maturational, situational, or adventitious. · Maturational crises occur during developmental events that require role change, such as when a teenager transitions into adulthood. · Situational crises occur when a life event disrupts a person's psychological equilibrium, such as loss of a job or death of a loved family member. · Adventitious crises include accidental and unexpected events resulting in multiple losses, and major environmental changes—such as fires, earthquakes, and floods—that involve not only individuals but also entire communities. · In a crisis, the person's usual methods of coping are ineffective. This failure produces high levels of anxiety, disorganized behavior, and an inability to function adequately. The crisis and associated anxiety initially activate the person's usual methods of coping. If these are not effective, the person experiences more anxiety because the coping mechanisms are not working. As the crisis continues, the person tries new methods of coping or redefines the threat. This may lead to resolution of the crisis or, if not effective, may result in severe or panic levels of anxiety. The crisis is more likely to be successfully resolved if the person views the event realistically, effective coping mechanisms are present, and situational support systems are available.

crisis intervention

· A crisis is a situation that cannot be resolved by usual coping mechanisms. As a result, the person cannot function normally and requires interventions to regain equilibrium. Crisis intervention is a five-step problem-solving technique (similar to the nursing process) designed to promote a more adaptive outcome, including improved abilities to cope with future crises. The steps are as follows: Identify the problem. This may be more difficult than it appears, as the cause of the crisis is often difficult for the person to identify accurately. Until it is clear, a solution is impossible. List alternatives. All possible solutions to the problem need to be listed. An appropriate solution to a problem is much more likely if many options are considered. Choose from among alternatives. Each option needs to be carefully considered, using a "what would happen if" approach. The alternative chosen will be highly individualized, based on the person's priorities and values. Implement the plan. The alternative chosen is put into action. The nurse may need to provide support and encouragement so that action is taken. Evaluate the outcome. In this final step, the effectiveness of the plan needs to be carefully considered. If it did not work as well as expected, another alternative should be tried. If it did work, it has the positive benefit of improving self-confidence and future problem-solving efforts. · The major factor in helping patients adapt to high levels of stress is to identify and plan individually for situations causing the stress. Maintaining immediate safety is a priority. Facilitate the patient's recognition of his or her own stress level and specific responses to stress. Encourage adoption of a philosophy of accepting what cannot be changed and changing what cannot be accepted. Emphasize the importance of accepting help from others and giving support to others when needed, as well as being actively involved in problem solving and decision making. · Nurses must use therapeutic communication skills in all interactions, but must be especially cognizant of their words and actions in a crisis situation. Nurses should also keep in mind that a crisis can occur with a group as well as with an individual.

motivation

· A desire to be wakeful and alert helps overcome sleepiness and sleep. For example, a tired person may be wakeful and alert when at a party or when attending an interesting play or concert. · The opposite is also true: When there is minimal motivation to be awake, sleep generally follows. For example, a student who is bored and disinterested in a lecture or class may doze during the lecture.

good death

· A good death is one that allows a person to die on his or her own terms, relatively free of pain, and with dignity. It is free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients' families' wishes; and reasonably consistent with clinical, cultural, and ethical standards (Institute of Medicine [IOM], 1997). · The characteristics of a good death vary for each patient; several important factors include control of symptoms, preparation for death, opportunity for the person to have a sense of completion of his or her life, and a good relationship with health care professionals. · The indicators for care that promotes a good death are listed in Box 43-1; although they were developed by the American Geriatrics Society (2007), they apply to people of all ages. Nurses play a critical role in focusing the health care team's attention on meeting the needs of dying people and their families. · In 2015, the IOM issued a new report, Dying in America: Improving quality and honoring individual preferences near the end of life. The IOM recommended that comprehensive care should: Be seamless, high quality, integrated, patient centered, family oriented, and consistently accessible around the clock. Consider the evolving physical, emotional, social, and spiritual needs of individuals approaching the end of life, as well as those of their family and caregivers. Be competently delivered by professionals with appropriate expertise and training. Include coordinated, efficient, and interoperable information transfer across all providers and all settings. Be consistent with individuals' values, goals, and informed preferences Providing Care to Facilitate a Good Death Although death occurs at any age, the probability of death increases as a person grows older. These selected statements from The American Geriatrics Society Ethics Committee provide guidance for all health care providers in providing excellent care for dying patients of any age. · The care of the dying patient should be guided by the values and preferences of the individual patient. Independence and dignity are central issues for many dying patients, particularly in older adults. Maintaining control and not being a burden can also be relevant concerns. · Palliative care of dying patients is an interdisciplinary undertaking that attends to the needs of both patient and family. · Care for dying patients should focus on the relief of symptoms, not limited to pain, and should use both pharmacologic and nonpharmacologic means. · Physicians and other health care professionals, at all levels of training, should receive in-depth, insightful, and culturally sensitive instruction in the optimal care of dying patients. · Adequate funding for research on the optimal care of dying patients is essential to improving end-of-life care.

· Advocating Sexuality Needs of Patients

· A hospital experience or institutionalization puts a strain on a person's individuality and sexual self. Illness may diminish feelings of sexual desire, and the desire for sexual interaction can signal a patient's improving health. The nurse should provide anticipatory guidance because many patients may hesitate to request help for fear of being ridiculed. Often, a patient merely desires privacy to hold and caress his, her, or their partner. The intimacy of this act often fulfills the patient's feelings of longing to be needed and loved. · There are many ways to advocate for a patient's sexual needs (Box 45-4). Some may seem obvious and commonplace, whereas others may first require coming to terms with your own sexuality. All patients should be accepted as sexual beings with the right to be treated with dignity and with sensitivity to their feelings. All patients have the right to some degree of privacy. Anticipate the patient's desire for privacy by the simple act of drawing a curtain or closing a door. Give patients the option of wearing their own sleepwear to promote sexual identity. Anticipate potentially shaming situations for the patient. Give information regarding the procedure and why it needs to be done, and acknowledge that the patient's embarrassment is normal and understandable. Health care providers should not simply take for granted that patients do not mind intrusive or embarrassing procedures performed on their bodies and private parts. Patients have a right to question the heath care provider regarding sexual needs or future sexual functioning. Anticipate these questions for the patient. Ask patients if they have any concerns regarding sexuality that can be answered by the nurse. Interface with the health care provider to obtain information required by the patient. The atmosphere in health care settings needs to allow for sexual expression between patients and their partners. Confidentiality is a right of every patient. Do not promise confidentiality if that promise cannot be kept. Do not allow anyone not directly involved with the patient's care access to a patient's personal records. Allow no information regarding patients to escape into idle conversation. Patients should be referred to formally as Mr., Mrs., Miss, or Ms., according to the patient's preference. Use patient-preferred pronouns. Patients should be allowed to keep some personal possessions, if it is practical to do so.

Offering Supportive or Healing Presence

· A nurse's gift of supportive presence must underlie all other types of intervention to meet the patient's spiritual needs. The aim of this intervention is to create a hospitable and sacred space ("holy ground") in which patients can share their vulnerabilities without fear. Supportive presence communicates value and respect (Fig. 46-4). Chapter 8 presents basic communication skills helpful in establishing this type of presence. Box 46-2 outlines helpful steps for nurses intent on developing the art of healing presence. · The patient who senses that the nurse is sincerely concerned and committed to helping meet human needs is better able to participate in the care plan. Patients who experience respect and affirmation from other humans find it easier to hold spiritual beliefs that meet their needs for meaning and purpose, love and relatedness, and forgiveness.

· Teaching About Rest and Sleep

· A well-informed person is better able to cope with distressing situations. Teach patients and their families about the nature of rest and sleep and their importance to well-being. For example, the fact that children and adults are getting less sleep has been implicated as a contributing factor to the obesity epidemic in the United States. This information appears to verify that lack of sleep affects not just the brain, but also the entire body (see Physical and Psychological Effects of Insufficient Sleep). · Also teach patients about normal variations in sleep patterns and common measures to promote relaxation and sleep (Teaching Tips 34-1). Discuss sleep hygiene recommendations with the patient. Sleep hygiene refers to nonpharmacologic recommendations that help a person get a better night's sleep. These entail reviewing and changing lifestyles and environment. Sleep hygiene suggestions include the following: Restricting the intake of caffeine, nicotine, and alcohol, especially later in the day Avoiding mental and physical activities after 5 PM that are stimulating Avoiding daytime naps Eating a light carbohydrate/protein snack before bedtime Avoiding high fluid intake in the evening so as to minimize trips to the bathroom during the night Sleeping in a cool, dark room Eliminating use of a bedroom clock Taking a warm bath before bedtime Trying to keep the sleep environment as quiet and stress-free as possible (Hedges & Ruggiero, 2012) · Stimulus control involves using the bedroom for sex and sleep only. People with insomnia who have problems initiating sleep should stay in the bedroom for only 15 to 20 minutes. If after this time they cannot fall asleep, they should leave the room and return only when they feel sleepy. Getting up at the same time every day, no matter what time the person fell asleep, and refraining from napping during the day are recommended. · Sleep restriction is based on the theory of limiting the time in bed to actual sleep time. It is thought that excessive time in bed may result in fragmented sleep, which may exacerbate the insomnia. A sleep diary helps to determine sleep patterns. The focus of sleep restriction is to avoid naps and early bedtimes and actually change the way a person sleeps. · Relaxation therapy involves any type of relaxation, such as progressive muscle relaxation, imagery training, or meditation. Not all relaxation methods are beneficial for all patients. Relaxation therapy and biofeedback are discussed in detail in Chapter 42. Discuss the plan of care with the patient to make sure that the patient deems it acceptable. If a sleep disorder becomes a problem and common nursing measures are inadequate, the nurse may need to refer the patient to a health practitioner with the expertise to deal with it.

personal factors

· Adaptation to stress, whether positive or negative, is influenced by a number of personal factors. A person's physiologic reserve and genetic inheritance are important in maintaining homeostasis and adapting to stressors. · The ability to adapt is lower in the very young, the very old, and those with altered physical health who do not have the necessary physiologic reserves to cope with physical changes such as dehydration or fluid excess. · Adequate nutrition and sleep are necessary for enzyme function, immune responses, wound healing, and energy production and restoration. · Malnutrition, dietary deficits or excess, and sleep deprivation all impair a person's ability to adapt to stress. · People with mental health issues may lack adaptability and flexibility because their resources, both internal and external, are already dedicated to maintaining balance; a new stressor can send them into crisis. Social factors and life events also affect a person's adaptation to stress. · People who have strong support systems and relationships better able to adapt to stress and remain healthy.

caring for the family

· After a patient has died, the nurse provides support and care to the patient's family (see Through the Eyes of a Student). In most cases, this involves listening to the family's expressions of grief, loss, and helplessness. Because comforting words are often difficult to find, offer solace and support by being an attentive listener. Family members may need to see the patient's body to accept the death fully; in such cases, arrange for family members to view the body before it is discharged to the mortician. · Sudden death creates unique problems for the family. In the case of sudden injury or illness, the physical needs of the patient are paramount to the health care team. This means that family members are not provided as much emotional support or information as they would be if the patient's illness were prolonged, nor are they permitted to exercise as many options regarding the patient's care. The family that loses a member unexpectedly has not had an opportunity to begin the grieving process or to share in grieving with the deceased person. Allow family members to express grief and provide emotional support. Often the family is in the emergency department waiting room when death is confirmed. They are stunned, bewildered, and numb. Do not rush them from the waiting room, but rather provide them with a private place to begin their grieving. Acknowledge their shock and listen to their grief. The family needs guidance in making plans and help in making decisions. · It is appropriate for the nurse who was caregiver or who took care of the patient for a prolonged period to attend the funeral. It also is appropriate for the nurse to make a follow-up call to the patient's family after the funeral or memorial service to offer both concern and care for the family's well-being. Follow-up visits are important to give support to the family. If the nurse assesses that the family is not coping well, appropriate referrals should be made. If the patient was cared for by a hospice, the family is offered grief support for up to a year following the death.

CARING FOR THE BODY

· After the patient has been pronounced dead, the nurse is responsible for preparing the body. The body is placed in normal anatomic position to avoid pooling of blood, soiled dressings are replaced, and tubes are removed. In most cases, it is unnecessary to wash the body; the mortician normally attends to this. Some religions strictly forbid washing of the body, whereas in others a special person must perform it. In cultures in which the family's washing of the deceased's body is considered the last service a family can give a loved one, the family should be given the necessary supplies and left alone in the room with the body. If an autopsy is to be performed, any tubes that were in place should not be removed. In such cases, the nurse should follow the facility's policy. · The nurse is legally responsible for placing identification tags on either the shroud or garment the body is clothed in and on the ankle to ensure that the body can be identified even if it is separated from its shroud. The nurse also places an identification tag on the patient's dentures or other prostheses to ensure that the mortician receives these. The importance of proper and complete identification cannot be overemphasized. The patient's body may be placed in the hospital's morgue refrigerator if mortuary arrangements were not made before the patient's death. If the patient died of a communicable disease, the body may require special handling to prevent the spread of disease. Requirements for such handling are usually specified by local laws and depend on the disease-causing organism, mode of transmission, and other characteristics.

Explaining the Patient's Condition and Treatment

· All involved health care personnel should know exactly what the patient and family have been told. Conflicting information puts the nurse and other team members at cross-purposes and causes the family to distrust the patient's caregivers. Because patients and families often direct questions about the patient's prognosis to the nurse, the nurse should take the initiative in ensuring that terminology, prognosis, and the description of the progress are consistently presented and explained. · Explain the patient's condition and treatment to both the patient and the family. Patience is required during explanations. The patient and family members may be so overwhelmed by the diagnosis that they do not hear all the information that is shared with them. Question them to learn how much they have retained, then repeat the information they missed. Explain care options, as well as the expected outcomes of each option, fully. · Sadly, many health care professionals do not embrace "good dying" as a legitimate aim of medical and nursing care. As a result, the dying of many patients is painfully prolonged because no one initiates a patient or family conference to clarify the treatment goals when cure is no longer an option (see Promoting Health Literacy on page 1706 in Caregivers of Terminally Ill Patients). The nurse plays a key role in helping the patient and family prepare for a comfortable and dignified death. Here, the primary focus is palliative, such that the patient and family accept that death is inevitable and now focus on how to spend the remaining days. For some, this means a referral to hospice or a palliative care program. Nurses play an important role in ensuring that timely prognostic information is given to patients and families so that they can decide how to spend their last days together. Some patients want to "die fighting" and will insist on intensive, life-sustaining treatment until every system fails. Others will choose not to have further treatment and will want to spend their last days in a comfortable setting (see the Research in Nursing box on page 1706). See the Care Coordination Checklist (Box 43-7 on page 1707) for helpful hints on person-centered care at the end of life.

childbearing

· All sorts of questions surround childbearing, and the ability (or lack of ability) to procreate can put great pressure on a sexual relationship: Are we ready to be parents? What does it mean to be a responsible parent—especially in this age when an increasing number of prenatal interventions are available to maximize fetal outcomes (i.e., "quality control")? Should we choose life partners only if genetic testing reveals a good match for reproduction? If we choose to be sexually active and not have children, what are the best means to prevent unwanted pregnancies? If we become pregnant and choose not to continue the pregnancy, what are our options? If we desperately want a child and discover one or both to be infertile, what are our options? T · he age of biotechnology promises "designer babies" and raises difficult questions for individuals and society. People frequently look to nurses for help in sorting through how to respond to these challenges. · Experienced nurses are good at detecting when a fear of pregnancy or inability to conceive is interfering with a couple's normal sexual expression, or when a changing developmental stage (e.g., menopause) is interfering with normal sexual expression.

autopsy

· An autopsy is an examination of the organs and tissues of a human body after death. Consent for autopsy is legally required. The closest surviving family member or members usually have the authority to give or refuse consent. Some religious groups prohibit autopsies except for legal purposes. · It is usually the health care provider's responsibility to obtain permission for an autopsy. Sometimes the patient may grant this permission before death. The nurse can assist by explaining the reasons for an autopsy. Many relatives find comfort when they are told that the knowledge gained from an autopsy may contribute to advances in medical science as well as establish the exact cause of death. · If death is caused by accident, suicide, homicide, or illegal therapeutic practice, the coroner must be notified according to law. The coroner may decide that an autopsy is advisable and can order that one be performed, even if the patient's family has refused consent. In some cases, a death that occurs within 24 hours of admission to the hospital must be reported to the coroner.

anitcipatory guidance

· Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. Nurses use this technique when they teach patients about procedures and the surgical experience. When patients know what to expect, their anxiety is reduced and their coping mechanisms are more effective. For example, before performing a painful procedure (such as ambulating for the first time after surgery), teaching would include information about the pain involved, including onset, severity, cause, and methods of relief. With this knowledge, the patient feels less threatened and tolerates the procedure more easily. · A related process is anticipatory socialization, in which people prepare themselves for roles to which they aspire but do not yet occupy. This process may be used, for example, to prepare expectant parents for the role of parenting, thereby enhancing the potential for the child to experience normal growth and development.

Coping mechanisms

· Anxiety is often managed without conscious thought by coping mechanisms, which are behaviors used to decrease stress and anxiety. Many coping behaviors are learned, based on a person's family, past experiences, and sociocultural influences and expectations. As illustrated in the list that follows, coping behaviors may be positive or negative in terms of how they affect health. Typical coping behaviors include the following: Crying, laughing, sleeping, cursing Physical activity, exercise Smoking, drinking Lack of eye contact, withdrawal Limiting relationships to those with similar values and interests · Moderate, severe, and panic levels of anxiety are greater threats and involve more complex coping mechanisms as the person strives to reduce the stress and anxiety. Coping mechanisms often used at higher levels of anxiety are categorized as task-oriented reactions. Task-oriented reactions involve consciously thinking about the stress situation and then acting to solve problems, resolve conflicts, or satisfy needs. These reactions include attack behavior, withdrawal behavior, and compromise behavior. · Attack behavior occurs when a person attempts to overcome obstacles to satisfy a need; it may be constructive, with assertive problem solving, or destructive, with feelings and actions of aggression and hostility. Withdrawal behavior involves physical withdrawal from the threat, or emotional reactions such as admitting defeat, becoming apathetic, or feeling guilty and isolated. Compromise behavior is usually constructive, often involving the substitution of goals or negotiation to partially fulfill needs.

culture

· As a child internalizes the values of parents and peers, culture begins to influence a sense of self. If the culture is relatively stable, little tension may be experienced between what culture expects of the child and what the child expects of self. When parents, peers, and the adult world confront the child with different cultural expectations, however, the sense of self may become confused. · For example, an adolescent might realize his or her parents live by the work ethic and believe it is necessary to rise early every day and put in a full day's work. That adolescent's peer group, however, has few demands placed on it and encourages the adolescent to hang out with the group. The adolescent's vocational aptitudes, meanwhile, are leading him or her to consider a music career in a rock group, which will keep the adolescent out late many nights doing something the parents do not classify as work. · Children of immigrants whose values and practices of their culture of origin vary from the culture of adoption face cultural dissonance. Parents may expect children to behave according to their own cultural norms, whereas peers and society, as well as the adolescent's wish to "belong," may create the desire to abandon old cultural beliefs, attitudes, and practices. Conflict between parents and children, as well as cultural confusion, may occur.

· Offering Appropriate Bedtime Snacks and Beverages

· As discussed earlier in the chapter, combining foods that are high in tryptophan with healthy, complex carbohydrates improves sleep (NSF, n.d.d). As a result, there appears to be justification for offering a snack that contains a protein and a carbohydrate before bedtime, if this is allowed in the patient's treatment regimen. An alcoholic beverage helps to promote sleep for some people. However, alcohol after dinner generally should be avoided because it may interrupt the normal sleep cycle and interfere with deep sleep. For most patients, beverages containing caffeine should be avoided for at least 4 to 5 hours before bedtime. Recommend that the patient take fluids during the day but avoid excessive fluid intake before bedtime to prevent the need to use the bathroom during the night.

Voluntary Cessation of Eating and Drinking

· As seriously ill, competent patients make end-of-life treatment decisions, they may also choose to refuse food and fluid with the intention of hastening death. · It is important to distinguish the voluntary act of a patient who is still capable of eating and drinking, making the decision to refuse food and fluids from the natural anorexia and loss of thirst that frequently accompany the end stages of dying. · While some consider refusal of food and fluid to be a form of suicide, others view this as a decision to forego life-sustaining treatment. · When nurses care for patients who want to refuse food and fluids, they must ensure that this is an informed and voluntary choice and remember that honoring this preference requires the support of the family, physician, and health care team who focus on palliative measures as the dying process unfolds (Quill & Byrock, 2000, p. 410).

assessment

· Assessment Priorities · • Patient and family's understanding of medical condition, prognosis, and dying process · • Patient and family's attitude toward death and dying and knowledge of the dying process · • Patient's preferences for end-of-life treatment and care, such as desire to be at home or in a hospital, and decisions concerning treatment, resuscitation, advanced life support, organ donation, and so forth · • Documented evidence of advance care planning · • Existence of an advance directive (It is critical that the authorized decision maker be known to all members of the health care team.) · • Religious beliefs · • Cultural influences · • Stage of grief and death reaction · • Adequacy of coping behaviors · • Adequacy of resources · • Physiologic needs of the patient, for example, personal hygiene, pain control, nutritional and fluid needs · • Psychological needs of the patient and family, for example, fear of the unknown, pain, separation · • Spiritual needs of the patient and family: need for meaning and purpose, for love and relatedness, for forgiveness, for hope · Factors to AssessQuestions and Approaches · Adequacy of knowledge base · What have you been told about your condition? What do you know about this condition? Please describe what you have been told about your treatment options. Is there anything you don't understand about what your doctor is recommending? What else would you like to know about your present condition and treatment options? Do you know how to contact your doctor and to get the information you need or desire? OBJECTIVE: to identify whether or not the patient's and family's knowledge will allow them to make informed decisions that will serve their best interests. · Realism of expectations and perceptions · Have you had any previous experiences with this condition or with the death of someone you love? What are your expectations in this case? How do you see the next few weeks (days) playing out? What are your fears, hopes, concerns, worries? What good do you think might be happening in the midst of all this? OBJECTIVE: to discover whether the patient and family have unrealistic expectations or misperceptions about the diagnosis, prognosis, and care options that will interfere with their decision making and coping. · Adequacy of coping strategies · Dealing with our own dying is a once-in-a-lifetime experience, and sometimes we begin the process feeling totally unprepared. Tell me something about how you think you are coping with all this. How well do you think those around you are coping? How can I help you develop or tap the resources that will help you to cope better? OBJECTIVE: to identify whether the patient and family are using effective coping strategies. If you detect problems, try to identify coping strategies they have used effectively in the past. Also, identify and address destructive habits that have not served them well in the past such as addictions, destructive relationships, passivity, and acting out. Creatively problem solve about new strategies they might try. · Adequacy of resources · What is helping you to get through this? Do you think the resources available to you are adequate? If the sky was the limit, what help would you wish for? What is interfering with your getting the help you need? What community resources might be of help to you? Are you using these? OBJECTIVE: to assess the adequacy of the human, financial, spiritual, and psychological resources available to the patient. Questions should be directed to determining what, if anything, is interfering with the patient using whatever resources are available to facilitate coping. · Physical response · A physical assessment of the patient and the patient's family and caregivers should be performed. OBJECTIVE: to detect problems with coping that result in fatigue, decreased energy, decreased self-care (deficient grooming, unplanned weight loss), and other maladaptive responses.

· Conflict Resolution Strategies

· Avoiding: There is awareness of the conflict situation, but the parties involved decide to either ignore the conflict, or avoid, or postpone its resolution. The conflict has not been resolved and may resurface later in an exaggerated form. · Collaborating: This is a joint effort to resolve the conflict with a win-win solution. All parties set aside previously determined goals, determine a priority common goal, and accept mutual responsibility for achieving this goal. This focus on problem solving is based on mutual respect, honest communication, and shared decision making. · Competing: This approach results in a win for one party at the expense of the other group. This win-lose confrontation can leave the loser frustrated, with a desire to "get even" in the future. This strategy may be used when one party has more knowledge regarding the situation, or when resistance is appropriate because of ethical concerns or unsafe patient care practices. · Compromising: For this technique to be effective, both parties must be willing to relinquish something of equal value. If that does not occur, either or both parties may feel that they have lost the conflict and given up more than the other group. · Cooperating/Accommodating: One party makes a conscious decision to let the other group win and may collect an "IOU" for use in the future. This party's original loss may result in a more positive outcome in the future. · Smoothing: Smoothing is an effort to compliment the other party and focus on agreement rather than disagreement, thus reducing the emotion in the conflict. The original conflict is rarely resolved with this technique.

physologic indicators of prolonged stress

· Backache or stiff neck · Chest pain · Constipation or diarrhea · Decreased sex drive · Dilated pupils · Dry mouth · Headache · Increased urination · Increased perspiration · Increased pulse, blood pressure, and respirations · Nausea · Sleep disturbances · Weight gain or loss

history

· Because a person's spirituality and religious beliefs can influence every aspect of being, an assessment of the patient's spirituality—including beliefs and practices, the effect of these beliefs on everyday living, spiritual distress, and spiritual needs—should be included in each comprehensive nursing history. However, nurses often need guidance in assessing spirituality in their patients, and in providing spiritual care; the accompanying Research in Nursing box highlights two studies related to spiritual care. Many guides are available for eliciting a spiritual history, such as those from O'Brien (1982), Shelly and Fish (1988), and Puchalski and Romer (2000). One simple guide is Anandarajah and Hight's (2001) HOPE acronym: H—Sources of Hope, meaning, comfort, strength, peace, love, and connection O—Organized religion P—Personal spirituality and practice E—Effects on medical care and end-of-life issue · Sample questions are listed in the Focused Assessment Guide 46-1. · If the patient reveals a spiritual problem, use interview questions to determine the specific nature of the problem, its probable causes, its related signs and symptoms, when it began and how often it occurs, how it affects everyday living, its severity and whether it can be treated independently by nursing or needs to be referred, and how well the patient is coping.

Nursing Observation

· Because many patients find it difficult to talk about their spiritual beliefs and problems, also observe the patient's behavior for signs of spiritual distress. A family member or close friend may share significant observations: "He's been awfully moody since his heart attack. I can't believe how hopeless he seems now." "I've never seen my father so depressed. He's never in his life been away from the synagogue at Passover. I don't know how to help him." · Significant behavioral observations include sudden changes in spiritual practices (rejection, neglect, fanatical devotion), mood changes (frequent crying, depression, apathy, anger), sudden interest in spiritual matters (reading religious books or watching religious programs on television, visits to clergy), and disturbed sleep. If you observe these behaviors, you should follow up with appropriate interview questions. · Often, problems with spiritual distress do not surface until well after a patient's admission history and examination. Effective questions include the following: "You've been lying there so quietly. What are you thinking about?" "After all you've been through, you must have done a good bit of soul searching. Experiences like these are enough to shake anyone's faith—how is yours holding up?"

caring for patient

· Because nurses in institutional settings often provide care to more than one patient at a time, after the death of one patient, the nurse must continue to provide care to the other patients. Other patients are often aware of a death and may need to be consoled; this is particularly true of a patient who has shared a room with the deceased patient. Other patients may have grief reactions and should be supported through the grief process. Death of a patient may cause depression in other patients and may make them more aware of their own future deaths.

body image

· Body image is the person's subjective view of his or her physical appearance. Body image disturbances can be expected with any alteration in bodily appearance, structure, or function. · When a disturbed body image is suspected, carefully interview and observe the patient to identify the nature of the threat to the person's body image (functional significance of the part involved, importance of physical appearance, visibility of the part involved), the meaning the patient attaches to the threat, the adequacy of the patient's coping abilities, response of family members and significant others, and help available to the patient and patient's family. · Assess the patient's response to the deformity or limitation, including changes in independence-dependence patterns and in socialization and communication.

Resolving Conflicts Between Spiritual Beliefs and Treatments

· Both the patient and members of the patient's family may experience conflict between a particular spiritual belief or religious law and a proposed medical treatment or health option. · The patient may want assistance when conferring with the spiritual adviser about a particular procedure. · The nurse's role is to help the patient obtain the information needed to make an informed decision and to support the patient's decision making. Because what the nurse says and the way it is said may powerfully influence the patient's decision, it is important to maintain objectivity. Conflicts that resist resolution may be referred to an ethics committee or consult team (see Chapter 6).

change

· Change is the process of transforming or modifying something. It might be a planned change, and unplanned change, a developmental change, or, as Porter-O'Grady and Malloch (2003) suggested, a quantum change and ever present. · Nursing and the health care system are continually changing and evolving—that momentum will only escalate in the years to come. · Factors such as the increasing number of chronically ill and older people, the increasing role of government and industry in health care, the rising cost of health care, and the changing patterns of health care delivery have produced a need for innovation and change in health care. · Patient care safety and quality issues play a vital role in the transformation occurring in the health care system. · Nurse managers, once they have assessed the need for change, function as visionary, assertive, and supportive role models in the implementation of the planned change.

Developmental Considerations

· Children do not understand death on the same level as adults do, but their sense of loss is just as great. Both terminally ill children and their siblings are likely to talk about and ask questions about death in an attempt to understand it. Terminally ill children require parental love and support as well as social interaction with other children. Death of a parent or another significant person can retard a child's development or may cause the child to regress developmentally. Children need to go through the same grief reactions as adults to accept such a loss and maintain emotional well-being. · The loss of a parent by a middle-aged adult helps to prepare the adult for the loss of a spouse or significant other and to accept his or her own eventual death. Older adults may lose a spouse or friends and relatives their own age. As this happens, they reminisce about life, put their lives and the purpose of living in perspective, and prepare themselves for their own inevitable death.

RELIGION AND LAW, ETHICS, AND MEDICINE

· Christian Scientists, Jehovah's Witnesses, and members of certain faith-healing groups are among those challenging the intricate web of rights and responsibilities that links people, society, church, and state. · These religious bodies are asking for protection, under the umbrella of religious freedom, of the believer's right to exercise individual decisions in accordance with scriptural interpretations, even though those decisions may result in a person's own death or that of a family member, including a child. Most troubling are those cases in which treatable problems, such as bacterial meningitis, diabetes, or bowel obstruction, resulted in the death of minors whose parents choose religious means of healing over traditional medicine. (See Focused Critical Thinking Guide 46-1 on page 1802.) The American Academy of Pediatrics urges that all child abuse, neglect, and medical neglect statutes be applied without potential or actual exemption for religious beliefs. · Perhaps even more troubling for nurses are situations in which family members insist on painful care that is deemed medically futile (i.e., the likelihood of medical benefit is virtually nonexistent) because they believe that God is going to work a miracle. · In these cases, simple nursing measures, such as turning or bathing patients, can become occasions of pain and torment to both the patient and nurse. Nurses are forced to administer care that they take to be cruel and abusive to patients capable of experiencing pleasure and pain. This nursing care can needlessly prolong a patient's painful dying. · Unfortunately, there are no clear guidelines for drawing a line between promoting life and prolonging the dying process. Although nurses always have the moral right to withdraw from administering care that violates their personal moral code, this does not resolve the problem for the patient. More dialogue is needed on the interaction between religion and law, ethics, and medicine. Ideally, the religious freedom of patients and their families is respected, as is the moral autonomy of caregivers and the integrity of the healing professions. Nurses in these situations should seek the assistance of the ethics committee or ethics consultation service.

sleep wake disorders

· Circadian rhythm sleep-wake disorders are characterized by a chronic or recurrent pattern of sleep-wake rhythm disruption primarily caused by an alteration in the internal circadian timing system or misalignment between the internal circadian rhythm and the sleep-wake schedule desired or required; a sleep-wake disturbance (e.g., insomnia or excessive sleepiness); and associated distress or impairment, lasting for a period of at least 3 months (except for jet lag disorder) (Sateia, 2014). There are several disorders within this group of sleep disorders, with the most common being shift work disorder and jet lag disorder. · Shift work disorder results from working on a schedule that goes against the body's natural circadian rhythm, outside the traditional 0900 to 1700 day. A constant or recurrent pattern of sleep interruption caused by difficulty adjusting to the different sleep and wake schedule results in difficulty sleeping or excessive sleepiness (Cleveland Clinic, n.d.a). Many industries and other occupations and professions rely on shift work, including nursing. The work schedule of shift workers may prevent attainment of sufficient sleep (NSF, n.d.g). Shift workers are more likely to sleep fewer than 6 hours on workdays and experience drowsy driving at least once a month (NSF, n.d.g). Not all shift workers experience sleep issues, but approximately 25% to 35% of shift workers experience symptoms of the disorder, including excessive sleepiness or insomnia. In addition, shift work has been linked to problems with physical and mental health, performance, accidents, work-related errors, increased irritability or mood problems, and safety (Cleveland Clinic, n.d.a; National Safety Foundation, n.d.g). · Jet lag disorder results from a conflict between the pattern of sleep and wakefulness between the internal biologic clock and that of a new time zone (Cleveland Clinic, n.d.b). This temporary disorder occurs as a result of travel across time zones, producing difficulty adjusting and functioning optimally in the new time zone. Symptoms of jet lag include daytime fatigue, an unwell feeling, difficulty staying alert, and gastrointestinal problems · Treatment for circadian rhythm sleep-wake disorders varies based on the type of disorder and the degree to which it affects a person. Behavior therapy includes maintaining regular sleep-wake times, avoiding naps, keeping to a regular exercise routine, and avoiding caffeine, nicotine, and stimulating activities within several hours of bedtime (Cleveland Clinic, n.d.b). Light therapy helps ease the transition to a new schedule or time zone. It involves exposing the patient's eyes to an artificial bright light that simulates sunlight for a specific and regular amount of time during the time the person should be awake (The Mayo Clinic, 2016). Chronotherapy requires a commitment on the part of the patient to act over a period of weeks to progressively advance or delay the time of sleep for 1 to 2 hours per day. Over time, this results in a shift of the sleep-wake cycle (Cleveland Clinic, n.d.b).

hope

· Closely related to spirituality, faith, and religion, hope is the ingredient in life responsible for a positive outlook, even in life's bleakest moments. It enables a person both to consider a future and to work to actively bring that future into being. · Hope originates in imagination but must become a valued and realistic possibility in order to energize action. · Hope allows a person to embrace the reality of suffering without escaping from it (false hope) or being suffocated by it (despair, helplessness, hopelessness). Hope is unique to each person. Box 43-6 on page 1705 contains a set of suggestions, developed by an interdisciplinary team, for enabling hope in the terminally ill that can apply to any situation in which people feel hopeless (Creen, 2002).

Developing Trusting Nurse-Patient and Nurse-Family Relationships

· Communication is a lifelong need up to the moment of death and should be maintained at all times with the patient and family. To develop meaningful communication, the nurse must develop a trusting relationship with the patient. The nurse needs listening skills and the ability to recognize both verbal and nonverbal cues given by the patient and family. These skills are discussed in Chapter 8. · Be willing to discuss the patient's fears and doubts openly and to serve as a nonjudgmental listener. However, talking with dying patients is often difficult. The following observations and suggestions by Rancour (2008 personal communication) are helpful: Often, when patients initiate conversations about dying, you may feel unprepared for their questions. They can take you by surprise, and can often lead you to believe that the patient expects a crystal ball response. Remember that the purpose of all such discussions is to keep the lines of communication open with the patient. The idea is to keep the subject of dying open to discussion and to communicate to the patient that it does not make you afraid to talk about it. An open-ended statement, such as, "Tell me what concerns you the most," provides a means of encouraging communication. Some patients may be too fearful to ask health care providers questions about dying. They often approach staff whom they perceive as less intimidating or more approachable. The question often comes in the middle of the night, when there are no distractions, when anxiety or pain may keep the patient awake, and when the patient may feel most alone with psycho-spiritual distress. In any case, it is often on the nurse's watch when questions about dying may arise. Because of the surprising nature of such questions, you may feel tempted to escape ("I've got to go take that patient's vital signs right now ..."), or pass the buck ("That sounds like a question for your doctor."). Be vigilant to prevent such reactions, keeping in mind that avoidance would only help reduce your own anxiety and would do nothing to assist with the patient's anxiety. It is well within the scope of your professional practice as a competent nurse to provide counseling and death education, especially when the patient asks you for it or indicates an unmet need for such information and support. When in doubt, ask a question in response, such as "What do you feel about that?" or "What have you been told already?" This will accomplish several things. It will help you regain your composure and will give you more information about what is on the patient's mind so that your intervention can be as specific and responsive to that patient as possible. Do not provide false reassurance. Remember that avoiding discussions about death robs the patient of precious time to accomplish goals that produce hope (Box 43-6). People who are dying hope for many things even when they cannot hope for a cure, such as hope for freedom from pain, to be surrounded by loved ones, and for the rest of their allotted time to be spent in meaningful pursuits. · A caring nurse feels at ease in crying with the grieving person and sharing experiences with fears, loneliness, and death. This allows the griever the freedom to express his or her deepest concerns. Nonverbal communication is equally important. A smile, holding a hand, and eye-to-eye contact are all meaningful (Fig. 43-5). The warmth behind the gesture and the honest concern of the nurse are what count. · Hearing is believed to be the last sense to leave the body; many patients retain their hearing almost to the moment of death. Demonstrate kindness and thoughtfulness by speaking to a comatose patient and encouraging family members to do likewise. Explain to the patient the nursing care being given and the people and sounds in the environment.

mind body interaction

· Consider the following examples of mind-body interaction: Tomorrow, you are scheduled to take a final examination, and you must earn a passing score to pass the course and remain in the nursing program. After being awake most of the night, you cannot swallow any food at breakfast, you have a rapid heartbeat, you are filled with feelings of apprehension, and you have diarrhea. Since his wife was killed in a car crash, Tom Green has been the sole support of his 4-year-old son, who is developmentally disabled and hyperactive. Tom has been coming to the neighborhood health clinic with increasing frequency over the past 5 months, complaining of weight loss, headaches, and stomach pain. · These examples illustrate the relationship between psychological stressors and the physiologic stress response (the GAS). In the first example, as you begin the test and discover that you know most of the answers, your stress decreases and your symptoms disappear rapidly. Tom's stress, however, is always present and is long term, increasing his risk for developing an illness. · What causes this link between psychological stressors and the physiologic stress response? Although the exact cause is not well understood, it is thought that humans react to threats of danger as if they were physiologic threats. A person perceives the threat on an emotional level, and the body prepares itself either to resist the danger or to run away from it (the fight-or-flight response). Box 42-4 lists the physiologic indicators of prolonged stress. · Each person reacts in her or his own way to prolonged stress. Some may develop chronic diarrhea, while others may develop nausea or heart palpitations. Such illnesses are real and are called psychosomatic disorders, because the physiologic alterations are thought to be at least partially caused by psychological influences. · Another component of mind-body interaction is the effect of life changes on a person. Researchers have found that the number of changes a person has in life (both positive and negative) can be correlated with illness. A life change is defined as an event in a person's life that requires energy for adaptation. When energy is expended to adapt to the event, the person's resistance to illness is lowered. For example, although a holiday celebration with family and friends is considered a positive event in a person's life, factors including the time necessary to prepare for the party, worrying about how everyone will get along, and trying to decide how much money to spend can generate stress.

cultural, biological sex, and religion

· Culture influences a person's expression of grief. In many families in the Western culture, grief is a private matter shared only with the family. As such, many people internalize their feelings of grief and may not express their feelings of loss to others. On the other hand, cultural background may necessitate that the patient's and family's public display be emotional and distressed, with loud weeping and moaning. · p. 1697 · p. 1698 · Although biological sex roles have become less differentiated in the past few decades, male and female reactions to death may differ. Whereas men are often expected to be stoic and not cry in public, women may be judged as "cold" if they do not grieve publicly. A widow who has a job may not be as emotionally distraught as a woman who needed her husband for financial and other support. Likewise, a widower who has not taken care of the children or the house may view the future more bleakly than a man who has cooked meals and changed diapers. Some ethnic traditions may be ingrained in certain people. For example, the woman may be expected to be weak and need support, whereas the man may be expected to be emotionally supportive. This varies from culture to culture and from person to person. · Faith and religious practices play an important role in the expression of grief and may provide comfort and solace to the person experiencing loss. However, some people may blame God for their suffering and the death of their loved one and turn away from God. Many people who have put spiritual matters in the background of their lives have found death to be an impetus for a return to earlier practices of religion. The thought of death also invites many to contemplate life's big questions: Is there life after death? Is there a supreme being? And if there is a supreme being, where do I stand in relationship to that being? What is the ultimate source of meaning in my life? See Chapter 46 for a discussion of spiritual care.

Advance Care Planning

· Decisions about health care are becoming increasingly complex. Patients, family members, and health care professionals are voicing frustration as they grapple with complex decisions about prolonging life. Some of the most difficult cases involve patients who are no longer able (competent) to indicate their treatment preferences. Advance care planning (ACP) is a process of planning for future care in the event a person becomes unable to make his or her own decisions. Because such events can occur in healthy people as well as in older adults or patients with serious illnesses, ACP is recommended for all adults, whatever their age or health status (Izumi, 2017, p. 57). · Two kinds of written advance directives—a living will and a durable power of attorney for health care—can minimize difficulties by allowing people to state in advance what their choices would be for health care should certain circumstances develop. Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. A durable power of attorney for health care appoints an agent the person trusts to make decisions in the event of subsequent incapacity. A combination directive is illustrated in Figure 43-3 (on pages 1692-1693). The organization Aging with Dignity offers a popular living will entitled Five Wishes (available at https://www.agingwithdignity.org) that allows people to specify the following: The person I want to make care decisions for me when I can't The kind of medical treatment I want or don't want How comfortable I want to be How I want people to treat me What I want my loved ones to know · Many methods have been suggested to ensure that adult patients have an opportunity to learn about and use advance directives to indicate their wishes about life-prolonging treatment and to appoint surrogate decision makers should they lose decision-making capacity. Nurses play an important role in facilitating this dialogue. In the United States, the Patient Self-Determination Act of 1990 requires all hospitals to inform patients about advance directives. o urses can also be instrumental in developing institutional policies that ensure that patients on admission are encouraged to talk with family, significant others, and health care professionals about their treatment preferences. Important resources for advance care planning include the National Hospice and Palliative Care Organization's CaringInfo program (www.caringinfo.org); the American Bar Association's Toolkit for Health Care Advance Planning

spiritual health and healing

· Defined most simply, spiritual health, or spiritual well-being, is the condition that exists when the person's universal spiritual needs for meaning and purpose, love and belonging, and forgiveness are met. O'Brien's conceptual model of spiritual well-being in illness (Fig. 46-2) identifies three empirical referents of spiritual well-being: personal faith, spiritual contentment, and religious practice. Spiritual healing is the movement toward integration, from brokenness to wholeness.

delegation

· Delegation involves the transfer of responsibility for the performance of an activity to another person while retaining accountability for the outcome. It is a critical competency and essential skill for an RN in today's health care environment. RNs may never delegate any elements of the nursing process itself. · The ANA, which is committed to monitoring the regulation, education, and use of UAPs, recommends adherence to eleven broad principles guiding RNs prior to delegating care (ANA, 2012b). In addition to the RN's responsibility, several principles focus on the accountability of the health care organization. Initially, the RN must be fully aware of the parameters for delegation as outlined in their state's Nurse Practice Act as well as the employing organization's policies and procedures regarding delegation (Daley, 2013). As a general rule, you should not delegate the assessment, planning, and evolution steps of the nursing process. UAPs can collect patient data but only the nurse can interpret this data. This means that professional nurses are responsible for the initial patient assessment, discharge planning, health education, care planning, triage, interpretation of patient data, care of invasive lines, administering parenteral medications. What you can delegate are assistance with basic care activities (bathing, grooming, ambulation, feeding) and things like taking vital signs, measuring intake and output, weighing, simple dressing changes, transfers, and post mortem care. Facilities are responsible for ensuring that UAPs are qualified and capable of performing nursing tasks that RNs may delegate to them. RNs should have involvement in the development of facility policies regarding delegation and also have access to any information regarding competency of the UAPs on their team. · Before the RN delegates any nursing intervention, a number of additional factors, including the qualifications and capabilities of the UAP, should be considered: (1) the stability of the patient's condition, (2) the complexity of the activity to be delegated, (3) the potential for harm, (4) the predictability of the outcome, and (5) the overall context of other patient needs (ANA, 2012b). The RN remains accountable for any delegated nursing care or outcomes and is responsible for the supervision of the UAP to whom tasks are delegated. UAPs need an awareness of any patient precautions, when to seek assistance, and what should immediately be reported to the RN. Inappropriate delegation decisions can jeopardize the safety of patients and endanger a nurse's professional practice. · Delegation skills must be developed, practiced, and strengthened. Nurse educators are encouraged by the ANA to integrate principles for delegation into the curriculum and ensure that nursing students have opportunities to practice delegation skills. Chapter 17 has additional information on delegation and the student nurse. Professional development offerings assist RNs to develop critical thinking skills that promote good judgment and provide strategies to delegate effectively. Experienced and reliable UAPs who perform delegated skills competently allow RNs to focus more on assessment and development or revision of the nursing care plan and learn skills that improve their nursing practice. The Decision Tree for Delegation by Registered Nurses distributed by the ANA is a helpful guide for nurses who are learning to delegate (Fig. 10-3). Refer to Chapter 17 for additional information on nursing delegation, including the five rights of delegation. Gradually, new nurses assume increased leadership responsibilities as they become primary nurses, case managers, or unit coordinators. An understanding of the function and organization of both the nursing department and health care organization is required to be an effective leader.

diabetes

· Diabetes mellitus (DM) is a hormonal disease in which an inadequate amount of insulin is secreted by the pancreas. Although almost all hormonal disorders affect sexuality in some way, diabetes is the most prevalent and well known. ED, or impotence, is a great concern among men with type 2 diabetes. · Treatment to date depends largely on the degree of erectile ability lost. Some men may be candidates for a penile prosthesis, which was developed in 1973. The prosthesis is surgically implanted below the base of the penis, and inflation of the device produces an erection when sexual activity is desired. Pharmacologic management (e.g., sildenafil, vardenafil, or tadalafil) may also be indicated. · Women with type 2 diabetes may also experience loss of capacity for orgasm (orgasmic dysfunction). Difficulty experiencing arousal and loss of vaginal lubrication have also been reported. Women with diabetes are more prone to urinary tract or vaginal infections, which can cause discomfort during coitus.

Teaching Self-Care and Promoting Self-Esteem

· Encourage the patient to retain independence and make decisions as long as possible. Allow the patient to manage personal hygiene practices and self-feeding for as long as possible. After the patient is confined to bed, the creative nurse and family caregivers should attempt to find self-care activities the patient can perform. When physical abilities fail, determining when to take medication, for example, may be all the control the patient can retain. · Having familiar objects in view can help make the patient feel more comfortable and secure. Whether the patient is at home or in a health care facility, it is desirable to have the environment reflect personal preferences. This gives the patient some degree of control when health and other activities of daily living have slipped out of the patient's reach. It also supports self-esteem. · In the transition from independence to interdependence and ultimately to dependence, the patient may experience depression and express frustration and grief about "being a burden." It is crucial for professional and nonprofessional caregivers to respond to the dying patient as a person of worth whose life has meaning and value. Chapter 8 discusses practical ways in which nurses can use looks, touch, words, and actions to communicate respect and caring.

Active and Passive Euthanasia

· Euthanasia literally means "good dying." Active euthanasia is taking specific steps to cause a patient's death, while passive euthanasia is defined as withdrawing medical treatment with the intention of causing the patient's death. In other words, active euthanasia is doing something to end a patient's life, whereas passive euthanasia is not doing something to preserve a patient's life. In assisted suicide (which could be considered a form of active euthanasia), the clinician provides the patient with the means to cause his or her own death (e.g., a prescription for a lethal dose of barbiturates). In active euthanasia, the clinician acts directly to cause the death of the patient (e.g., administers a lethal dose of medication). · Until recently, most societies maintained that the distinction between "killing" and "allowing to die" was morally relevant. This meant that passive euthanasia, the withholding or withdrawing of medically ineffective or disproportionately burdensome therapies, was morally and legally justified even when this hastened or directly caused a patient's death. On the other hand, making a lethal combination of drugs available to a patient wishing to die (assisted suicide) or administering a lethal injection or carbon monoxide, even when performed with compassionate intent at the request of a patient (active euthanasia), was deemed both immoral and illegal. Some are questioning this distinction today, and efforts are underway to legalize assisted suicide and active euthanasia in numerous countries. · Nurses are often the first to hear a patient's plea, "Please help me die." It is critical for nurses to reflect carefully on what they believe about assisted suicide and active euthanasia and how this influences the responses they make to patients. As of 2017, five states (Oregon, Washington, Colorado, Vermont, and California) and the District of Columbia have passed laws legalizing assisted suicide in certain limited circumstances. Laws and rulings in Montana and New Mexico are less clear but have allowed assisted suicide. If practicing in one of these states, be sure you understand your state's requirements. Talk with your classmates about your responses to the following questions and the reflection questions in Box 43-4 (on page 1696). Should the principle of respect for autonomy be expansive enough to embrace respect for, and acquiescence to, a competent patient's request for assistance in dying? Does the right to privacy entail a person's right, in effect, to decide the time and manner of his or her own death and to gain assistance in implementing that decision? Is there such a thing as rational suicide? If assisted suicide and active euthanasia were to become accepted practices, would this simply represent a logical, defensible extension of the well-established moral basis for refusal of treatment and withholding or withdrawing treatment? Are assisted suicide and active euthanasia acts of mercy, morally grounded in the principles of benefiting and not harming patients and expressive of the virtues of compassion and beneficence? Is it possible to conceive of situations in which a nurse or a health care provider has a duty to help a patient die (specifically via active euthanasia or assisted suicide)? Is refusal to accede to a patient's request for assisted suicide or active euthanasia a form of abandonment, or are there limits to the duty to respect autonomy, right to privacy, and self-determination? Are calls for assisted suicide and active euthanasia emblematic of failure to provide adequate palliative care and to address the suffering of the dying? If medicine and nursing possess an "internal" morality, are assisted suicide and active euthanasia consistent with that morality? Should assisted suicide and euthanasia be limited to those with a terminal illness with 6 months or less to live, or should it also be an option for those with intractable psychological suffering? · The ANA Code for Ethics states that the nurse "should provide interventions to relieve pain and other symptoms in the dying patient consistent with palliative care practice standards and may not act with the sole intent to end life" (2015, p. 3). Yet nurses may be confronted by patients who seek assistance in ending their lives. Unless you think through this issue carefully, you will be unprepared to respond to the request, "Nurse, please help me die."

patient care coordination

· Even new graduate nurses have leadership and coordination responsibilities when they begin nursing. Nursing leadership begins with nursing care of the individual patient. Although patients are partners in their care planning, most do not have the knowledge base and skills to direct the plan. Through interpersonal skills and effective communication techniques, nurses lead their patients to acquire new knowledge, solve problems, and change behaviors. · Managing care for even one patient can be an overwhelming responsibility for those new to nursing and its challenges. The student guide to organizing clinical responsibilities in Chapter 17 offers practical help. · An ongoing leadership challenge for all nurses is time management. The following are helpful steps for using your time effectively: Establish goals and priorities for each day. Identify what you need to accomplish each day, differentiating "need to do" from "nice to do" tasks. Be sure to include the patient and the patient's family in establishing these priorities. Ask, "What is it important for you to accomplish today?" Evaluate your goals in terms of their ability to meet the needs of the patients entrusted to your care as well as your duties to yourself and your colleagues (other students and members of the team). If one student has a patient whose care requires assistance, other students can plan their day to be able to help at a particular time. This sort of teamwork is an important element of care coordination. Establish a time line. Allocate priorities to hours in your workday so that you will recognize when you are falling behind schedule in time to correct it before the day is lost. Evaluate your success or failure in managing time. If you fail to accomplish your goals in the time available, determine whether your goals were overambitious, whether things happened beyond your control (e.g., your patient's condition worsened, requiring more care, or another student required your assistance), or whether you wasted time that could have been better spent (Fig. 10-2). Use the results of this evaluation to direct your next day's priorities and time line.

developing resilience

· Every nurse needs to be a leader to make health care work for those who need it. Nursing is often hard work, and at times the challenges can be daunting. Never has it been more important for nurses who are passionate about patients, families, and communities, as well as their own health, to be intentional about developing resilience—the capacity to thrive not only in spite of, but because of, challenges. Here are a few hints for developing resilience: Begin and end the day with gratitude. Practice mindfulness: What is the most important thing right now? See Chapter 1. Appreciate that all humans are limited; some things can't be "fixed." Appreciate the power of connectedness and presence. Stop frequently to stretch and take deep diaphragmatic breaths. Reflect frequently on what brings you joy, makes you smile. Keep a positive, hopeful outlook. Hope allows us to envision a positive future and work to bring this into being. · The authors of this text celebrate the leadership potential in every nurse and our profession's ability to be the critical difference for those in need.

family

· Family roles have an important effect on a person's reactions to and expressions of grief. For example, the eldest sibling may feel a need to "be strong" and therefore may not grieve openly; a person who loses a spouse may display the same type of behavior to "protect the children." · The death of a child is a devastating experience for the family. The family needs time to accept the reality of the situation, opportunities to talk and to be listened to, and the experience of being able to express themselves behaviorally in a nonjudgmental environment. For example, the family of a terminally ill child may express feelings of guilt by wondering if they were responsible for the impending death. A sibling may suppress a guilt feeling for having wished the ill child (or a parent) dead.

Global self

· Global self is the term used to describe the composite of all the basic facts, qualities, traits, images, and feelings people hold about themselves. These factors strongly influence a person's ability to manage life events and ensure emotional stability. A person's self-knowledge includes: basic facts (sex, age, race, occupation, cultural background, sexual orientation). the person's position within social groups. qualities or traits that describe typical behaviors, feelings, moods, and other characteristics (e.g., generous, hotheaded, ambitious, intelligent, sexy). · Although some labels cannot be changed (e.g., age and race), most are subjective and sensitive to change. Some conditions associated with alterations in self-concept or global self-worth include developmental changes, life crisis, illness, and loss.

grief

· Grief is an internal emotional reaction to loss. It occurs with loss caused by separation or by death. For example, many people who divorce experience grief. Loss of a body part, job, house, or pet may also cause grief. Normal expressions of grief may be physical (crying, headaches, difficulty sleeping, fatigue), emotional (feelings of sadness and yearning), social (feeling detached from others and isolating yourself from social contact), and spiritual (questioning the reason for your loss, the purpose of pain and suffering, the purpose of life and the meaning of death). · Mourning is the actions and expressions of that grief, including the symbols and ceremonies (e.g., a funeral or final celebration of life) that make up the outward expressions of grief. · Bereavement is a state of grieving due to loss of a loved one.

grief reactions

· Grief reactions and reactions to dying are similar. The stages of these reactions overlap and vary among people (see Factors That Affect Grief and Dying, later in this chapter). One person may skip a reaction stage, whereas another may repeat an earlier stage. Each person is different, and patients and family members may be at different reaction stages. Several theories explain the stages of grief reactions and reactions to dying; two discussed here are by Engel and Kübler-Ross. More important than the actual stages of any given grief reaction is the idea that grief is a process that varies from person to person. · Engel (1964) was among the first to define stages of grief. Engel's six stages are (1) shock and disbelief, (2) developing awareness, (3) restitution, (4) resolving the loss, (5) idealization, and (6) outcome. Shock and disbelief are usually defined as refusal to accept the fact of loss, followed by a stunned or numb response: "No, not me." Developing awareness is characterized by physical and emotional responses such as anger, feeling empty, and crying: "Why me?" Restitution involves the rituals surrounding loss; with death, it includes religious, cultural, or social expressions of mourning, such as funeral services. Resolving the loss involves dealing with the void left by the loss. Idealization is the exaggeration of the good qualities of the person or object, followed by acceptance of the loss and a lessened need to focus on it. Outcome, the final resolution of the grief process, includes dealing with loss as a common life occurrence. · Kübler-Ross (1969), a pioneer in the study of grief and death reactions, defined five stages of reaction similar to Engel's. These stages—(1) denial and isolation, (2) anger, (3) bargaining, (4) depression, and (5) acceptance—are discussed later in the chapter. Dysfunctional grief is abnormal or distorted; it may be either unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them; unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations.

effects of harrassment

· Harassment can cause feelings of helplessness, worthlessness, and guilt in the victim. This can often lead to less career satisfaction and feelings of loss of control. · Anger is commonly experienced by those who have been harassed, which may lead to requests for transfer, resignation, or withdrawal from the environment where the harassment occurs. In many cases, job performance is affected due to reduced levels of concentration. · Loss of job motivation and skill confidence, along with reduced job satisfaction and organizational commitment, are common.

sexual harrassment

· Harassment is any annoying or distressing comment or conduct that is known or should be known to be unwelcome. · Sexual harassment is unwelcome behavior that is based on a person's sex or gender. This type of harassment usually occurs in the context of an asymmetrical relationship in which one person has more formal power than the other (e.g., a faculty member over a student) or more informal power (e.g., one peer over another). · Sexual harassment can be directed toward people of any age, any gender, and any sexual orientation. There are two forms of sexual harassment: quid pro quo and environmental harassment (also called a hostile environment). Quid pro quo means something given or withheld in exchange for something else. Quid pro quo harassment occurs when a person's employment or well-being is dependent on agreeing to unsolicited and unwelcome sexual demands. This type of harassment is typically initiated by a person in a position of authority who offers either direct or indirect reward or punishment based on the granting of sexual favors. Quid pro quo harassment is a clear abuse of power and is legally, morally, and ethically wrong. · Hostile work environment occurs when sex- or gender-based behaviors create a hostile, intimidating environment that hurts a person's work performance, classroom performance, or general sense of well-being. In the workplace, for example, the negative behaviors in hostile environment harassment are not directly linked to job-related consequences; instead, the employee's willingness to suffer the experience of the demeaning environment becomes a condition of employment. · This type of harassment is not necessarily caused by a person with formal power. A hostile environment is sometimes difficult to identify, as it is not always easy to determine when offensive speech or behavior actually turns to true harassment. In order to be considered a hostile work environment, the behaviors must be unwanted, frequent (not a one-time event), and pervasive. Coworkers and peers can create a hostile environment for a member of the group through the following: Unwelcome sexually oriented and gender-based behaviors Sexual bantering Sexual jokes Offensive pictures and language Sexual innuendoes Sexual behavior Unwanted attention such as asking for dates constantly, physically blocking movement, or creating unwanted interactions

medications

· Health care practitioners must also take into account the effect that drugs used to treat medical or psychological disorders have on sleep. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems. · Chronotherapeutics is a growing field of study that involves the strategic use of time in the administration of medicine. Researchers have determined that certain treatments for disease are more effective when circadian rhythms are taken into account. For example, a larger midafternoon dose of asthma medication may be more effective in preventing attacks that commonly occur at night during sleep. The timing of antihypertensive medication administration may need to be adjusted to provide peak protection during early-morning hours, when heart attacks are more common. Cancer chemotherapy appears to be less toxic when administered at certain times of the day. Paying attention to biologic rhythms may influence drug tolerance and medication effectiveness, and reduce adverse effects, including those related to rest and sleep.

ethics

· Healthy sexuality depends on freedom from guilt and anxiety. What one person believes is wrong may be perfectly natural and correct to another. · Some people may feel that certain forms of sexual expression are bizarre, and the people who participate in them are perverted. · If the sexual expression is performed by consenting adults, is not harmful to them, and is practiced in privacy, it should not be considered a deviant behavior. · People should personally decide which aspects of sexual expression are comfortable for them. Frequently, all a person needs to alleviate guilt, and consequently enhance sexual satisfaction, is permission from a health care professional to engage in a different form of expression

Hypersomnolence

· Idiopathic hypersomnia is characterized by excessive sleep, particularly during the day. A person may fall asleep for intervals during work, while eating, or even during conversations. These naps do not usually relieve their symptoms. When they awake, they are often disoriented, irritated, restless, and have slower speech and thinking processes. Some people may have a genetic predisposition to hypersomnia. It appears most often in adolescents and young adults. Although not usually life threatening, hypersomnia can have some serious consequences, such as motor vehicle accidents that occur because of drowsiness or falling asleep while driving. These attacks may occur indefinitely (NSF, 2011d). · Treatment of hypersomnia is symptomatic in nature. Stimulant drugs may prove effective, or in some cases, antidepressants may be prescribed. Attention to diet (avoidance of alcohol and caffeine) and behavioral changes (avoidance of night work and social activities later in the evening) may offer some relief from such episodes.

Centralized and Decentralized Management Structures

· In a centralized management structure, senior managers generally make decisions. Those further down in the hierarchy of the organization are often responsible for implementing decisions into which they had little input. · In a decentralized management structure, on the other hand, decisions are made by those who are most knowledgeable about the issues being decided. Nurses are thus intimately involved in decisions concerning patient care. · Nurse managers are accountable for what happens on their nursing unit, including patient census, staffing, supplies, and budget. · A decentralized system invites greater accountability and responsibility because most nurses feel more responsible for decisions they have made themselves. · You will most likely experience both modes of decision making—centralized and decentralized—in nursing units. · Financial targets and other broad strategic directions are frequently established at executive levels of the organization. Clinical issues, processes of care delivery, clinical outcomes, and unit governance are usually resolved at the unit or department level.

· Nursing, Religion, and Conscientious Objection

· In recent years, some pharmacists attracted media attention by refusing to fill prescriptions for contraceptives. These pharmacists supported their refusals by claiming that fulfilling such a prescription would violate their religious beliefs and convictions. In this situation, the woman's right to access medications is pitted against the pharmacist's right to practice with personal integrity. · Nurses can also find themselves in situations in which their professional or institutional responsibilities involve participation in activities, such as abortion, assisted suicide, and counseling about birth control, that may violate their personal integrity. Nurses therefore must ensure that they can fulfill the responsibilities of their job or that they are free to exercise the right of conscientious objection. · As legislation addressing these conflicts is in a state of flux, you should be familiar with federal and state guidelines. For example, in September of 2011, the University of Medicine and Dentistry of New Jersey announced that all nurses employed in its hospital would have to help with abortion patients before and after the procedure, "reversing a long-standing policy exempting employees who refuse based on religious or moral objections." After a group of objecting nurses filed a federal lawsuit, the hospital backed down, agreeing that nurses with conscientious objections do not have to assist with pre- or postoperative care for abortions except when the mother's life is threatened and no other nonobjecting staff are available to assist (Galston & Rogers, 2012, p. 1).

· PROMOTING MEANING AND PURPOSE

· In the book Man's Search for Meaning, psychiatrist Victor Frankl, who survived the horrors of the Nazi concentration camps, writes, "Once an individual's search for meaning is successful, it not only renders him happy, but also gives him the capability to cope with suffering" (1985, p. 163). To help patients searching for meaning, explore with them what has given their life meaning and purpose up to the present, sources of meaning for other people, and possible meanings for patients' current experience of illness, pain, suffering, or impending death. If a patient desires, arrange for referral to a spiritual adviser. Explore with patients spiritual practices that may give them strength and hope (e.g., prayer or reading scripture or other spiritual books). You might also want to recommend that patients read spiritual biographies or Harold Kuschner's book When Bad Things Happen to Good People (1983) or Kathleen Brehony's book After the Darkest Hour: How Suffering Begins the Journey to Wisdom (2000), or Oliver Sack's Gratitude (2015). Referring patients to appropriate support groups (e.g., self-help groups for people with stroke, cancer) also is helpful. · PROMOTING LOVE AND RELATEDNESS · First and foremost, always treat the patient with respect, empathy, and genuine caring. Encourage the patient to talk about relationships with others and to identify the origin of any negative beliefs about people. Box 46-3 may be a good starting point for reflection on loving kindness. · Encourage conversation about how a patient experiences God or a higher being if that is part of the patient's spiritual beliefs. If appropriate, introduce or reinforce the belief that God is a loving and personal God who is concerned about the patient. Whenever possible, encourage and facilitate visits from the patient's family, friends, and spiritual adviser. · PROMOTING FORGIVENESS · Offer a supportive presence to the patient that demonstrates your acceptance of the patient. Explore with the patient the importance of learning to accept self and others, including both strengths and limitations. Explore negative feelings that make it difficult for the patient to seek forgiveness and to believe that he or she is forgiven. Explore the patient's self-expectations and assist the patient to determine how realistic these are. Allow the patient to verbalize shame, guilt, and anger, and counsel about the importance of expressing negative emotions in healthy ways. Refer the patient to a spiritual adviser, if appropriate. Offer the patient examples of how not forgiving others can end up hurting only the person who cannot forgive.

terminal illness

· In the case of a terminal illness, an illness in which death is expected within a limited period of time, the health care provider is usually responsible for deciding what, when, and how the patient should be told. The nurse, along with members of the clergy and other health care professionals, may be involved with these decisions and in discussing the condition with the patient. · Most patients want to know their diagnosis and prognosis as soon as possible so that they can begin appropriate planning and take care of business and personal affairs. · It is critical for terminally ill patients and their families to have some sense of how the disease is most likely to progress and what this will mean for the patient. All who are involved with the patient's care should know exactly what the patient and the family have been told; members of the patient's health care team need to communicate among themselves. · Cultural influences may dictate how much information is desired and which family members are to be informed. For example, in some cultures it is still the norm that the patient's family—not the patient—is told the diagnosis and prognosis. Since this is now changing, nurses must check local practice standards and policies as well as the preferences of individual patients and families. · You can never go wrong if you ask patients how much information they would like about their medical condition. "We will be learning things about your health as a result of the diagnostic testing we are doing. Do you want to receive this information or would you prefer that we give this to a family member or someone else of your choosing?"

Responding to Harassment in the Nursing Environment

· Inappropriate sexual behavior by a patient may cause the nurse to respond with either passive avoidance or aggressive retaliation. An assertive response that supports the nurse in maintaining self-respect and encourages the patient to accept responsibility for his, her, or their behavior is recommended. Be self-aware: Do not deny feelings about being harassed. Confront: Provide feedback to the patient in a nonthreatening way and clearly state what behavior is or is not acceptable. Set limits: Define clear and reasonable consequences that will be enforced if the behavior continues. Enforce the stated limits: Maintain boundaries. Report: Document the incident and submit to supervisor. · Colleagues may also be a source of harassment. The objective of employers should be to create a positive work environment that is characterized by mutually respectful behavior. Many have taken steps to eliminate hostile work environments by educating employees, developing policies against workplace harassment, and outlining guidelines for responding to sexual harassment. If harassed by a coworker, confront the behavior immediately. An assertive statement is sometimes sufficient to stop the behavior. If the harassment continues, document the date and time, and describe the behavior. Consult a supervisor not involved in the harassment. If the harassment still does not stop, file a grievance with administration. Seek legal advice if all previous efforts to stop the behavior have been unsuccessful. Sexual harassment is illegal and you have the right to ask for legal representation.

faith

· It can involve a person, idea, or thing, and is usually followed by action related to the ideals or values of that belief. · For example, if I have faith in my doctor, parish nurse, or healer, I am more likely to adhere to a prescribed regimen or care plan and to experience benefits. Similarly, patients who believe in a loving and all-powerful being who knows them and cares for them are often better able to cope with the suffering related to injury and illness. · The declaration made by the World Conference of the Religions for Peace in Kyoto, Japan, in 1970 is an excellent example of a confident belief in something for which there is no proof or material evidence. At this conference, Baha'i, Buddhist, Confucian, Christian, Hindu, Jain, Jew, Muslim, Shintoist, Sikh, and others discovered that the beliefs that unite them were more important than those that divided them. They discovered that they shared: A conviction of the fundamental unity of the human family, of the quality and dignity of all human beings A sense of the sacredness of the individual person and the person's conscience A sense of the value of the human community A belief that love, compassion, unselfishness, and the force of inner truthfulness and of the spirit have ultimately greater power than hate, enmity, and self-interest A sense of obligation to stand on the side of the poor and the oppressed as against the rich and the oppressors A profound hope that good will finally prevail. · Faith is a term also used to describe a cultural or institutional religion, such as Judaism, Islam, or Confucianism. An atheist is a person who denies the existence of a higher power; an agnostic is one who holds that nothing can be known about the existence of a higher power. Atheists and agnostics deserve respect for what they choose to believe, just as do those who accept a particular religious creed.

· Establishing a Trusting Nurse-Patient Relationship

· It is impossible to address a patient's sexuality if trust has not been developed between you and the patient (see Through the Eyes of a Student). To develop trust, project an objective, nonthreatening, and nonjudgmental attitude, and emphasize that the information the patient gives will be kept confidential. You need to be aware of your own behavior and verbal and nonverbal cues. You also need to anticipate the patient's concerns in order to help the patient trust you with information of an intimate nature. Be sure to establish respect for the patient and empathy before discussing sexual issues. Consider all of the patient's circumstances and life experiences using a therapeutic approach. Only when you are accepted as a trusted, caring person will the patient reveal details of his, her, or their private life, including sexual concerns.

REM sleep

· It is more difficult to arouse a person during rapid eye movement (REM) sleep than during NREM sleep. In normal adults, the REM state consumes 20% to 25% of a person's nightly sleep time. People who are awakened during the REM state almost always report that they have been dreaming. They can usually vividly recall their dreams even if they were absurd or have no sensible meaning for them. Everyone dreams. · During REM sleep, the pulse, respiratory rate, blood pressure, metabolic rate, and body temperature increase, whereas general skeletal muscle tone and deep tendon reflexes are depressed. REM sleep is believed to be essential to mental and emotional equilibrium and to play a role in learning, memory, and adaptation. · A person who is deprived of REM sleep for several nights generally will spend more time in REM sleep on successive nights. This phenomenon, termed REM rebound, allows the total amount of REM sleep to remain fairly constant over time · Eyes dart back and forth quickly. · Small muscle twitching, such as on the face · Large muscle immobility, resembling paralysis · Respirations irregular; sometimes interspersed with apnea · Rapid or irregular pulse · Blood pressure increases or fluctuates · Increase in gastric secretions · Metabolism increases; body temperature increases · Encephalogram tracings active · REM sleep enters from stage II of NREM sleep and reenters NREM sleep at stage II: arousal from sleep difficult · Constitutes about 20% to 25% of sleep

Crises & life events

· Life stressors or crises (e.g., cyber bullying, marriage, divorce, acute or chronic illness, an exam, a new job or job loss, a gray hair, a fire) may call forth a personal response and mobilize a person's talents, resulting in good feelings about oneself, or it might result in emotional paralysis with diminished self-concept. · People vary greatly in their perception of what constitutes a crisis or stressor, as well as the degree to which such experiences disrupt or diminish self-concept. · However, major stressors place anyone at relative risk for maladaptive responses, such as withdrawal, isolation, depression, extreme anxiety, substance abuse, or exacerbation of physical illness. How the person perceives the stressor (threat, challenge, defeat) and the person's ability to mobilize personal strengths and other resources are determined largely by that person's self-concept, which, in turn, is influenced by the response the person chooses. · Aguilera (1998) described three factors that determine a person's response to crisis: (1) the person's perception of the event or situation, (2) the person's situational supports (external resources), and (3) the coping mechanisms the person possesses (internal resources). · All of these factors are related to self-concept. The degree of strength a person has in each area is related to the person's pre-crisis self-concept. Similarly, each of these factors can alter self-concept either positively or negatively during or after the crisis. Intervention to strengthen any of these three areas can help people better cope with crisis and emerge with enhanced self-concept.

Long-Term Stress

· Long-term stress poses a serious threat to physical and emotional health. As the duration, intensity, or number of stressors increases, a person's ability to adapt is lessened. The failure of adaptive mechanisms is also influenced by a person's state of health and past experiences with stress. · Long-term stress affects physical status, increasing the risk for disease or injury. Recovery and return to normal function are also compromised. High levels of ongoing stress are associated with multiple health disorders (see Box 42-2 on page 1661). Alcoholism and drug abuse, depression, suicide, accidents, and eating disorders have also been associated with chronic stress (Porth, 2015). It is believed that these diseases are the result of various factors, including the effects of the fight-or-flight response, eating patterns, lifestyle, and coping mechanisms. Stress alone does not cause autoimmune diseases such as rheumatoid arthritis, but is believed to contribute to the progression of these diseases. Researchers have confirmed that chronic stress affects the ability of immune cells to respond to the hormones that normally regulate inflammation, thus allowing the development and progression of some diseases. · Stress has negative effects on the entire body—the cardiovascular, respiratory, musculoskeletal, endocrine, gastrointestinal, nervous, and reproductive systems. Under normal circumstances, cortisol, an anti-inflammatory hormone released by the adrenal glands, regulates the inflammatory response, but prolonged stress may decrease the effectiveness of cortisol, or the immune cells may be resistant to its effects (American Institute of Stress, 2017; American Psychological Association, 2018; Porth, 2015). A person who reacts to stress by overeating, smoking, using alcohol or illegal drugs, or becoming hyperactive puts additional strain on the body. See the Promoting Health Literacy box on page 1668 for tips useful for patients experiencing long-term stress.

loss

· Loss occurs when a valued person, object, or situation is changed or becomes inaccessible such that its value is diminished or removed. There are several types of loss, all of which everyone may experience at some time. · Actual loss can be recognized by others as well as by the person sustaining the loss—for example, loss of a limb, a child, a valued object such as money, and a job. · Perceived loss, such as loss of youth, financial independence, or a valued environment, is experienced by the person but is intangible to others. Directly related to actual and perceived loss are physical and psychological loss. A person who loses an arm in an automobile crash suffers from both the physical loss of the arm and the psychological loss that may be caused by an altered self-image and the inability to return to his or her occupation or other activities. These losses are simultaneously physical, psychological, and actual. A person who is scarred but does not lose a limb may suffer a perceived and psychological loss of self-image. · Other types of loss are maturational loss, situational loss, and anticipatory loss. · Maturational loss is experienced as a result of natural developmental processes. As examples, a first child may experience a loss of status when a sibling is born, and the parent of a single child may experience a sense of loss when the child begins school. · Situational loss is experienced as a result of an unpredictable event, including traumatic injury, disease, death, or national disaster. · Anticipatory loss occurs when a person displays loss and grief behaviors for a loss that has yet to take place (Fig. 43-1 on page 1687). Anticipatory loss is often seen in the families of patients with serious and life-threatening illnesses and may lessen the effect of the actual loss of the family member.

· Respecting Normal Sleep-Wake Patterns

· Make every effort to allow patients to experience their normal period of sleep. In many instances, insisting that all patients retire and awaken at specific times is not necessary. For example, is there a good reason to wake a patient at 0700 if the patient ordinarily sleeps until 0800? The patient's normal napping habits should also be followed when possible. REM sleep is more common during morning naps, whereas NREM sleep is more common during naps later in the day. With this knowledge, help patients plan napping periods that best fit their needs and interfere the least amount with nighttime sleeping.

pain and mental illness

· Many chronic illnesses are accompanied by constant pain, and a person with persistent pain may not desire any sexual contact. However, the desire for human warmth and contact does not cease because of pain. · Altered or modified positions for coitus are sometimes necessary; discussing these positions with patients can be an important part of implementing the nursing process, reviewed later in this chapter. Mental Illness · Various psychological and physical disorders can cause mental illness. · The mind plays a powerful role in sexuality; any disruption of its functioning will no doubt cause some disturbance in sexual functioning. Even mild depression can affect desire and sexual functioning. · Sometimes, it is difficult for the partner of a patient who has developed a mental illness to continue the sexual relationship. · People afflicted with Alzheimer's disease can lose the memory of any contact with a partner or spouse. At times, patients with mental illness act out in a sexual manner, such as touching themselves or removing their clothing at inappropriate times and places.

personal strength

· Many patients focus naturally on their deficiencies; asking pointed questions about personal strengths can help a patient identify positive factors: · "What are some of your personal strengths ... qualities you are proud of ... things you do well?" · "What has helped you cope in the past when things were tough?"

effect on the Patient

· Many patients realize without being told that they have a terminal illness, picking up this knowledge from nonverbal communication by their families and by health care professionals. · Patients must be allowed to go through the stages of the grieving process and be supported in their decision making. · Competent patients have the right to consent to or refuse any and all indicated medical treatment—even life-sustaining treatment—and should be made aware of this right. In the past, patients and family members complained about receiving care they did not want and of not being allowed to die. · In today's climate of cost-conscious decision making, some patients and family members are complaining that they are being denied costly life-sustaining treatment because of inadequate personal funds or insurance or because they are deemed a poor "investment" of scarce resources. Remember that a patient's wishes should, if possible, be followed. Box 43-2 lists the rights of people who are dying.

· Scheduling Nursing Care to Avoid Unnecessary Disturbances

· Many patients report being awakened to take sleeping pills and are roused in the early morning to prepare for breakfast long before it is served. Consider these common complaints when developing the patient's plan of care to promote rest and sleep. Whenever possible, provide care during periods when the patient is normally awake. When this is not feasible, avoid awakening the patient during REM sleep, when the rapid eye movements can be observed. Because a patient's need for sleep is important, examine priorities for nursing care. For example, consider whether checking a vital sign or carrying out a particular nursing measure is more important than the patient's sleep

Identify the physiological and psychological effects of insufficient sleep.

· Many people have sleep disturbances that go undetected for years, progressively undermining their energy and destroying their sense of self. The term short sleeper refers to someone who sleeps less than 6 hours a night. Over the past 30 years, there has been a significant increase in short sleepers in the United States. Some 25% of adults in the United States report that they get insufficient sleep approximately 15 days of each month (ODPHP, 2017). Insufficient sleep in children may affect normal growth and development and could be a contributing factor in performance deficits and behavioral problems. Furthermore, short sleep duration in childhood is associated with an increased risk of obesity during childhood or later in life (Miller, Lumeng, & LeBourgeois, 2015). The NSF (n.d.b) has also identified a link between insufficient sleep and obesity in adults and children. Various studies confirm that adults and children who slept less than the recommended hours per night were more likely to be overweight. This sleep-weight link is possibly related to two hormones: leptin and ghrelin. Leptin signals the brain to stop eating, whereas ghrelin promotes continued eating. Research suggests that sleep deprivation lowers leptin levels and elevates ghrelin levels, thus increasing one's appetite. To compound the problem, the brain may interpret a drop in leptin as a sign of starvation. Unfortunately, the brain then signals the body to eat more while it simultaneously lowers the body's metabolic rate. When this happens, people are more likely to gain weight, even if food intake is decreased (Miller et al., 2015). · People who suffer sleep difficulties caused by working night shifts or constantly changing work shifts may experience adverse effects, including anxiety, personal conflicts, loneliness, depression, gastrointestinal symptoms, increase in type 2 diabetes, hypertension, and higher rates of cardiovascular disease including strokes, and substance abuse (Buysse, 2014). A person who has experienced shortened sleep by just a few hours a night can have a reaction time similar to someone intoxicated with alcohol (NSF, n.d.c). · Sleep loss that results in fatigue and decreased competence increases the risk of a sleep-related motor vehicle accident. The NSF (n.d.c) reports that 55% of Americans admitted driving while feeling drowsy during the past year and drowsy driving is implicated in at least 100,000 motor vehicle accidents a year. A large study of critical care nurses reported that 43% of the nurses stated that they fell asleep while stopped at a traffic light and 20% had a traffic accident or a near miss directly associated with their fatigue (Johnson, 2011). · In addition, studies of physicians' and nurses' work habits have concluded that shiftwork sleep disorders (SWSD) from extended work schedules are a causative factor in a substantial number of adverse medical events and errors (Caruso, 2014; Freeman, 2015; Johnson, Jung, & Brown, 2014; The Joint Commission, 2011). Fatigue and sleepiness can compromise patient safety and increase the risk for adverse events such as medication errors. Sleep deprivation and the resulting consequences of decreased alertness and ability to perform tasks competently are well documented. The Office of Disease Prevention and Health Promotion (2017) recognizes that improved attention to sleep health promotes a safer environment for health care workers and their patients. Objectives related to sleep health identified in Healthy People 2020 include increasing the proportion of adult who get sufficient sleep; increasing the proportion of students in grades 9 through 12 who get sufficient sleep; expanding the proportion of people with obstructive sleep apnea (OSA) who seek medical evaluation; and reducing the rate of vehicular crashes related to drowsy driving (Office of Disease Prevention and Health Promotion, 2017). The Joint Commission (2011) acknowledges the impact of fatigue on health care workers and urges greater attention to the issue, suggesting actions for health care facilities to reduce fatigue-related risks. These include: Assess work schedules and staffing to address extended work shifts and hours. Review hand-off processes and procedures to ensure safe transfer of information. Request staff input in designing work schedules to minimize staff fatigue. Develop and implement a fatigue management plan. Educate staff about sleep hygiene and the effects of fatigue on patient safety. Address staff concerns about fatigue. Encourage teamwork to support staff who work extended shifts. Keep the effects of fatigue in mind when reviewing adverse events.

illness, trauma, & aging

· Many people take a healthy body for granted. Society encourages a kind of denial of the eventuality of aging, chronic illness, and the necessity to integrate crisis and change throughout each person's lifetime. · Society emphasizes and rewards youth, health, and narrow norms for physical attractiveness while devaluing seniors, those with chronic illness, and those whose appearance does not correspond to celebrity standards. Thus, a sudden illness, trauma, or bodily disfigurement, or even the suggestion of disease, as well as signs of the aging process may pose serious threats to the self. · People vary greatly in their response to aging, illness, and trauma (Fig. 41-4). This is due to the threats to self-concept and internal beliefs about the self that these conditions may pose.

· Using Medications to Promote Sleep

· Medications may be prescribed as part of the plan of care to address disturbances in sleep disturbances. A thorough health history, drug history, and sleep history, as well as assessment of stress and coping patterns and any underlying medical conditions, are required prior to the use of medications to induce or maintain sleep. The underlying cause for the sleep disturbance must be determined; nonpharmacologic interventions should be tried first or in combination with pharmacologic therapy (Adams, Holland, & Urban, 2017; Singh, 2016). Refer to the discussion in the Insomnia and Teaching About Rest and Sleep sections. · When sleep disturbances cannot be managed by other means, medications may be prescribed (pharmacotherapy). Sedative-hypnotic drugs are commonly prescribed for treatment of sleep disorders (Kee, Hayes, & McCuistion, 2015). These medications are used to induce sleep and maintain sleep, and include barbiturates, benzodiazepines, and nonbenzodiazepines, as well as some miscellaneous drugs. Some of these drugs are short-acting hypnotics, inducing sleep and allowing the patient to awaken early in the morning without experiencing lingering side effects (Kee et al., 2015). Intermediate-acting hypnotics are useful for sustaining sleep, but may be associated with residual drowsiness or hangover in the morning (Kee et al., 2015). Use of some hypnotic medications, including the barbiturates and benzodiazepines, should usually be short term, as these drugs are associated with drug dependence and drug tolerance. In addition, if these drugs are used over a long period of time, abrupt discontinuation should be avoided; these drugs should be tapered to avoid withdrawal symptoms. It is important for the nurse and patient to know and understand the action and potential adverse effects of any prescribed medication to ensure responsible administration. · The most commonly prescribed sleep aids are discussed here. The nonbenzodiazepine, nonbarbiturate CNS depressants are often prescribed to promote sleep because there is less residual sleepiness with these medications and they do not appear to produce dependence or tolerance (Adams, Holland, & Urban, 2017). These drugs include zaleplon, eszopiclone, and zolpidem tartrate. Zolpidem tartrate sublingual tablets have been approved by the FDA for insomnia associated with middle-of-the-night awakening. It is intended for use when at least 4 hours of sleep time remain and is a lower dose formation of zolpidem tartrate (Jeffrey, 2011). Eszopiclone is prescribed for longer-term treatment of chronic insomnia. Ramelteon is a selective melatonin receptor agonist prescribed to facilitate the onset of sleep but is not intended for sleep maintenance. It may be used long-term and activates receptors for melatonin (Lehne, 2013). A new class of drug to treat sleep disturbance is the orexin receptor antagonists (Singh, 2016). Orexin-A and orexin-B are neuropeptides that play an important role in promoting wakefulness and regulating the sleep-wake cycle. Suvorexant blocks the wake-promoting signal mediated by orexin receptors and these neuropeptides (Singh, 2016). · Sleep medications are often ordered on a PRN (as needed) basis. Administer these medications only when indicated and always with the full knowledge of their limitations. Provide thorough patient education about these medications. In addition, help patients develop other self-care strategies, including developing healthy sleep and lifestyle behaviors. Use alternative nonpharmacologic measures to promote sleep when appropriate (refer to the Teaching About Rest and Sleep section). Over-the-counter (OTC) sleep medications most often contain antihistamines and should only be used on a short-term basis because of the potential for adverse effects and their lack of effectiveness over a lengthy time period. · Some patients use complementary health approaches that include hypnotic herbs. Hypnotic herbal therapies include valerian and Pacific valerian. Nervines are another type of herb that have a mild effect on sleep and include passionflower, lemon balm, skullcap, and gotu kola (Yarnell, 2015). Herbal medicines may offer ways to improve sleep; it is important to include questions about use of these agents as part of a nursing assessment related to sleep, as some patients may not consider OTC herbs to be medication.

mentorship

· Mentorship is a relationship in which an experienced person (the mentor) advises and assists a less experienced person (protégé). This is an effective way of easing a new nurse into leadership responsibilities. Mentors link with protégés by common interest and provide support, information, and network links. The relationship does not include financial reward. · Mentors should be excellent role models. If you find a nurse with expertise in practice or topics that interest you, you can ask if she or he would be interested in becoming your mentor. The advantages of having an effective mentor are many. Ideally, good mentors can suggest options for your growth and development and identify helpful resources. Good mentors will welcome your questions and provide honest feedback on your progress. Many nurses who are passionate about nursing and the profession's future are happy to share what brings meaning and purpose to their lives. · Mentorship is valuable in all types of nursing positions. As a nurse climbs the ladder of leadership responsibility, a mentor who is experienced in management and administrative functions may be of great assistance. A mentor can be key in helping a less experienced nurse assume added responsibilities and position changes. Many mentorship relationships also become lasting friendships.

lifestyle

· Modern lifestyles greatly affect sexuality and its expression. Both men and women are exposed to stress, and many are under considerable strain to perform and function in the workplace as well as at home. · Stressors may be external, such as job and financial demands, or internal, such as a person's competitive nature. Varied responsibilities may place a time constraint on communication between a couple, as well as on the energy level and motivation for sexual satisfaction. Although some couples view sexual activity as a release from the stressors of everyday life, most place nurturing relationships and sexual expression far from the top of the list of "things to do." · It is crucial to a relationship's survival that a couple set aside priority time for their relationship—if not for lovemaking, then for intimate, quiet contact. Lifestyle variables can also influence the sexual expression of adolescents and young adults. Those with more free time and fewer constructive developmental opportunities (e.g., education, sports, community service) are more likely to engage in risky sexual behavior.

· Teaching About Sexuality and Sexual Health

· Most nursing interventions pertaining to a patient's sexuality involve teaching to promote sexual health. Major goals of patient teaching involve effecting change in knowledge, attitude, or behavior. In some situations, patients need help defining or redefining their sexuality and its importance to their lives. Offering information, dispelling fears, and providing positive reinforcement are some ways to help patients increase their knowledge about their bodies and sexual functioning. Patients may need assistance in modifying behaviors or learning new skills to increase the quality of sexual health and functioning. · Part of teaching also includes correcting sexual myths and promoting body awareness. Many people believe things about sex that they have heard from family or friends that are not true or are not based on scientific data. During the assessment, or while providing care, take the opportunity to refute sexual myths and teach factual information (Table 45-4 on page 1772). · Patients may need assistance in becoming familiar with what they believe and feel about their sexual selves. Be helpful to patients who have difficulty accepting or developing their sexuality by promoting their self-confidence and a good self-concept. When patients feel comfortable about themselves and their sensual feelings, they can begin to focus on how they feel about their sexual functioning and specific sexual expressions. · Getting to know your physical body is important to healthy sexual development. All people, sexually active or not, need to be aware of the appearance of their genitalia. Some people, because of their background, feel ashamed and repulsed by their bodies; others feel that touching the body is dirty and may feel guilt and anxiety in stimulating themselves. Patients need assistance in improving body awareness if any of these issues are present. Patients can become accustomed to looking at their bodies by looking at nonthreatening anatomy first and then proceeding to the genitals. This can be done in the shower or with the use of a mirror. Knowing what looks normal can be of great importance so that patients can report the development of an unusual appearance later. · After patients have developed some degree of comfort in looking at their bodies, they can progress to experiencing touch. Again, patients should progress from nonthreatening parts of the body until the genitals can be touched without stress. · A good exercise for women in developing body awareness is the use of Kegel exercises. These exercises promote good vaginal tone by localizing and strengthening the pubococcygeal muscle. A woman can locate this muscle by stopping a stream of urine midway through urination. Contracting this muscle can be repeated at any time of the day in any circumstance because its performance is undetectable. Some women who practice Kegel exercises have found that their sexual satisfaction is improved.

dentify qualities associated with good leaders

· Most people admire a charismatic, dynamic, enthusiastic, visionary leader who is poised, confident, and self-directed. When you read these characteristics, who comes to your mind? Not everyone can be as dynamic and inspirational as such individuals, yet leaders do need to be comfortable with themselves (i.e., have a positive self-image) and present themselves as role models for followers. Ideally, they also have a vision that energizes the group and brings forth the best efforts of members. Critical thinkers and responsible decision makers commit high energy to achieving goals and are skilled in enlisting support and cooperation. · Leaders value learning and must be knowledgeable. Contemporary nurse managers draw upon their own staff for clinical and organizational knowledge. Understanding the culture in your practice environment is necessary to be successful. Flexibility is a must for all nursing leaders. All nursing functions and roles require flexibility. The needs of patients, families, and the nursing team can change from minute to minute. For example, a nurse coordinator may plan to involve staff in a discussion about how best to distribute new work responsibilities, but if there are three unexpected new admissions to the unit, the discussion may need to be postponed to a quieter time. · Leadership potential is present in all nurses. With education and practice, these qualities can be developed to the point at which a nurse is skilled in the many behaviors necessary for leadership.

· Promoting Bedtime Rituals

· Most people have bedtime rituals to help them relax and promote sleep. Reading, listening to the radio, watching television, talking to a family member, and praying are common before-sleep activities. Children may take a favorite doll, stuffed toy, or blanket to bed; listen to a bedtime story; kiss everyone good night; and say prayers before bed (Fig. 34-4). Readiness for sleep follows a personal hygiene routine for many people, such as brushing teeth, washing hands and face, voiding, or taking a bath or shower. Snacks are important elements in the bedtime rituals of many children and adults. Although eating the wrong foods may produce a bad night's sleep, going to bed hungry may also interfere with sleep. · To promote relaxation and sleep, be alert to the patient's bedtime rituals and observe them as much as possible. Include these rituals in the patient's plan of care so that all health personnel can observe them.

envirionmental factors

· Most people sleep best in their usual home environments. Sleeping in a strange or new environment tends to influence both REM and NREM sleep. · People accustomed to sleeping in a noisy environment, such as a busy large city, actually have a hard time falling asleep in an area that is extremely quiet. · By turning on a radio or other noise, the person may actually be able to rest in the new environment. Likewise, if a patient is accustomed to sleeping in a quiet environment, a room next to a high-traffic area, such as the nurse's desk, may not be the best place for this patient to rest.

smoking

· Nicotine has a stimulating effect; smokers usually have a more difficult time falling asleep. They are more easily aroused once asleep and may describe themselves as light sleepers. Eliminating cigarette smoking after the evening meal appears to improve the smoker's ability to fall asleep. Avoiding nicotine in any substance close to bedtime is suggested as part of good sleep hygiene practices (NSF, n.d.e). People usually report improved sleep patterns after discontinuing nicotine use. · Total withdrawal from smoking may be associated with temporary sleep disturbances. Patients who stop smoking often have more daytime sleepiness and report significantly more restlessness at night. Whether this is a short-term effect or is related to nicotine's effect on the central nervous system is uncertain.

NREM sleep

· Non-rapid eye movement (NREM) sleep, which comprises about 75% of total sleep time, consists of four stages. Stages I and II, consuming about 5% and 50% of a person's sleep time, respectively, are light-sleep states. During these stages, the person can be aroused with relative ease. · Stages III and IV, each representing about 10% of total sleep time, are deep-sleep states, termed delta sleep or slow-wave sleep. The arousal threshold (intensity of stimulus required to awaken) is usually greatest in stage IV NREM. Throughout the stages of NREM sleep, the parasympathetic nervous system dominates, and decreases in pulse, respiratory rate, blood pressure, metabolic rate, and body temperature are observed. Stage I · The person is in a transitional stage between wakefulness and sleep. · The person is in a relaxed state but still somewhat aware of the surroundings. · Involuntary muscle jerking may occur and waken the person. · The stage normally lasts only minutes. · The person can be aroused easily. · This stage constitutes only about 5% of total sleep. Stage II · The person falls into a stage of sleep. · The person can be aroused with relative ease. · This stage constitutes 50% to 55% of sleep. Stage III · The depth of sleep increases, and arousal becomes increasingly difficult. · This stage composes about 10% of sleep. Stage IV · The person reaches the greatest depth of sleep, which is called delta sleep. · Arousal from sleep is difficult. · Physiologic changes in the body include the following: · Slow brain waves are recorded on an EEG. · Pulse and respiratory rates decrease. · Blood pressure decreases. · Muscles are relaxed. · Metabolism slows and the body temperature is low. · This constitutes about 10% of sleep.

Contacting a Spiritual Counselor

· Not every nurse feels comfortable in the role of spiritual counselor. If you do not, suggest that the patient talk to a pastoral caregiver or spiritual counselor. When a patient expresses a desire to speak to a spiritual counselor, help make the appropriate referral or offer to contact the patient's own spiritual adviser. Other options are to contact the health care facility's pastoral ministry department or use a referral list of clergy in the local community. If no representative of the patient's own religion can visit in the hospital at a particular time, suggest a visit from a member of the clergy from another faith. The patient, depending on the situation and the immediacy of the need, may welcome such a suggestion. · In a health care setting, you can assist the spiritual counselor by making the counselor feel welcome, directing the counselor to the patient, and ensuring that the patient is ready to receive the counselor. Preparations of the patient's room for the visit may vary, but the following are generally recommended practices: The room should be orderly and free of unnecessary equipment and items. There should be a seat for the religious counselor at the bedside or near the patient so that both can be comfortable. The bedside table should be free of items and covered with a clean, white cover if a sacrament is to be administered. The bed curtains should be drawn for privacy if the patient can't be moved to a more private setting. · Some patients and spiritual advisers may value the nurse's participation in prayers, rituals, or the administration of sacraments. By having good working relations with chaplains and pastoral caregivers, you can quickly direct them to patients most likely to benefit from their visits.

Describe conflict management, engagement,

· Nurse managers frequently encounter conflict between employees and between themselves and employees. Unresolved conflict can lower morale and threaten quality care. Conflict management is a process to work through conflicts in a way that minimizes negative effects and promotes positive consequences. Conflict engagement teaches skills to help nurses perform well in the face of conflict instead of finding a work-around to avoid conflict. · Creating connection with others is a powerful tool in conflict engagement. Gerardi (2015b) recommends the PEARLA approach. PEARLA stands for Presence, Empathy, Acknowledgment, Reflect or Reframe, Listen openly, and Ask questions. When someone is agitated, taking the time to create a connection can deescalate the situation and lessen feelings of threat. The better we understand another's concerns, wants, and needs, the more likely we are to build trust as a foundation for problem solving (Gerardi, 2015b, p. 61). · It is important for each of us to recognize our hot buttons and patterns under stress. Gerardi (2015a, p. 61) recommends: Recognizing the physical sensations we experience when triggered by a situation (flushing, increased heart rate, shallow breathing) Taking a step back and breathing deeply three times Noticing and delaying our initial response in order to stop the habit of "fixing" or "solving" a situation too quickly Becoming curious about what we don't know, including discerning what the other person needs Avoid the situation, with the result that both Nurse C and Nurse P feel frustrated and powerless. Respond in a dominating or competing manner and tell Nurse S that the assignments are unacceptable. She intimidates Nurse S and also is upset because the nurses on the unit are not resolving their own problems. Ask Nurse C to accept the assignment in order to accommodate the charge nurse. Nurse P understands the inequity of this assignment but lets Nurse C know that she appreciates her team commitment and will remember this in the future. Attempt a compromise by providing Nurse S with a rationale for modifying the assignment. Both Nurse C and Nurse S should discuss the assignment with Nurse J and see if they can find a mutually agreeable solution. Collaborate with all parties to resolve the assignment issue and promote a safer work situation. Use a smoothing approach that involves complimenting all parties in an attempt to prevent emotional outbursts and focus on agreement.

employing institution or facility

· Nurses at all levels need to be knowledgeable about the administrative structure and functions of their employing institution or facility. · When problems arise concerning professional, unit, departmental, or institutional or facility objectives, nurses must be able to use the proper channels of communication and refer problems up the chain of command. · For example, if a nurse believes that work assignments are routinely incompatible with basic patient safety and quality, but gets no response after discussing this with an immediate nursing supervisor, the nurse should take those complaints to the director of nursing. If the director of nursing fails to respond adequately, the nurse should determine to whom the director of nursing reports and should approach that person. · Similarly, a nurse concerned about medical care should first approach the attending physician. If the attending physician fails to respond, the nurse must then contact the nursing coordinator and, in consultation with the nursing coordinator, approach the medical director. The structure of these channels is shown in the facility's organization chart, which details the relationships among the various administrative positions, departments, and job titles. Sometimes, the nurse is referred to committees that deal with specific issues.

nursing power

· Nurses in leadership and managerial roles who wish to be effective change agents are sensitive to both the uses and abuses of power. Power, the ability to influence others to achieve a desired effect, has many sources. Nurses in management positions within an institution have ascribed power associated with the role. · When introducing change, it is helpful to recognize and enlist the support of key power players who can then encourage others to become involved. A group may attribute power to certain individuals because of their expertise, leadership, or charisma. You can probably think of people in the groups to which you belong (school, church, civic groups) who are "natural leaders" because of their demonstrated ability to influence others. These are the "key power players" whose support is essential to effecting change. · All nurses should recognize the inherent power they have to ensure safe, quality, person-centered care and to cause change. Various nursing leaders have repeatedly emphasized that nurses need to use this power and be proactive rather than reactive to have a significant impact on a new vision for nursing. The following factors can play a role in increasing the power base of nursing: Right timing: Consumers and legislators are frustrated with errors reported in the health care system, the number of uninsured people, and overall problems with the health care system in the United States. Nurses, as the most respected health care providers, are poised to help improve health care and implement health care reform. Size of the nursing profession: This is one of nursing's greatest assets, with at least 3.6 million RNs in the United States. Nurses are an impressive voting bloc. Nursing's referent power: The public has expressed a high degree of trust and credibility in the nursing profession. Increasing knowledge base and education for nurses: More nurses are assuming advanced practice roles, and nursing graduates are strongly encouraged to achieve higher levels of education. Nursing's unique perspective: The caring component of nursing coupled with evidence-based practice and critical thinking has positioned nurses to deliver complex care to a variety of patients and positively affect quality of care. Desire of consumers and providers for change: Consumers are increasingly aware of the need for accessible, affordable, and safe quality care (Marquis & Huston, 2017). · Transformational leaders empower their staff by communicating and encouraging learning as well as promoting and verifying a sense of value about the powerful, life-saving work that nurses perform. Nurses who feel they have no control over their environment are more likely to express frustration toward a coworker and to leave their position or even the profession.

· Developing Self-Esteem in Children and Adolescents

· Nurses who work in practice settings where they have access to groups of parents, adult caregivers, or teachers can offer specific guidelines for creating developmental environments that build high self-esteem. Box 41-1 (on page 1648) offers five strategies for building self-esteem in children. Because some parents and educators may not have experienced these aids to personal growth themselves, it is beneficial to role-model these behaviors when interacting with children. · Important learning tasks for children include understanding and accepting themselves, their feelings, and others; independence; goals and purposeful behavior; mastery, competence, and resourcefulness; emotional maturity; and choices and consequences. •Look at the positive & the negative •Actively listen to the child/adolescent •React to behavior & acknowledge feelings with language that enhances self-esteem •Help children/adolescents meet expectations •Explain expectations, allow for practice & failure, & be patient

nutrition

· Nutrition plays an active role in maintaining the body's homeostatic mechanisms and in increasing resistance to stress. (Nutrition is discussed in detail in Chapter 36.) Obesity and malnutrition are major stressors and greatly increase the risk for illness. In addition to maintaining a routine exercise schedule, people of all ages should maintain a normal body weight by following the healthy eating pattern guidelines listed below, as established by Dietary Guidelines for Americans (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015). · Food included in a healthy eating pattern: A variety of vegetables and whole fruits Whole grains Fat-free or low-fat dairy, including milk, yogurt, cheese, or fortified soy beverages Protein-rich foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts, seeds, and soy products · Food limited in a healthy eating pattern: Saturated and trans fats, added sugar, and sodium Alcohol

· Promoting Relaxation

· One can relax without sleeping, but sleep rarely occurs until one is relaxed. Stress and anxiety interfere with a person's ability to relax, rest, and sleep. Means for dealing with worries include dealing with problems as they arise, conditioning yourself to consider stressful issues only at certain times, teaching yourself that worrying never solves problems and is counterproductive, and giving the worries over to another (e.g., a trusted family member, friend, caregiver, or God). The distraction and relaxation techniques described in Chapters 28, 35, and 42 may be beneficial for a patient whose worries are contributing to a sleep disturbance. A backrub, music, a warm bath, and washing the face if the patient is bedridden are nursing measures that may be used to help patients relax. The technique for back massage is described in Skill 35-1 (on pages 1271-1274).

homeostasis

· Our bodies are always interacting with a constantly changing environment, including the external environment that surrounds our bodies and the internal environment that includes the mechanisms that regulate body functions and the fluids that surround body cells. · To maintain health, the body's internal environment must remain in a balanced state. Various physiologic mechanisms within the body respond to internal changes to maintain relative constancy in the internal environment, a process called homeostasis. · The concept of homeostasis has been expanded to include both physiologic and psychological balance.

Palliative Sedation

· Palliative sedation is the lowering of patient consciousness using medication for the express purpose of limiting patient awareness of suffering that is intractable and intolerable (Kirk & Mahon, 2010). · When patients who are imminently dying have pain and suffering that is unresponsive to other palliative interventions, palliative sedation to unconsciousness may be considered. Some are concerned that palliative sedation to unconsciousness offers a "back door" to euthanasia, since death is hastened for an unconscious patient who is not being artificially fed. Be sure to check your facility policies. Most restrict palliative sedation to unconsciousness to the imminently dying and exclude patients asking for such sedation for existential suffering or angst

praying with patients

· Patients accustomed to regular periods of prayer but who feel too ill to pray as they would like or who enjoy praying with others may ask the nurse to pray with them or hope that the nurse will suggest this. Because there are many forms of prayer—quiet reflection, silent communion with God or a higher power, reading or recitation of formal prayers, silent or loud calling on God or a higher power or conversation with God or a higher power, lamentations, or reading a holy book or other religious materials—the nurse can take the lead from the patient by asking, "How would you like us to pray?" Consider the patient's religious background along with the type of prayers that have been meaningful in the past. Ask whether the patient has a particular prayer request. · A nurse unaccustomed to praying aloud or in public may find it helpful to have a Bible passage or formal prayer readily available. The prayer may also be a simple expression aloud of the patient's needs and hopes. A sample follows: · Lord God, our Creator and Healer, I entrust Mrs. Smith and her family to your loving care. Bring peace to her mind and health and strength to her body. Be with her [as her treatment begins today, as she goes for surgery, and so on]. We remember all your blessings to us in the past and thank you. We are confident of your help now as we claim your promises. · Prayer should not block communication with the patient. Praying before a patient feels ready to pray may communicate to the patient a lack of interest in the patient's feelings. Because prayer often evokes deep feelings, the nurse should be prepared to spend time with the patient after sharing prayer to respond to these feelings.

organ donation

· Patients who express a wish to donate functional organs, such as heart, corneas, liver, lungs, and kidneys, can fill out an organ donor consent card. In addition, depending on state law, a person may sign the back of his or her driver's license indicating approval of organ donation. The family of a deceased patient may also decide to donate the patient's functional organs. The nurse should be able to review options and provide consent forms to interested patients and their families. · Until recently, most organs were retrieved from totally brain-dead patients. New protocols for retrieving organs from non-heart-beating cadavers are raising multiple practice concerns. Comprehensive attention to optimal patient and family care at the time of withdrawal of life-sustaining therapy must remain the nurse's priority. · The scarcity of organs has resulted in legislation mandating hospitals and other health care facilities to notify transplantation programs of potential donors. Consult the United Network for Organ Sharing (UNOS; www.unos.org), the private, nonprofit organization that manages the nation's organ transplant system under contract with the federal government, to learn more about donation and transplantation.

1. Kubler-Ross stages of death/grief.

· People have varying attitudes about death. Increasing numbers are choosing to die at home surrounded by loved ones. Others die alone or in intensive care units surrounded by health care professionals and technologic equipment. Although each person reacts to the knowledge of impending death or to loss in his or her own way, there are similarities in the psychosocial responses to the situation. Kübler-Ross (1969) studied the emotional responses to death and dying in depth, and nursing and other helping professions have used her findings extensively. · The stages of dying, much like the stages of grief, may overlap, and the duration of any stage may range from as little as a few hours to as long as months. The process varies from person to person. Some people may be in one stage for such a short time that it seems as if they skipped that stage. Sometimes a person returns to a previous stage. According to Kübler-Ross, the five stages of dying, with common reactions, are: Denial: The patient denies the reality of death and may repress what is discussed. The patient may think, "They made a mistake in the diagnosis. Maybe they mixed up my records with someone else's." Anger: The patient expresses rage and hostility and adopts a "why me?" attitude: "Why me? I quit smoking and I watched what I ate. Why did this happen to me?" Bargaining: The patient tries to barter for more time: "If I can just make it to my son's graduation, I'll be satisfied. Just let me live until then." Many patients put their personal affairs in order, make wills, and fulfill last wishes, such as trips, visiting relatives, and so forth. It is important to meet these wishes, if possible, because bargaining helps patients move into later stages of dying. Depression: The patient goes through a period of grief before death. The grief is often characterized by crying and not speaking much: "I waited all these years to see my daughter get married. And now I may not be here to see her walk down the aisle. I can't bear the thought of not being there for the wedding—and of not seeing my grandchildren." Acceptance: When the stage of acceptance is reached, the patient feels tranquil. The patient has accepted the reality of death and is prepared to die. The patient may think, "I've tied up all the loose ends: made the will, made arrangements for my daughter to live with her grandparents. Now I can go in peace knowing everyone will be fine."

Helping At-Risk Patients Maintain a Sense of Self

· People who are acutely ill are often separated not only from their strengths, but also from any real sense of self. This occurs largely because, as patients in health care facilities, they are removed from their personal roles, environments, and belongings, and stripped of their individuality by staff caring for them. One patient, a college president who was recovering from serious complications after surgery for ovarian cancer, shared the following: · When I first got sick, it didn't matter how people treated me because I knew who I was. As I've grown sicker and weaker, I become whatever people make me. If a nurse walks in here and moves me like meat, I become a slab of meat. My sense of self seems more and more dependent on how people respond to me. · Help patients maintain a sense of self and worth by doing the following: Use looks, speech, and judicious touch to communicate worth. Acknowledge the patient's status, roles, individuality. Speak to the patient respectfully and in a nonpatronizing manner. Converse with the patient about the patient's life experience. Address the patient by preferred name whenever entering the patient's room. Offer the patient a simple explanation before initiating any procedure. Move the patient's body respectfully if the patient is unable to do this. Respect the patient's privacy and sensibilities. Acknowledge and allow expression of negative feelings. Help the patient to recognize strengths and explore alternatives. · Always keep in mind that patients are people, first and foremost. See Through the Eyes of a Nurse. A person's illness does not define who that person is. Too often, health care professionals tend to focus primarily on a patient's illness, and the whole person is forgotten or ignored, with potential negative consequences for that patient's sense of self, such as lack of motivation to learn or execute important health care behaviors. The way nurses care for patients can directly affect self-concept; self-concept, in turn, directly affects health. Person-centered nursing care does not require additional nursing time or energy. It does require from the nurse continual reaffirmation that nursing is a thoughtful, person-centered profession, and that nothing is more important at any moment of a nurse's workday than the person being served.

History of success & failure

· People with a history of repeated failure (in school, friendships, work, or marriage) may perceive themselves as failures and actually perpetuate this image by unconsciously encouraging others to treat them this way. · They may come to fear success, and actually find it easier to fail even though they do not like themselves that way. · Thus, failure influences a person's self-concept negatively (e.g., Sullivan's "bad-me" self-representation), and that negative self-concept causes the person to continue to fail. · On the other hand, a series of successful experiences—especially when occurring in the context of an accepting, nurturing, caring relationship—may condition a person to strive for the next success, forging a positive self-concept that fosters an expectation of success and encourages the person to "make it happen."

physical assessment

· Physical examination of the reproductive or genitourinary system is necessary for both male and female patients under the following circumstances: As part of a routine physical examination Annual women's health care examination, including a Pap smear Suspected STI Suspected pregnancy Workup for infertility Unusual lump, discharge, or appearance of the genital organs noticed by the patient Request for birth control Change in urinary function · The examiner may routinely perform a complete physical examination along with assessment of the reproductive system if the patient has not had contact with the health care system within 1 year, or if the assessment findings from a complete examination would be useful in diagnosing something reported by the patient. See Chapter 26 for a detailed description of how to examine the female and male genitalia. · Initially, ask whether the patient has had this type of examination in the past (if this information is not evident in the patient's records). Depending on the patient's knowledge base, explain the progressive steps of the examination and what the patient may feel during the examination. This will give the patient some feeling of control and security during the examination. The nurse's responsibilities during an examination of the reproductive system are as follows: Provide information about the examination. Teach the patient. Provide support to the patient during the examination. Perform the examination or assist the examiner, if appropriate, with any procedures or laboratory studies. · Keeping the patient comfortable and respecting the patient's privacy and modesty should be primary nursing considerations. Some female patients may be uncomfortable with a male examiner, or vice versa, for religious, cultural, or other reasons. The examiner can adapt to such concerns, for example, by ensuring that a female nurse is in the room when a female patient is undergoing a pelvic examination by a male provider.

ADDRESSING PHYSIOLOGIC NEEDS

· Physiologic care of the patient involves meeting physical needs such as personal hygiene, pain control, nutritional and fluid needs, movement, elimination, and respiratory care. Personal hygiene includes cleanliness of the skin, hair, mouth, nose, and eyes. Frequent baths and linen changes may be necessary. The mouth and nose should be kept free of mucus, and secretions should be wiped from the eyes. · The health care provider determines the medication and dosage needed for pain control, but the patient's wishes should be considered (see Chapter 35 for a further discussion of pain control). Some patients prefer and are able to control their own medication. A patient requiring nutritional support should be encouraged to take sips of water or ice chips if still able to swallow. The dying patient may elect to forego artificial nutrition and hydration because the burdens of feeding and hydrating artificially may outweigh the benefits. Problems with elimination include the development of incontinence, constipation, and urinary retention. Absorbent pads or a nearby bedpan may be used for patients experiencing incontinence, laxatives or enemas may be used for relieving constipation, and catheterization may be required for urinary retention. Bed linens should be changed often. Periodic movement should also be assisted; regular changes of position help prevent pressure injuries. Repositioning the conscious patient in semi-Fowler's position can facilitate respirations; positioning the unconscious patient in a semiprone position allows drainage of saliva and mucus. Oxygen therapy may be necessary for some patients.

Physiologic Stressors

· Physiologic stressors have both a specific effect and a general effect. The specific effect is an alteration of normal body structure and function. The general effect is the stress response. · Primary physiologic stressors include chemical agents (drugs, poisons), physical agents (heat, cold, trauma), infectious agents (viruses, bacteria), nutritional imbalances, hypoxia, and genetic or immune disorders.

process planned change

· Planned change is a purposeful, systematic effort to alter or bring about change through the intervention of a change agent. The same steps apply whether dealing with individuals or groups. Recognize symptoms that indicate a change is needed and collect data. Identify a problem to be solved through change. Analyze the symptoms and reach a conclusion. Note resistance or barriers to change and factors that promote the desired change. Determine and analyze alternative solutions to the problem. Consider the advantages, disadvantages, and consequences of each alternative. An analysis of various proposed solutions to a problem may result in using a combination of alternatives. Select a course of action from possible alternatives. Avoid initiating too many courses of action and thereby dissipating resources and energy. Plan for making the change. This step is crucial to effect change successfully. Start by stating specific objectives, designing a plan for change, developing timetables, selecting people to assist with making the change, and anticipating how to stabilize change and deal with resistance to change. Unless a plan is clearly designed, effecting change is likely to be a chaotic experience. Implement the selected course of action to effect change. Put the plan for change into effect. During this period, flexibility is important to adapt to unforeseen problems. Evaluate the effects of change by comparing them with objectives stated in the plan for change. Adjustments can be made in the plan as necessary after evaluation. If the results of evaluation indicate that the course of action selected to solve a problem has been unsuccessful, an adjustment should be made or another course of action selected. Stabilize the change. When a solution has been found, take measures to make the change permanent. Continue follow-up until the change is firmly established. · Similarly, someone who takes good health for granted may fail to develop healthy lifestyle practices until illness results in recognition of the need for change (unfreezing). A careful process of consultation and study may lead to the development of a well-developed fitness plan (moving), which ideally becomes part of the person's everyday life (refreezing). Effective nurses pay attention to their ability to influence the person's thinking and behavior in each stage of change.

planned changed

· Planned change is a purposeful, systematic effort to bring about change. Nurse managers most often implement planned change. The eight steps in the process of change, which are somewhat similar to the steps of the nursing process, are shown in Box 10-6. Kotter (1996) emphasized that for change to be successful, it is important to progress in sequence through each of the eight stages. Skipping any of the steps can result in the vision being sabotaged, momentum faltering, and frustration increasing for all involved in the process. · Before planning to make a change, a nurse manager should consider the following: What is amenable to change? Considering this question may reveal a behavior not amenable to change. How does the group function as a unit? Certain forces within a group may favor change, whereas other forces may resist it. Is the person or group ready for change and, if so, at what rate can that change be expected to be accepted? The pace of change must be consistent with the person's or group's readiness to assimilate change. Readiness involves both the ability and willingness to change. In contemporary health care organizations, change is dynamic, persistent, and very challenging. The concept of flexibility previously mentioned is put to a real test in any clinical or managerial arena. Are the changes major or minor? A series of small changes may be more easily accomplished than one large, dramatic change. The nursing leader/manager must support the staff during the difficult task of acquiring new skills and, frequently, new professional identities. · In today's dynamic health care environment, nurses play a pivotal role in the change process. They must be prepared to initiate and implement quality change projects. The Robert Wood Johnson Foundation and the Institute for Healthcare Improvement originated a program called Transforming Care at the Bedside (TCAB) that focuses on instituting changes to improve patient care on medical-surgical units. Nurses are empowered to address inefficiencies and changes in workflow in an effort to improve the quality of patient care. An additional change effort, the Care Innovation and Transformation (CIT) initiative, was developed by the American Organization of Nurse Executives (AONE). This program supports nurse managers and provides training and tools to ensure a successful change environment.

Quantum

· Porter-O'Grady and Malloch (2003), in Quantum Leadership: A Textbook of New Leadership, argued that leaders must move beyond the traditional modes used by all levels of workers. They, like Drucker (1999) and others, focused on the impact of the information age, identified at the turn of the century, on work and workers. The vertical command and control structures that generated the leadership styles previously mentioned are no longer useful for managers and workers, nor do they yield productivity for organizations. The explosion of information and technology in health care, as in other industries, has spawned, by necessity, the "knowledge worker." This social transformation is affecting aspects of all of our lives, including, perhaps most importantly, how we lead and manage our organizations. · We are in a difficult transition period between the old and the new. In the old, change was viewed as an entity to be planned, carefully managed, and accepted. In the new "quantum age," change is conceived as dynamic, ever present, and continually unfolding. We are forced to experience change at the same time we perceive it, with little or no opportunity to definitively and laboriously plan and manage it. Quantum leadership theory views an organization and its members as interconnected and collaborative—a helpful approach when unpredictable events and changing environments present themselves (Curtin, 2013). Nursing leaders can model these new behaviors by combining these new attributes with the requisite technical skills.

teaching family members to assist in care

· Preparing family members to help provide care yields benefits to both the patient and family members. Having loved ones near comforts the patient. Family members, too, are comforted by knowing that they helped comfort the patient. Teach family members how to provide care to the patient. Family members may not want to provide physical care themselves but may want to know what to expect and how they can psychologically aid the patient. Provide assistance in this area by explaining the patient's condition, what treatment the patient is undergoing, and what result the family can expect from the treatment. Knowing the facts may help family members to cope better with impending loss.

exercise

· Regular exercise helps maintain physical and emotional health. The benefits of exercise include an improved musculoskeletal system, more effective cardiovascular function, weight control, and relaxation. · Exercise improves a person's general sense of well-being, relieves tension, and enables coping with day-to-day stressors. · General health guidelines recommend that an exercise program consists of 30 to 45 minutes of moderate activity above usual activity on most days of the week. · People who are overweight, chronically ill, or older than 35 years of age should have a physical examination before beginning such a program. The type of exercise depends on what the person enjoys—for example, walking, jogging, bicycling, swimming, or sports such as golf or tennis.

relaxation

· Relaxation techniques are useful in many situations, such as childbirth, pain, anxiety, sleeplessness, illness, and anger, and other uses are being discovered. Relaxation promotes a body reaction opposite to that of the fight-or-flight response: respiratory, pulse, and metabolic rates, as well as blood pressure and energy use, can all be decreased using relaxation methods. · Relaxation can be taught to individuals or groups. It is especially helpful because it allows people to control their feelings and behaviors. Various techniques can be used, but most involve rhythmic breathing, reduced muscle tension, and an altered state of consciousness (National Center for Complementary and Integrative Health [NCCIH], 2017). Relaxation is discussed as a comfort measure in Chapter 35. Two helpful relaxation activities, to be practiced three or four times at each session, are deep breathing and progressive muscle relaxation; see Guidelines for Nursing Care 42-2 for a description of these activities.

religion

· Religion can be defined as an organized system of beliefs about a higher power that often includes set forms of worship, spiritual practices, and codes of conduct. Although it is impossible for nurses to be knowledgeable about all religions, we are better able to meet patients' spiritual needs when we understand their religious beliefs and practices. These can directly influence patients' responses to illness and suffering, self-care practices such as diet and hygiene, birth and death rituals, biological sex roles, spiritual practices, and moral codes. The beliefs and health practices of major religious traditions in the United States are briefly described in Table 46-1 on pages 1796-1797. Please remember that these are generalizations and that not all members of religious traditions hold the same beliefs or practices. · The U.S. Religious Landscape Survey of 35,000 Americans by the Pew Research Center's Forum on Religion & Public Life (2015) found that most Americans were religious and most had a nondogmatic approach to faith. At the time of the survey, the largest percentage of Americans—70.6%—were Christian, and 5.9% belonged to non-Christian faiths (Jewish, Muslim, Buddhist, Hindu, and other world religions). Religious "nones" (those unaffiliated with a religion) represented 22.8% of Americans, and of these 3.1% were atheist and 4% were agnostic. · This study found a modest drop between 2007 and 2014 in the percentages of those who say they believe in God, pray daily, and regularly go to church or other religious services. This recent decrease in religious beliefs and behaviors is largely attributable to the "nones"—the growing minority of Americans, particularly in the Millennial generation, who say they do not belong to an organized religion. In addition: Most Americans who are affiliated with a religion do not believe their religion is the only way to salvation. Most also believe that there is more than one true way to interpret the teachings of their religion. More than half of Americans rank the importance of religion very highly in their lives, attend religious services regularly, and pray daily. A plurality of adults who are affiliated with a religion want their religion to preserve its traditional beliefs and practices rather than either adjust to new circumstances or adopt modern beliefs and practices. Significant minorities across nearly all religious traditions see a conflict between being a devout person and living in a modern society. The relationship between religion and politics is particularly strong with respect to political ideology and views on social issues such as abortion and homosexuality, with the more religiously committed adherents across several religious traditions expressing more conservative political views. Americans are very similar in some basic religious beliefs. For instance, Americans are nearly unanimous in saying they believe in God (91%); large majorities believe in life after death (74%) and believe that Scripture is the word of God (63%). More than three quarters of American adults (78%) believe there are absolute standards of right and wrong, with a majority (52%) saying they rely primarily on practical experience and common sense for guidance regarding right and wrong. Far fewer say they rely mainly on their religious beliefs (29%), and fewer still say they rely on philosophy and reason (9%) or scientific information (5%). The United States has largely avoided the secularizing trends that have reshaped the religious scene in recent decades in European and other economically developed nations—but not entirely. The Landscape Survey documents, for example, that the number of Americans who are not affiliated with a religion has grown significantly in recent decades, with the number of people who today say they are unaffiliated with a religious tradition (16% of U.S. adults) more than double the number who say they were not affiliated with a religion as children (7%). Nurses who are unfamiliar with a patient's religion can gain valuable knowledge by discussions with the patient and the patient's family and spiritual adviser. · Never presume to know what a patient's religious beliefs or practices are just because you have learned the patient's faith tradition. Many religious groups and people work out their own set of beliefs and practices, which may or may not be compatible with the tradition at large. Also, you should not interpret the fact that a patient does not belong to an organized religion to mean that the patient has no spiritual needs; a person may be deeply spiritual yet not profess to belong to an organized religion.

sexuality

· Sexual health may be defined as the integration of the somatic, emotional, intellectual, and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication, and love. Because our sexuality is so basic to our sense of self, nurses need to value sexuality as a critical element of general health and well-being. Nurses must also be skilled in identifying and addressing problems related to sexual self-concept, body image, sexual identity, sexual activity, and sexual discrimination or violence. · Sexual identity encompasses a person's self-identity, biological sex, gender identity, gender role behavior or expression, and sexual orientation. · Biological sex is the term used to denote chromosomal sexual development: male (XY) or female (XX), external and internal genitalia, secondary sex characteristics, and hormonal states.

sexual orientation

· Sexual orientation refers to romantic, emotional, affectionate, or sexual attraction to other people (Regents of the University of California, Davis campus, 2017). Here is an informal way to think about this: gender/gender identity is who one goes to bed as, whereas sexual orientation is who one goes to bed with. The origins of sexual orientation are unknown, but many studies claim a genetic basis. Some sexual preferences are culturally determined or may be dictated by opportunity. · Although there is possible fluidity and ongoing debate regarding the human sexuality spectrum, commonly identified sexual orientations are as follows: Heterosexual or straight refers to a person who experiences sexual fulfillment with a person of the opposite gender. Gay (males or females) or lesbian (females) refers to a person attracted to members of the same gender. (Note that the term homosexual is outdated and no longer considered appropriate [GLAAD, n.d.].) Bisexual refers to a person who is attracted to both men and women. A bisexual relationship or encounter does not necessarily mean a person is gay. Transsexual refers to a person who lives full-time as a member of a gender that differs from the sex and gender he/she/they were assigned at birth. This term sometimes specifically refers to those transitioning with hormones or confirmation surgery. Asexual refers to a person who lacks romantic or sexual attraction to others. Questioning refers to a person who is unsure of his/her/their sexual orientation.

sexually transmitted infections

· Sexually transmitted infections (STIs), or sexually transmitted diseases (STDs), once called venereal diseases, are infections that are spread primarily through sexual contact. Although STIs and STDs are often used interchangeably, in health care, STI is more commonly used because not every STI results in disease or has active symptoms. · STIs are among the most common infectious diseases in the United States today. More than 27 STIs have been identified by the Centers for Disease Control and Prevention (CDC, 2017). The CDC (2016b) estimates that nearly 20 million new STIs occur every year in the United States, half among young people ages 15 to 24. Each of these infections is a potential threat to a person's immediate and long-term health and well-being, and can lead to severe reproductive health complications, such as infertility. · Table 45-2 on page 1760 lists common types of STIs and their signs and symptoms. The annual comprehensive cost of STIs in the United States is estimated to be almost $16 billion. · According to the National Institute of Allergy and Infectious Diseases (NIAID, 2015), understanding the basic facts about STIs—the ways in which they are spread, their common symptoms, and how they can be treated—is the first step toward prevention. News releases, fact sheets, research studies, and other NIAID-related materials are available on the NIAID website at www.niaid.nih.gov. NIAID recommends understanding at least five key points about all STIs in the United States today: STIs affect men and women of all backgrounds and economic levels. They are most prevalent among teenagers and young adults. The incidence of STIs is rising, in part because in the last few decades, young people have become sexually active earlier yet are marrying later. In addition, divorce is more common. The net result is that sexually active people today are more likely to have multiple sex partners during their lives and are potentially at risk for developing STIs. Most of the time, STIs cause no symptoms, particularly in women. When symptoms develop, they may be confused with those of other diseases not transmitted through sexual contact. Even when an STI causes no symptoms, a person who is infected may be able to pass the disease on to a sex partner. That is why many doctors recommend periodic testing or screening for people who have more than one sex partner. Health problems caused by STIs tend to be more severe and more frequent for women than for men, in part because the frequency of asymptomatic infection means that many women do not seek care until serious problems have developed. Some STIs can spread into the uterus and fallopian tubes to cause pelvic inflammatory disease (PID), which is a major cause of both infertility and ectopic (tubal) pregnancy. The latter can be fatal. STIs in women may also be associated with cervical cancer. One STI, human papillomavirus (HPV) infection, causes genital warts and cervical/other genital cancers. STIs can be passed from a mother to her baby before, during, or immediately after birth; some of these infections of the newborn can be cured easily, but others may cause a baby to be permanently disabled or even to die. When diagnosed and treated early, many STIs can be treated effectively. Some infections have become resistant to the drugs used to treat them and now require newer types of antibiotics. Experts believe that having STIs other than HIV increases a person's risk for becoming infected with the HIV virus (NIAID, 2015). · Reported STIs are at an all-time high in the United States, with men who have sex with men (MSM) and young people ages 15 to 24 years disproportionally affected (CDC, 2016b). Providers, the public, parents (with provider support), and state and local health departments must work together to provide targeted education on chlamydia, gonorrhea, and syphilis, which are increasing in prevalence and are curable with antibiotics. Left untreated, the effects of these STIs can be devastating. Sexual dysfunction is a problem that prevents a person or couple from engaging in or enjoying sexual intercourse and orgasm. Dysfunctions might occur as a result of physiologic malfunctions, conflicts with cultural norms, interpersonal problems, or any combination of these. Anxieties and fears concerning the sexual act are almost always present. Patients with severe sexual dysfunctions require intensive professional therapy from a qualified sex therapist.

medication

· Some medications have side effects that may affect sexual functioning · . These include nitrates, anticonvulsants, antidepressants, antihistamines, antihypertensives, antipsychotics, antispasmodics, barbiturates, and narcotics. Recreational drugs including cocaine, alcohol, and marijuana are used by some to heighten the sexual experience. · These drugs can have serious and even deadly side effects. While some use alcohol to release inhibitions and to increase sexual arousal and desire, heavy drinking can decrease libido and negatively affect sexual functioning.

· Promoting Comfort

· Some of the greatest deterrents to rest and sleep are discomfort and pain, which commonly occur in illness. Depending on the cause and severity of the discomfort or pain, appropriate nursing measures include remaining with a lonely and frightened child or adult, using the simple strategy of caring presence and touch, offering a back massage, obtaining an extra blanket, or administering an analgesic. These and other nursing techniques to promote comfort are described in Chapter 35. Be sensitive to the patient's discomfort to recognize and implement interventions to relieve it.

nuturing spirituality

· Some patients who experience a need to get in touch with their spiritual self and to nurture their spiritual development look to the nurse for direction. Someone who lives life enmeshed in the action and noises of society may feel strange and uncomfortable when illness forces introspection. Be helpful by recommending methods a person might use to develop a relationship with his or her own inner world (such as prayer, reflection, dream analysis, nature walks, enjoying art) and ways to manifest spiritual energy in the outer world (such as loving relationships, compassion, forgiveness, joy, service). · Spiritual nurturing for the patient's family caregivers is also important. Recent research findings support the importance and value of caregivers' spirituality, yet this resource is often overlooked. Consider using interventions that enhance a caregiver's ability to take part in church activities to satisfy spiritual needs and to work with church groups to secure helpful services. Using clergy, prayer, forgiveness, and spiritual reading materials as resources for caregivers may also be helpful. · Finally, remember that, as nurses, we cannot give what we don't have. Unless our own spiritual needs are met, we will never be able to be truly present to another. Thus, the art of being a healing presence requires a lifestyle that supports our being a healing presence. Reflect on this proverb: A happy heart is like good medicine. But a broken spirit drains your strength (dries your bones).—Proverbs 17:22 · The nurse can help patients to nurture their own spirituality by promoting meaning and purpose, love and relatedness, and forgiveness.

religion

· Some people view organized religion as having a generally negative effect on the expression of sexuality. For example, in many religions, the concept of virginity came to be synonymous with purity, and sex became synonymous with sin. · In addition, many forms of sexual expression other than male-female coitus are considered unnatural by some religions. As a result of the rigid regulations and negative connotation of sex dictated by some religious groups, a number of sexual dysfunctions can be related to a person's resulting guilt and anxiety. · Most major religions are reexamining their teachings on sexuality in response to challenges posed by their members. Organized religions, such as Catholicism, have public figures who are moving toward gender inclusivity by accepting and having frank conversations with and about the LGBT (Lesbian, Gay, Bisexual, Transgender) communities (Martin, 2017). · Many people have recognized the importance of solid sex education within the realm of the church and organized religions. There is also a new interest in the spirituality of marriage: churches and organized religions are examining their role in supporting the intimate sexual relationship of married couples.

Spirituality

· Spirituality is anything that pertains to a person's relationship with a nonmaterial life force or higher power. While one person describes spirituality in terms of coming to know, love, and serve God, another speaks of transcending the limits of body and experiencing a universal energy. · Aspects of spirituality include the following: Spirituality is experienced as a unifying force, life principle, essence of being. Spirituality is expressed and experienced in and through connectedness with nature, the earth, the environment, and the cosmos. People express and experience spirituality in and through connectedness with other people. Spirituality shapes self-becoming and is reflected in a person's being, knowing, and doing. Spirituality permeates life, providing purpose, meaning, strength, and guidance, and shaping the journey. · While analyzing concepts of spirituality through a review of related literature, nurse scholar Bernice Golberg (1998) identified the following phenomena: meaning, presencing (standing in the presence of another consciously believing in—and affirming—his or her capacity for wholeness), empathy/compassion, giving hope, love, religion/transcendence, and touch and healing. All appeared to be products of relationships, some physical (presencing, touch and healing), and others emotional (meaning, empathy/compassion, hope, love, and religion/transcendence). Golberg combined these and gave spirituality the label "connection" (1998, p. 836).

stress management

· Stress creates emotional distress that often produces physical signs and symptoms. One person may have tension headaches, another may become irritable, and yet another may clench both fists. · Some people take legal or illegal drugs, smoke, drink to excess, or eat compulsively. These behaviors can be modified, and adaptive mechanisms strengthened, through specific techniques aimed at managing stress. · Only a few techniques are included here, but the literature describes many stress reduction methods, including exercise, prayer, art therapy, music therapy, massage, and therapeutic touch. Chapter 28 provides more information. Students should learn different methods they can use for themselves and in varied clinical situations.

· Minimizing Sleep Disturbances in Health Care Settings

· Studies have demonstrated that excessive noise on patient care units interferes with sleep and that these noise-related disruptions can increase blood pressure, decrease oxygen saturation, and delay wound healing (Delaney, 2016; Haupt, 2012). Behavioral manifestations such as disorientation, restlessness, and irritability are also possible consequences, particularly in older adults. Patient surveys consistently report that noise and sleep deprivation are among the top concerns during a hospitalization (Adatia, Law, & Haggerty, 2014; Anderson, 2012; Fillary et al., 2015). The most commonly implicated sources of noise include staff conversations, roommates, and electronic sounds such as IV alarms and phones. Researchers have reported that the patient's stage of sleep can affect the patient's response to hospital noises. Sleep disruption is more common during non-REM stage II sleep. One group of researchers reported that hospital noise levels during the day were above World Health Organization recommendations and at times even approached the sound level produced by a chain saw (Wallis, 2012). In an ICU setting, sleep is even further challenged by the level of light in the unit. Nighttime light can range from a level similar to that at twilight and peak at a level brighter than lighting in some television studios (Dave, Qureshi, & Gopichandran, 2015). Environmental factors impacting a good night's sleep are not limited to acute care settings; residents in long-term care settings can encounter challenges in obtaining adequate sleep as well (Ellmers et al., 2013). Nursing interventions to manage the level of light and sound, thus facilitating a more restful environment, include: Maintaining a brighter room environment during daylight hours and dim lights in the evening Decreasing the volume on alarms, telephones, overhead paging, and staff conversations Closing doors to patient rooms Scheduling procedures together so as not to awaken patients multiple times for vital signs, blood draws, bathing, or medication administration that can safely be postponed for a short time Medicating for pain if needed · Keeping the room cool and providing earplugs and eye masks if requested and as appropriate (Dave et al., 2015). · Some health care facilities have implemented specific efforts to minimize noise levels. These initiatives include innovative use of communication technology to target noise reduction; the use of ear plugs and eye masks (see the accompanying Research in Nursing display); and campaigns titled "Shhh" (Silent Hospitals Help Healing), and "Hush" (Help Us Support Healing), and institution of a Quiet Hour (AACN Bold Voices, 2014; Chen, 2012; Haupt, 2012). It is difficult to guarantee a good night's sleep during a hospitalization but recognizing and listening to patients' concerns are critical to delivery of individualized, quality nursing care.

surgery and body image

· Surgery is performed to remove diseased tissue and repair body organs, usually requiring an incision with resulting scars. The most devastating kinds of surgery are those used to remove cancerous tissue and surrounding structures. Patients are almost always distressed about a diagnosis of cancer and possible death. After surgery, patients need to adjust to major alterations in their bodies. Changes in body image also affect a person's self-perception as a sexual being. · Mastectomy is a surgical procedure to remove a breast and surrounding tissue. After such a surgery, a woman's return to sexual functioning depends on many factors, such as support of her partner, the value placed on the breast by the man or woman, and fear of discomfort during sexual activity. Allowing the patient time to grieve the loss of her uterus or breast(s) is appropriate and may help with long-term coping. · An ostomy is a surgical opening placed on the outside of the body to allow for the passage of secretions and elimination into a closed drainage bag. Grieving over the loss of the natural means to eliminate waste, such as urine or feces, accompanies learning to live with an obvious artificial device. Many people are anxious as to how this apparatus will affect their sex lives and how accepting their partners will be of it. Odor and leakage concerns need to be addressed to increase comfort with the device.

terminal weaning

· Terminal weaning is the gradual withdrawal of mechanical ventilation from a patient with a terminal illness or an irreversible condition with a poor prognosis. In some cases, competent patients wish their ventilatory support to be ended; more often, the surrogate decision makers for an incompetent patient determine that continued ventilatory support is futile. · Although it may be expected that a patient will not survive the weaning, death is never a certain outcome, and it is not unusual for a patient to begin spontaneous respirations once ventilatory support is withdrawn and live for several hours to several days. · Competent patients and family members should be prepared for all possibilities. A nurse's role in terminal weaning is to participate in the decision-making process by offering helpful information about the benefits and burdens of continued ventilation and a description of what to expect if terminal weaning is initiated. · Supporting the patient's family and managing sedation and analgesia are critical nursing responsibilities. Unfortunately, many facilities and institutions do not have policies covering this issue. Nurses involved in terminal weaning should consult the literature and be familiar with the latest research.

1. legal death & medical death

· The accurate definition of death has proven difficult over time, as technologic advances, such as cardiopulmonary resuscitation, have been able to restore lost functions and "bring a person back to life." · The Uniform Determination of Death Act (1981) provides a legal definition of death as either (1) irreversible cessation of all functions of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brainstem. A determination of death must be made in accordance with accepted medical standards. · A Harvard University Medical School committee later added that the irreversible loss of brain function, accompanied by the more traditional signs, should be the definitive definition of death. These "Harvard criteria" are generally accepted with the understanding that errors in certification of death could occur in conditions that may not permanently suspend life processes, such as hypothermia (extreme cold), drug or metabolic intoxication, or circulatory shock. In addition, special attention must be paid when establishing death in a child under the age of 5. · Most protocols for establishing death require two separate clinical examinations. The medical criteria used to certify a death are as follows: Cessation of breathing No response to deep painful stimuli Lack of reflexes (such as the gag or corneal reflex) and spontaneous movement Flat encephalogram (brain waves) · You may hear clinicians refer to heart-lung death (cessation of the apical pulse, respirations, and blood pressure) and cerebral or higher brain death (when the cerebral cortex is irreversibly destroyed). These clinical signs may be further confirmed by an electroencephalogram or cerebral blood flow study.

Physiologic Homeostasis

· The autonomic nervous system and the endocrine system primarily control homeostatic mechanisms. Involved to a lesser degree are the respiratory, cardiovascular, gastrointestinal, and renal systems. These mechanisms are self-regulating, organized, and coordinated; they occur without conscious thought, and defend against change to the body's internal environment. On a simple level, these self-regulating mechanisms are like a thermostat regulating a furnace. When the temperature in a house falls below the preset temperature on the thermostat, the thermostat turns on the furnace, which heats the house to the desired temperature and then shuts off. This is a classic example of a negative feedback system, which is the primary means by which homeostasis is maintained (Porth, 2015). · The regulatory mechanisms of the body are reacting constantly to internal changes to maintain homeostasis and health. The homeostatic mechanisms of the body systems are summarized in Table 42-1 on page 1662. These mechanisms explain the consequences of both short- and long-term stress, which can threaten physiologic homeostasis and result in illness. In the 1980s, some investigators began using the term allostasis to describe this process of achieving stability or homeostasis through physiologic or behavioral change. The cumulative negative effects of these physical responses to prolonged environmental and psychosocial stressors are referred to as an allostatic load. This represents the consequences of ongoing stress on the body with its resultant risks for a variety of diseases (Pender et al., 2015; Porth, 2015). Box 42-2 provides examples of illnesses known to be associated with stress.

sexual history

· The comprehensive health history should include information regarding a patient's reproductive and sexual health, depending on the circumstances in which the patient is receiving care. As a rule, three general categories of patients should have a sexual history recorded by the nurse: Any inpatient or outpatient receiving care for pregnancy, STI, infertility, or contraception Any patient experiencing sexual dysfunction Any patient whose illness will affect sexual functioning and behavior in any way · Information is best obtained from the patient by beginning with nonthreatening questions and progressing to more sensitive concerns (see Focused Assessment Guide 45-1 on page 1766). Patients usually have no difficulty answering questions regarding their bodies and general reproductive issues, such as, "When did your menstrual periods first begin?" Explain to patients that this information may help you develop the care plan and identify any sexual problems or concerns. The assessment provides an excellent opportunity to teach by helping the patient confront fears. · Four general levels of sexual history are: · Level 1: Sexual history as part of a comprehensive health history—obtained by a nurse · Level 2: Sexual history—obtained by a nurse with education and training in sexuality · Level 3: Sexual problem history—obtained by a sex therapist · Level 4: Psychiatric/psychosocial history—obtained by a psychiatric nurse clinician · Each level acquires more specific information from the patient regarding sexual health, and thus requires the interviewer to have more sophisticated preparation and skills. The clinical nurse usually performs a sexual history on level 1. · The nurse sets the tone or atmosphere for the interview. The nurse's attitudes will greatly affect the patient's response to the sexual history; patients will be more cooperative if they sense the nurse's security and ease during the interview. Privacy is essential for the sexual history; doors should be closed and no interruptions allowed. Sit close to the patient and speak in a quiet, relaxed, objective tone of voice. Use eye contact and open body posture. Explain to the patient that only providers directly involved with the care of the patient will have access to this information. · Obtain reproductive health information first, followed by the sexual health history. The best approach is to begin with general open-ended questions and progress to more specific ones. Try to use the terminology used by the patient because the patient may be reluctant to admit not understanding certain terms for fear of appearing ignorant or foolish. For example, the patient may use the term "come" or "cum" to mean climax or orgasm. Although gender identity is different from biological sex or sexual identify, it may need to be discussed if working with a patient whose gender is different from his, her, or their biological sex. For example, gender discussion will help determine preferred pronouns and ensure the appropriate biological questions are asked. Use appropriate terms and allow the patient to provide whatever information the patient is comfortable sharing. · It is useful to begin questions with phrases such as "many people like" or "many people feel." This gives patients security in knowing they are not alone in how they feel and will encourage them to talk about their problems or concerns. For example, "Many people feel that it's helpful to discuss their concerns about sex with their partner. What do you think about this?" · One helpful structure for obtaining information about sexual problems follows: Description of the problem: "How would you describe the problem?" Onset and cause of the problem: "What do you think caused the problem, or what was happening when you first noticed it?" Past attempts at resolution: "What have you tried in the past to correct the problem?" Goals of the patient: "What do you wish to accomplish?" · A narrative format is generally used for recording a sexual history because it allows the interviewer to document the data in many of the patient's own words. If a patient is seeking help for a sexual problem, a more specific format is used to record information obtained by a skilled therapist.

Identify physical assessment findings that would indicate insufficient sleep

· The findings in the physical assessment may either confirm that the patient is getting sufficient rest to provide energy for the day's activities or validate the existence of a sleep disturbance that is decreasing the quantity or quality of sleep. Key findings include energy level (presence of physical weakness, fatigue, lethargy, or decreased energy), facial characteristics (narrowing or glazing of eyes, swelling of eyelids, decreased animation), or behavioral characteristics (yawning, rubbing eyes, slow speech, slumped posture). Physical data suggestive of potential sleep problems (e.g., obesity, enlarged neck, deviated nasal septum) may also be noted. · If the nurse or a bed partner can observe the patient sleeping, other sleep characteristics to assess include restlessness, sleep postures, and sleep activities such as snoring or leg jerking (RLS). Snoring is caused by an obstruction to airflow through the nose and mouth. Other than disturbing others in the same bedroom, snoring is not ordinarily a sleeping disorder. However, snoring accompanied by apnea can present a problem. When snoring changes from the characteristic sawing-wood sound to a more irregular silence followed by a snort, this indicates obstructive apnea. As mentioned earlier, the American Academy of Pediatrics states that snoring in children needs to be evaluated as a possible indication of OSA.

· Promoting Responsible Sexual Expression

· The form of sexual expression used by patients should not inflict unwanted harm on themselves or others. When sexual expression encroaches on the rights of others, it is neither healthy nor desirable. Sexual acts that violate another's rights are usually considered to be acts of aggression or hostility rather than stemming from sexual need or desire. Rape, in particular, is motivated by a need to dominate and humiliate the victim. · PREVENTION OF UNWANTED PREGNANCY · Contraception is a process or technique for preventing pregnancy by means of a medication, device, or method that blocks or alters one or more of the processes of reproduction in such a way that sexual intercourse can occur without impregnation. The prevention of unwanted pregnancy must be a conscious decision. Anyone who is unprepared for pregnancy should refrain from intercourse or obtain a contraceptive method from a health care provider or from the pharmacy; it is too late to think about contraception during sexual intercourse. To practice responsible sex, the contraceptive method must be used consistently and according to instructions. · PREVENTION OF STIs · As described earlier, STIs are widespread. The only sure way to avoid an STI is to avoid all types of intimate genital contact. When this is impractical, there are other practices that can decrease a patient's risk for STIs (Box 45-1). In the United States, Black women account for most new cases of HIV and AIDS among women. In fact, HIV diagnosis in Black women in 2015 was second only to Black, White, and Hispanic/Latino men who have sex with men (MSM; CDC, 2018a). Most women of color acquire the disease from heterosexual contact, often from a partner who has undisclosed risk factors for HIV infection. A combination of testing, education, socioeconomic support, and brief behavioral interventions can help reduce the rate of HIV infection and its complications among women of color. · SEX EDUCATION · Sex education is critical to healthy sexual development and safe sexual behaviors. Information received from peers and friends is almost always inadequate and may be erroneous. Parents should be taught to answer children's questions immediately and accurately. Evidence-based, age-appropriate teen pregnancy programs are funded by Congress through Teen Pregnancy Prevention (TPP) Program grants (Office of Adolescent Health, USDHHS, 2017). Abstinence-only programs that do not include more comprehensive approaches have limited (if any) impact on reducing sexual activity. Abstinence-only programs do not influence the number of sexual partners, use of contraceptives, incidence of STIs, or even pregnancy rates. Comprehensive sex education programs improve knowledge, change attitudes and behaviors, and affect outcomes; abstinence-only programs have not been shown to have this positive effect

general adaptation syndrome

· The general adaptation syndrome (GAS) is a biochemical model of stress developed by Selye (1976). The GAS describes the body's general response to stress, a concept essential in all areas of nursing care. The three stages in the GAS are alarm reaction, stage of resistance, and stage of exhaustion (Fig. 42-2). Although the alarm stage is short term (minutes to hours), the length of the resistance and exhaustion stages varies greatly, depending on such variables as the severity and duration of the stressor, the person's previous health and coping mechanisms, and the immediacy and effectiveness of health care interventions. · The GAS is a physiologic response to stress, but it is important to remember that the response results from either physical or emotional stressors. The stages occur with either physical or psychological damage to the person. Obvious examples are seen in patients with severe injury or an illness, but GAS is also a factor in mental illness, social isolation, and loss of (or lack of) human relationships. · ALARM REACTION · Alarm is initiated when a person perceives a specific stressor and various defense mechanisms are activated. The perception of threat may be conscious or unconscious. The hypothalamic-pituitary-adrenal (HPA) axis controls the neuroendocrine response, and hormone and catecholamine levels rise to prepare the body to react. The sympathetic nervous system initiates the fight-or-flight response, preparing the body to either fight off the stressor or to run away from it (usually not literally in the modern world). This phase of the alarm reaction, called the shock phase, is characterized by an increase in energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness. (If you recall the last time you almost had a car crash, you can easily identify these body reactions!) During the second phase of the alarm reaction, countershock, there is a reversal of body changes. · STAGE OF RESISTANCE · Having perceived the threat and mobilized its resources, the body now attempts to adapt to the stressor. Vital signs, hormone levels, and energy production return to normal. If the stress can be managed or confined to a small area (LAS), the body regains homeostasis. If the stressor is prolonged or strong enough to overwhelm the body's ability to defend itself (e.g., severe injury and bleeding or a major illness such as cancer or a heart attack), the adaptive mechanisms become exhausted. · STAGE OF EXHAUSTION · Exhaustion results when the adaptive mechanisms can no longer provide defense. This depletion of resources results in damage to the body in the form of wear and tear or systemic damage (Porth, 2015). Without defense against the stressor, the body may either rest and mobilize its defenses to return to normal or reach total exhaustion and die.

cause of death

· The grief response often depends on the cause of death. Many deaths are sudden and involve shock as well as normal grieving in the survivors. Death from disease may generate several types of responses, including the belief that the death is a punishment (e.g., when AIDS was first diagnosed in homosexuals and drug users); terror and panic (e.g., when people are reminded of the devastation caused by plagues of earlier centuries); and guilt (e.g., when family and friends believe that they could have prevented the death). · Accidental death is often associated with feelings of bad luck. The guilt response can be enormous, especially when children die as the result of an accident. Death while defending a country usually is viewed by most of society as honorable and necessary. Violent deaths occur daily, especially in larger cities. Suicide accounts for a great number of violent deaths; in fact, among teenagers, it has become a major concern. It is also believed that many accidental deaths are actually suicides.

· Health Care Needs of Lesbian, Gay Male, Bisexual, and Transgender People

· The health and well-being of lesbian, gay male, bisexual, and transgender (LGBT) people has been made a priority by major federal health care facilities. The term LGBT has been expanded to LGBTQIA (Lesbian, Gay, Bisexual, Transgender/Transsexual, Questioning/Queer, Intersex, Ally/Asexual), but the terms associated with the acronym vary slightly depending on the source. The Institute of Medicine's consensus report (IOM, 2011), Healthy People 2020 (2018b), and USDHHS (2016) all highlight the need for better science-based knowledge on how best to address the existence of health disparities of LGBT people and the lack of compassionate services. Stigma and a range of other social and cultural factors affect the health of LGBT people, as well as the ability of the health care system and providers to care for them. LGBT people come from diverse cultural backgrounds, have varied ethnic or racial identity, and differ in terms of education, age, income, and place of residence. Those who identify as lesbian, gay, bisexual, or other may be defined by their sexual orientation, but this definition is complex and variable. Sexual behavior, cultural factors, disclosure of sexual orientation and/or gender identity, prejudice and discrimination, and concealed sexual identity each present unique health challenges to this population Other issues that affect health care delivery to the LGBTQIA population include the following: Public health infrastructure: Efforts to research and address the health care needs of LGBTQIA people are hindered by an inadequate infrastructure to support and fund population-specific initiatives. Access to quality health services: Financial, structural, personal, and cultural barriers limit access to screening and prevention services and cause delays in care for acute conditions in the LGBTQIA population. Health communication: Negative provider attitudes, lack of provider education regarding unique aspects of lesbian and gay health, and exclusion of same-sex partners in care planning seriously hamper therapeutic communication between members of the LGBTQIA community and those who provide care. Educational and community-based programs: Some government facilities, professional organizations, and health care organizations address health issues of the LGBTQIA community, but this population still relies heavily on self-created community-based programs to address their special health care requirements. Clearly, significant research is needed regarding the unique experience and health care needs of the LGBT population, along with increased education for health care providers. Issues of prejudice and inequitable service distribution in the health care system need to be addressed to improve the health of this population.

Health & response to illness

· The health-illness continuum (described in Chapter 3) is affected by stress. Health and homeostatic balance are at one extreme of the continuum; exhaustion and death are at the other extreme. · Stress in a healthy person may promote health and prevent illness. For example, the fear of developing lung cancer may motivate a person to stop smoking, or anxiety about baby care may prompt prospective parents to attend prenatal classes and read childcare books. Stressors in health also facilitate normal growth and development, provide the stimulus for learning constructive adaptive behaviors, stimulate problem-solving abilities, encourage social relationships, and help develop spiritual strength. · The effects of stress on a sick or injured person are, in contrast, usually negative. Stress can make illness worse, and illness can cause stress. The presence of an illness or a disability demands new coping skills at a time when homeostasis is challenged. People who enter health care settings as patients are also subjected to situational stressors. · Adaptation to acute and chronic illness or to traumatic injury involves two sets of adaptive tasks: General tasks (as in the case of any situational stress) involve maintaining self-esteem and personal relationships and preparing for an uncertain future. Illness-related tasks include such stressors as losing independence and control, handling pain and disability, and carrying out the prescribed medical regimen. · Every situation is different, and each person perceives and reacts to stressors in an individual manner. There is no one best way to cope with a given situation. Nursing considerations include the person's major concern, specific illness, sociocultural background, and available resources. For example, an older woman may be anxious about the cost of treatment for her hip fracture, whereas another woman with the same injury may be seriously worried about the care of her cats while she is in the hospital. As another example, Kristin and Jane have both entered the hospital for treatment of breast cancer. Kristin is worried about possible disfigurement and death, but she believes that with the help of surgery and chemotherapy, she can overcome the cancer. Jane, on the other hand, comes from a community that has strong fundamental religious beliefs. She believes that the cancer is a punishment from God and refuses treatment, even though she fears death.

SPIRITUAL DIMENSION

· The human "spirit" dimension was first recognized in ancient cultures. One person often played the roles of both priest and health care provider, ministering to the spirit and the body. Over the years, however, medicine and religion evolved separately. · Not until the holistic health movement took root was the person once again viewed as an integrated whole of body, mind, and spirit. Health care practitioners began again to probe the relationships among physical, psychological, social, and spiritual health. · Two models are currently used to illustrate these relationships (Fig. 46-1 on page 1793). In the integrated approach, the physio-psycho-socio-spiritual model has four equal dimensions, each of which influences the other. In the unifying approach, the spiritual dimension grounds the physiologic, psychological, and sociologic dimensions. · While it is interesting to interview professional healers about which model is more consistent with their experience, both demand of the nurse greater competence in identifying and meeting spiritual needs than most practicing nurses today display. National guidelines now mandate spiritual care—see The Joint Commission requirements (2017) and the National Consensus Project for Palliative Care (2018). In 2016, the HealthCare Chaplaincy Network developed the most comprehensive evidence-based indicators that demonstrate the quality of spiritual care in health care in a move aimed at advancing spiritual support and meeting the needs of patients, their families, and health care institutions. · According to Shelly and Fish (1988), three spiritual needs underlie all religious traditions and are common to all people: Need for meaning and purpose Need for love and relatedness Need for forgiveness · Although nurses may differ in their beliefs about how involved they should become in meeting patients' spiritual needs, it is impossible to nurse patients well while ignoring the spiritual dimensions of health. Nurses can assist patients to meet spiritual needs by offering a compassionate presence; assisting in the struggle to find meaning and purpose in the face of suffering, illness, and death; fostering relationships (with a higher being or other people) that nurture the spirit; and facilitating the patient's expression of religious or spiritual beliefs and practices (e.g., see the Reflective Practice box on page 1792).

ideal vs false self

· The ideal self constitutes the self one wants to be. · These self-expectations develop unconsciously early in childhood and are based on images of role models such as parents, other caregiving figures, and public figures. · These personal expectations may be healthy or unhealthy. · Contrast the significance of a child's identifying a television "bad boy" or a drug dealer as his hero rather than parents, government leaders, or other professional people. False self · may develop in people who have an emotional need to respond to the needs and ambitions significant people, such as parents, have for them

local adaptation syndrome

· The local adaptation syndrome (LAS) is a localized response of the body to stress. It involves only a specific body part (such as a tissue or organ) instead of the whole body. The stress precipitating the LAS may be traumatic or pathologic. LAS is a primarily homeostatic, short-term adaptive response. Although the body has many localized stress responses, the two most common responses that influence nursing care are the reflex pain response and the inflammatory response. · REFLEX PAIN RESPONSE · The reflex pain response is a response of the central nervous system to pain. It is rapid and automatic, serving as a protective mechanism to prevent injury. The reflex depends on an intact, functioning neurologic reflex arc and involves both sensory and motor neurons. For example, if you step into a bathtub of dangerously hot water, sensors in your skin detect the heat and immediately send a message to the spinal cord. A message is then sent to a motor nerve, which activates the muscles in your leg to pull back your foot. All of this happens before you consciously realize that the water is too hot to be safe. · INFLAMMATORY RESPONSE · The inflammatory response is a local response to injury or infection. It serves to localize and prevent the spread of infection and promote wound healing. When you cut your finger, for example, you often develop the symptoms of the inflammatory response: pain, swelling, heat, redness, and changes in function.

· Enhancing Self-Esteem in Older Adults

· The many losses associated with aging (e.g., diminished strength and physical health, interpersonal losses, retirement, shrinking income) make older adults especially vulnerable to disturbances in self-concept, particularly chronic low self-esteem. Society's generally negative view of aging compounds the problem. When interacting with older adults, employ the following interventions to enhance and maintain self-esteem in this population: Identify your own attitudes and feelings about aging and older adults. Address seniors respectfully, communicating that you take their concerns seriously. Respect and affirm seniors' intellect, individuality, personal strengths, culture, and spirituality. Adjust your communication style to accommodate any sensory or cognitive deficits. Encourage sharing of life experiences. Assist the person to identify strengths and coping mechanisms to deal with problems. Provide a safe environment for older adults to communicate such concerns as interpersonal or physical loss, feelings about illness and death, sexuality, or financial issues. Advocate for seniors needing help in attaining services necessary to meet their health care needs. Explore the personal meaning of dependency for the person, and help seniors adapt both physically and emotionally to any necessary dependency.

participation in nursing and other professional organizations

· The many nursing organizations at the international, national, state, district, and local levels are discussed in Chapter 1. They are major forces for nursing leadership and have active groups throughout the United States and abroad. The more than 100 professional organizations address specialty interests, goals, and purposes, as well as advocate for nurses and nursing. Representatives of these nursing organizations also work with ANA lobbyists in Congress and state legislatures regarding nursing concerns, health care issues, and quality care. · The AONE, recognizing the need for leadership development for nurse managers, united with the American Association of Critical-Care Nurses (AACN) and the Association of periOperative Registered Nurses (AORN) to develop a model that includes content on the science and art of management for nurses, and creation of the leader within yourself (Fig. 10-5) (AONE, 2012). This model is intended to engage nurses in exploring potential solutions to achieve their management goals. · Nursing leadership can define what the future should look like and help make it happen. Participation in nursing and other professional organizations provides important opportunities for nurses to develop and exhibit leadership.

· Facilitating Coping With Special Sexual Needs

· The nurse can help patients cope with sexual concerns generated by diseases and their treatments. See the accompanying Research in Nursing box. Offer anticipatory guidance and information to patients, stressing the importance of open communication with the patient's partner, and also include the partner in teaching. · For appropriate patients, start a discussion about possible sexual positions that can reduce pain during coitus. Show the patient drawings of possible sexual positions. Inform the patient that intercourse may be more comfortable if pain medication is taken before beginning sexual activity. When teaching patients about medications, mention any sexual side effects that may occur to prevent anxiety and depression. Patients should alert the health care provider if these side effects occur because often the drug dosage can be modified or the drug changed. If patients are unaware of this, they may discontinue the medication on their own rather than sacrifice sexual functioning, if this is an important aspect of life for them

Meeting the Needs of the Family

· The nurse can provide care for the family facing loss by listening to their concerns. Family members need to verbalize their worries and fears; nurses and other health care personnel can provide support by being nonjudgmental listeners. Likewise, nursing care of the grieving family involves communication and listening. Use the communication skills discussed in Chapter 8 and earlier in this section to be a nonjudgmental listener. Feedback to the family can be provided by summarizing or paraphrasing, without questioning the validity of the family's emotions. Be sure that all family members, including children, are able to participate in the grieving process. Family members may need to be reminded to get rest and to eat. Too many visitors may tire the patient; when explanations are offered, most relatives readily understand this. · The reality of death can be made less painful by preparing the family ahead of time. When the process has been explained to the family, they are better prepared to understand the needs of the dying person and how to support the person. · Explain the steps of the grieving process to all family members ahead of time so that they will recognize the specific stages as they experience them and understand that the process is normal. They can then recognize that other members of the family are going through the same stages, perhaps at different times. This preparation promotes better understanding and communication within the family. · Death creates a change in family roles. As one person (the dying person) leaves a role, adjustments must be made within the family to compensate. Each member plays a part in that compensation, and the nurse can help with these adjustments.

Internal & external resources

· The personal strengths a person recognizes, develops, and uses are powerful but subjective determinants of self-concept. · For example, one person may use humor as both an effective coping mechanism and a successful interpersonal tool. Another person may use humor to avoid facing conflict, but may feel badly about being known as a "joker" or "clown." · The degree to which a person integrates healthy, useful internal resources or personal strengths is associated with how well a person has been able to establish a positive self-concept in the context of nurturing experiences. · Self-concept is also associated with the ability to identify and use external resources, such as a network of support people, adequate finances, and organizational supports. People who feel more positively about themselves tend to feel connected to others and to society; they can identify and use more external resources. People who feel disconnected and alone tend to perceive and use fewer environmental resources.

Family events

· The stress that affects an ill person also affects the person's family members or significant others. When the family is viewed as a system, the behavior of the individual is influenced by family, and any alterations in the individual's behavior in turn affect the family. Stressors for the family include changes in family structure and roles, anger and feelings of helplessness and guilt, loss of control over normal routines, and concern for financial stability. · The family, both as individuals and as a unit, uses many of the same coping and defense mechanisms described previously. Family members may be overly protective, deny the seriousness of the illness, or blame health care providers for the patient's condition or behaviors. On the other hand, the family can provide the social support necessary to help the patient manage and adapt to stress. Emotional support from family members allows open expression of feelings and helps meet love and belonging needs. The inclusion of family members in problem solving, teaching and learning activities, and physical care helps both the patient and the family maintain their self-esteem and feeling of worth. · Caring for a family member at home for long periods can also cause prolonged stress. Called caregiver burden, this stress response includes chronic fatigue, sleep problems, and an increased incidence of stress-related illnesses, such as high blood pressure and heart disease. Prolonged stress can seriously threaten mental health. As coping or defense mechanisms become ineffective, a person may try less effective coping patterns or maladaptive defense mechanisms. As anxiety increases despite these measures, the person may experience difficulties on the job, with personal relationships, and with self-esteem. · People who were neglected or abused as children are more vulnerable to stress as adults. An ongoing study of adverse childhood experiences (ACEs) by the Centers for Disease Control and Prevention (CDC, 2016) and Kaiser Permanente documents and tracks the development of chronic diseases, mental health, health risk behaviors, and other health and social behaviors associated with negative childhood experiences. When the abuse occurs early in a child's life and is ongoing, changes in the brain's structure and function can occur, resulting in an altered immune response to inflammation and wound healing. The family is an integral part in the assessment, planning, nursing interventions, and evaluation of actions to prevent ACEs and promote adaptation to stress.

Modifying a Negative Self-Concept

· The time is ripe for change when a patient realizes that a negative self-concept is hindering personal development related to health care. One option is using a cognitive-behavioral approach to assist the patient in modifying self-concept. The general principle is to help the patient alter his or her perspective of a situation from a more negative view to a more positive view, a process known as "reframing." Once a person can view his or her situation more positively, a wider variety of behavioral options, coping mechanisms, or internal or external supports can be identified and activated. While any person's self-concept is usually firmly entrenched and naturally resists change, you should remain optimistic that change is possible, if even in small increments. Helpful nursing interventions include the following: Help the patient identify and describe in detail how the patient thinks and feels about situations related to self-concept. Identify the patient's faulty thinking patterns. Explore with the patient alternative ways of viewing the same situation—that is, reframe the patient's thinking about the situation. Teach the patient to "red flag" faulty thinking behavior as soon as the patient is aware of it. The goal is to replace the negative thinking and self-talk with thinking and self-talk that will develop a more positive self-image. Help the patient explore the positive dimensions of the self that the patient wishes to develop, and incorporate this new knowledge into the self-concept.

Psychosocial Stressors

· There are an almost infinite variety of psychosocial stressors, which become so much a part of our daily lives that we often overlook them. · The environment, interpersonal relationships, or a life event can lead to the stress response if a person does not have the resources to adequately respond to the perceived or actual stressor. · Psychosocial stressors include both real and perceived threats. The person's responses are continuous and include individualized coping mechanisms for responding to anxiety, guilt, fear, frustration, and loss. The mechanisms serve to maintain psychological homeostasis.

Dietary Habits

· There is some evidence supporting a sleep moderating effect of the dietary amino acid L-tryptophan in promoting sleep (Yurcheshen, Seehuus, & Pigeon, 2015). A small protein-containing snack (a source of tryptophan) before bedtime has been recommended for patients with insomnia. However, as nutritionists have studied the effects of various foods on mood, new information has emerged. Carbohydrates make tryptophan more available to the brain. This explains why meals heavy in carbohydrate content tend to cause drowsiness. Combining foods that are high in tryptophan with healthy, complex carbohydrates improves sleep. Therefore, a small protein- and carbohydrate-containing snack such as peanut butter on toast or cheese and crackers about an hour before bed may be more effective (NSF, n.d.d). · Alcoholic beverages, when used in moderation, appear to induce sleep in some people. However, large quantities have been found to limit REM and delta sleep. Initially, alcohol consumption may help to induce sleep but once the alcohol is cleared from the body, sleep is fragmented and disrupted often. Alcohol also interferes with entering deeper stages of sleep, which may result in feelings of fatigue upon wakening despite having spent an adequate amount of time in bed (NSF, n.d.d). In addition, the more alcohol consumed, the more pronounced are the adverse effects (Ebrahim et al., 2013). Most recommendations to promote effective sleep state that alcohol and products containing alcohol should be avoided in the evening to promote better sleep habits. · Caffeine is a central nervous system stimulant. For many people, beverages containing caffeine interfere with the ability to fall asleep. Caffeine is thought to interfere with the action of adenosine, which is a compound found in every cell in the body. It binds to adenosine receptors in the brain, thus preventing the adenosine from entering nerve cells and causing drowsiness. Caffeine consumption should be avoided too close to bedtime as its effect may persist for several hours (NSF, n.d.d). Examples of beverages containing caffeine include coffee, tea, energy drinks, and most cola drinks. Chocolate also contains caffeine.

spinal cord injuries

· Thousands of people are victims of spinal cord injuries each year as a result of various types of accidents. This type of injury almost always results in some degree of permanent disability. Such people face multiple adaptations in their lifestyles, including those related to mobility, bowel and bladder control, sexual functioning, and role expectations. · The extent of sexual response that remains after a spinal cord injury depends primarily on the level and extent of the injury. · Ejaculation and orgasm are most likely to remain with low spinal injuries. Women are more likely to experience orgasm than men, but they more frequently report a lack of physical sensations during the excitement phase than do men. Many people find that other erogenous zones become more easily stimulated after the injury.

clinical nurse leader role

· To have a positive effect on fragmented health care and promote improved collaboration within the entire health care team, the American Association of Colleges of Nursing (AACN) created the nursing professional role of clinical nurse leader (CNL). This master's-prepared nurse who has earned the certified CNL credential works collaboratively with the health care team to facilitate, coordinate, and oversee care provided to patients (Sheets et al., 2012; Stachowiak & Bugel, 2013). This role is not considered an administrative or management role, but rather one of leadership in all health care settings. The CNL should be able to clearly communicate with other health care professionals, integrate evidence-based practices into patient care, and evaluate risks and outcomes that may require change in care plans for patients (AACN, 2012). The person-centered focus of the CNL role includes functioning as a patient advocate, educator, and provider of patient care in complex situations. · Questions have arisen about a perceived overlap or duplication between the roles of the CNL and those of the clinical nurse specialist and case manager. Some nursing professionals also question the need for the CNL at this time. Clinical nurse specialists are advanced practice nurses with specialist education in a defined area of practice; case managers are closely involved with discharge plans, length-of-stay issues, and insurance constraints (Stachowiak & Bugel, 2013). Refer to Chapters 11 and 12 for additional discussions regarding case management.

Psychological Homeostasis

· To maintain mental well-being, humans also must maintain psychological homeostasis. As discussed in Chapter 4, each person needs to feel loved and a sense of belonging, to feel safe and secure, and to have self-esteem. When these needs are not met or a threat to need fulfillment occurs, homeostatic measures in the form of coping or defense mechanisms help return the person to emotional balance. · Everyone frequently encounters physical, psychological, and social changes in their internal and external environments. A person's perception of these changes may be conscious or unconscious. If the person has the necessary resources, adaptation takes place and balance is maintained. If the resources cannot reestablish balance, a state of stress results. The person's responses and the degree of stress depend in part on the nature, intensity, timing, number, and duration of stressors. Adaptation to stress also depends on a person's age, developmental level, past experiences, support systems, and coping mechanisms (see Box 42-3 for sources of stress with aging). Adaptive responses include the mind-body interaction, anxiety, and coping or defense mechanisms.

Allow Natural Death, Do Not Resuscitate, or No Code Order

· To prevent the improper use of cardiopulmonary resuscitation, which is designed to prevent unexpected death, some health care providers write Do Not Resuscitate (DNR) order, or No Code, on the medical record of a patient if the patient or surrogate has expressed a wish that there be no attempts to resuscitate the patient. A Do Not Resuscitate order means that no attempts are to be made to resuscitate a patient whose breathing or heart stops. Some facilities use the term Allow Natural Death (AND) order instead of Do Not Resuscitate because it is easier for families to authorize doing something positive rather than preventing something (i.e., a resuscitative effort) that is usually perceived to be helpful. You may also see a Do Not Intubate (DNI) order. Many health care providers are reluctant to write these orders, however, especially when the issue is a source of conflict between the patient and family or between individual family members. · In some cases, a health care provider who believes the patient will not benefit from resuscitative measures may indicate verbally to the nurse that only a Slow Code (or "Show Code") should be called—that is, in the case of cardiopulmonary or respiratory arrest, calling a code and resuscitating the patient are to be delayed until these measures will be ineffectual. Many health care institutions have policies forbidding this, and a nurse could be charged with negligence in the event of a Slow Code and resulting patient death. Be sure to check your facility's policies. · The standard of care still obligates health care professionals to attempt resuscitation if a patient's breathing or heart stops (cardiopulmonary arrest) and there is no AND or DNR order to the contrary. For this reason, nurses must clarify a patient's code status if the probable benefits of resuscitation are negligible or if the nurse has reason to believe a patient would not want to be resuscitated. Many states now allow patients living at home to craft POLST/MOLST orders that allow emergency medical technicians called to the home in the event of cardiopulmonary arrest to respect the patient's wishes not to be resuscitated.

Transactional

· Transactional leadership style is based on a task-and-reward orientation. · Team members agree to a satisfactory salary and working conditions in exchange for commitment and compliance to their leader. · Health care organizations have often used transactional leadership strategies to provide direction and recognize employees' progress in meeting pre-established goals and work deadlines. · Transactional leaders maintain control by rewarding good behavior and punishing behavior they perceive as detrimental or negative. · Employees have minimal opportunities for creative thinking and involvement in organizational decisions, and employer and employee may not share a common vision. · Transactional leaders provide little inspiration for nurses to participate in reforming health care, problem solving, or engaging in practices and research that promote nursing excellence

death certificate

· U.S. law requires that a death certificate be prepared for each person who dies, and specifies what information must be included. Death certificates are sent to local health departments, which compile many statistics from the information. · The mortician assumes responsibility for handling and filing the death certificate with proper authorities. A clinician's signature is required on the certificate (check your state law to see if nurses can sign death certificates), as well as that of the pathologist, the coroner, and others in special cases. The nurse is responsible to ensure that the death certificate is signed.

Lifestyle and habits

· Various lifestyle factors can affect a person's ability to sleep well. People working a shift other than the day shift must reorganize their priorities, or sleep difficulties may occur. Based on the circadian cycle, the body prepares for sleep at night by decreasing the body temperature and releasing melatonin (a natural chemical produced at night that decreases wakefulness and promotes sleep). Working the night shift disrupts this natural process and can result in loss of sleep and other adverse effects (see Physical and Psychological Effects of Insufficient Sleep). Developing a sleep pattern is especially difficult if the work shift changes periodically. Nurses and others who work long hours and varying shifts have difficulty finding time to exercise, which can promote weight gain. The National Institute for Occupational Safety and Health (NIOSH, 2015) offers information to educate nurses and their managers about the health and safety risks associated with shift work and long work hours and a training program to increase knowledge about personal behaviors and workplace systems to reduce associated risks. · The duration and quality of sleep can be affected by watching some types of television shows, participating in stimulating outside activities, and taking part in activity or exercise within 3 hours of the person's normal bedtime. A person's ability to relax from work-related pressures and to put aside home stresses are also important factors in the ability to fall asleep. Nurses who role model good health behaviors are more effective teachers. Use the Promoting Health 34-1 display for yourself before using it with others.

Comfort Measures Only and Other Special Orders

· When a discussion is taking place about resuscitation, it is also appropriate to question the use of other life-sustaining interventions, such as dialysis, ventilatory support, artificial nutrition and hydration, blood transfusions, antibiotics and other medications, and surgery. Whereas some patients may want aggressive life-sustaining treatment and such treatment may be medically beneficial, other patients may be at a point in their illness at which they choose to terminate all life-sustaining measures and allow the disease to progress naturally to death. There is no moral obligation to initiate or continue the use of life-sustaining treatment that is minimally effective or is a burden. However, laws may place constraints on those who decide to withhold or withdraw life-sustaining treatment for incompetent patients and, in some states, for patients who are pregnant. Nurses should know pertinent federal and state laws and the policies in their institution or facility concerning the withholding or withdrawing of life-sustaining treatment. Nurses should also be familiar with the forms used to indicate patient preferences about end-of-life care. · Patients or their surrogates may request a Comfort Measures Only order, which indicates that the goal of treatment is a comfortable, dignified death and that further life-sustaining measures are no longer indicated. A Do Not Hospitalize order is often used for patients in long-term care and other residential settings who have elected not to be hospitalized for further aggressive treatment.

Adaptation

· When a person is in a threatening or otherwise stressful situation, immediate responses occur. Those responses, which are often involuntary, are called coping responses. · The change that takes place as a result of the response to a stressor is adaptation. · Adaptation is, to some degree, an ongoing process as a person strives to maintain balance in the internal and external environments. · Adaptation also occurs in families and groups. Adaptation is necessary for normal growth and development, the ability to tolerate changing situations, and the ability to respond to physical and emotional stressors.

· Personal Identity

· When assessing self-concept, the information needed first is the patient's description of self. · Personal identity describes a person's conscious sense of who he or she is. "How would you describe yourself to others?" · Pay special attention to the labels used by the patient and the order in which they appear. A simple exercise consists of asking patients to "make a list of 10 labels that you believe identify yourself (e.g., gay man, student, Italian American, opera fan, premed major). · Put the most important label first, and then list the others in order of decreasing importance. What if the order were reversed? To what extent do you think your way of organizing information about yourself affects your behavior?" · It is important to discover whether people are comfortable with their perceived identity. Developmental changes, trauma, and cultural and biological sex dissonance may all place a patient at risk for personal identity disturbances.

Helping Patients Identify and Use Personal Strengths

· When confronted with a major stressor, many people forget that they have histories of successful coping and numerous personal strengths. Patients at high risk for giving up are those with low self-esteem or multiple stressors they perceive as overwhelming. · Although attributing strength to a patient sounds like something nurses would do naturally, nurses frequently fall into the trap of "doing" for patients (i.e., solving their problems rather than helping them to identify and tap their personal power and strengths). Moreover, patients continually instruct nurses about how they should be perceived, and some patients successfully communicate a manipulative helplessness that encourages the nurse to take charge. An appropriate nursing response in this case is, "I wonder why you want me to speak with your health care provider about treatment alternatives. I'm sure you would feel much better hearing this information firsthand. If you'd like, I will stay here while you talk with the health care provider." · Patients experiencing powerlessness may need help to recognize their strengths (Fig. 41-6). Examples of personal strengths that might better equip a person to respond to life's challenges include: Healthy, functioning body Ability to adjust to or function with chronic bodily malfunction Cognitive abilities Positive self-concept Interpersonal skills Sense of meaning and purpose in life Belief system Social support network Meaningful work Hobbies and other interests Education Life experience and a past history of effective coping Good sense of humor Spirituality Healthy nutritional state Ability to make decisions · If you search for "Self-Esteem Worksheets" online, you will find many resources to help your patients build their self-esteem. · Specific strategies that can be used to help patients identify and use personal strengths include the following: Encourage patients to identify their strengths. Replace self-negation with positive thinking. Notice and reinforce patient strengths. Encourage patients to will for themselves the strengths they desire and to try them on. Help patients cope with necessary dependency resulting from aging or illness.

how to assess self-esteem related to the bases of self-esteem

· When patients share their self-perceptions, use the opportunity to ask questions about whether patients like themselves, and whether they are pleased with their expectations and the progress they are making to realize these expectations. For example, you might state: · "Tell me what you like about yourself." · "What would you change about yourself if you could?" · You can obtain a quick indication of a patient's self-esteem by using a graphic description of self-esteem as the discrepancy between the "real self" (who we think we really are) and the "ideal self" (who we think we would like to be). Have the patient plot two points on a line—real self and ideal self (Fig. 41-5). The greater the discrepancy, the lower the self-esteem; the smaller the discrepancy, the higher the self-esteem. · A person's ideal self may differ dramatically from the current sense of self, and may positively or negatively influence behavior and personal development. If indicated, question the patient about self-expectations: · "You've told me something about who you are and how you view yourself now. Tell me who you would like to be in the future." · "What life goals are important to you?" · "Where do you see yourself 5 years from now? In 10 years?" · "Are these expectations realistic?" · "Are your expectations stemming from who you would like to be or from who you think you should be?" · "Who or what has influenced your self-expectations?" · Such questions help assess whether the patient possesses life goals that are positively motivating personal development. · Identify any unrealistic expectations and explore their source with the patient. For example: · "You seem to feel that it is necessary to be all things to all people—no matter what this costs you. How might this belief have developed? Is it helpful to you?" · "What I'm hearing is that your performance must always be perfect, that although you allow others to make mistakes, you cannot allow yourself this luxury. Tell me more about this." · "You state you have no goals for the future. When you wake up each morning, what gets you out of bed? What keeps you moving?" · If a more detailed assessment is needed, the concepts of socialization and communication, significance, competence, virtue, and power should be explored next.

ADDRESSING PSYCHOLOGICAL NEEDS

· When people speak of their fears of death, responses typically include fear of the unknown, pain, separation, leaving loved ones, loss of dignity, loss of control, and unfinished business. Kübler-Ross believes that there is still another, more overwhelming and more significant fear that often is repressed and unconscious: that of the catastrophic, destructive force that has befallen a person and that the person cannot change. Kübler-Ross points out that terminally ill people communicate this fear of a destructive force but do so largely through symbolic language. A person may use nonverbal language, such as a facial expression, a particular kind of handclasp, or, in the case of children, drawings and manner of play with toys. Verbal communication may also be used symbolically. · A fear of isolation, of having to face death alone, is a primary concern of the dying patient. Support the patient by indicating your presence, giving full attention, and showing that you care. Encourage the presence of family members in the room and sharing of reminiscences. There is now a national volunteer program designed to provide companionship and support for dying persons so that no patient dies alone (http://www.eskenazihealth.edu/programs/noda). Check to see if your hospital has a "No one dies alone" program.

caring for oneself

· Witnessing the deaths of patients we have cared for can take a toll on health care professionals who can become numb or burned out. Nurses are now being encouraged to "pause" after a patient dies to silently reflect and honor the life. It is also a good time to be grateful for the care that you provided the patient. "Pause" guidelines are now being implemented in many settings that stop professional caregivers in a reflective moment of silence to honor the newly dead (Mason & Warnke, 2017). How to cope with patient deaths "Pause" after a patient's death• Debrief with the healthcare team• Explore your own feelings • Take time to express your emotions• Be honest about maladaptive coping strategies• Go through the grieving process • Employee assistance programs

Laissez-Faire

· also called nondirective leadership, the leader relinquishes power to the group, such that an outsider could not identify the leader in the group. · This approach encourages independent activity by group members. · This style depends on the strengths of followers to direct the group activities. It is most effective when all staff are clinical experts with a deep understanding of both clinical and administrative processes. · This style is rarely useful because task achievement is difficult when each nurse is working independently, and the staff on most units and departments have varying levels of clinical maturity. However, it can be used effectively when the leader wants a problem to be solved completely by expert staff group members.

Democratic

· also called participative leadership, is characterized by a sense of equality among the leader and other participants. · Decisions and activities are shared. Participants are encouraged to develop their skills and strengths within the group. · The group and leader work together to accomplish mutually set goals and outcomes. As professionals, nurses generally respond well to this style of leadership when they are the followers and feel more comfortable when they are the leaders of democratic groups. · Group satisfaction and motivation are excellent benefits of this style. In situations in which a rapid response is essential, however, a democratic approach to leadership that requires gathering the input of team members may slow decision making. · An example of democratic leadership follows. Nurse B, a head nurse, observes that staff members have not been documenting patient teaching and learning in their progress notes. Nurse B is not sure why this is occurring but believes that this problem must be solved. He calls a staff meeting and leads a discussion to seek information on possible causes and solutions. Nurse B decides that staff members need to be included in the problem-solving approach. He thinks the staff will be more motivated to document their teaching and the patients' learning if they have a say in what changes in practice are necessary and how they will be implemented. Nurse B has used the democratic style of leadership and decentralized decision-making process to resolve this issue.

restless leg syndrome

· also known as Willis-Ekbom disease (WED), is a common sleep-related movement disorder that affects up to 15% of the population, most often middle-aged and older adults. Approximately 2% of children also suffer from RLS, and there appears to be a strong genetic component. Almost 75% of these children have a parent with RLS (NSF, 2011g). People with RLS cannot lie still and report unpleasant creeping, crawling, or tingling sensations in the legs. Usually, these sensations are in the calf, but they may occur anywhere from the ankle to the thigh. Occasionally, RLS can occur in the arms, face, or torso. Patients describe an irresistible urge to move the legs when these sensations occur, usually during the evening and night. In some cases, symptoms may affect both sides of the body. RLS is seen in patients with ESRD, diabetes, iron deficiency, peripheral neuropathy, and pregnancy. Over-the-counter (OTC) medications such as antihistamines can exacerbate the symptoms of RLS. This disorder has no specific diagnostic test and no known cure. · Nonpharmacologic measures to prevent or alleviate this discomfort include massaging the legs, walking, doing knee bends, and moving or gently stretching the legs. Research continues into additional treatment options, but the following may prove effective: Eliminating use of caffeine, tobacco, and alcohol Taking a mild analgesic at bedtime (provided it is compatible with the current medical regimen) Applying heat or cold to the extremity Using relaxation techniques. Biofeedback and transcutaneous electrical nerve stimulation (TENS) may also relieve symptoms (see the accompanying Promoting Health Literacy display on page 1212). · Several medications may be used if symptoms are clinically significant with associated impairment of nighttime sleep, daytime alertness, and quality of life (Klingelhoefer, Bhattacharya, & Reichmann, 2016). In general, the dosage is kept as low as possible and is administered as a single dose in the evening; medications recommended to treat RLS include ropinirole, pramipexole dihydrochloride, gabapentin enacarbil, and rotigotine transdermal system (Klingelhoefer et al., 2016). The Restless Legs Syndrome Foundation (http://www.rls.org) is a support group available for the millions of people with this disorder who experience chronic sleep loss.

Transformational

· an create revolutionary change. Often described as charismatic, transformational leaders are unique in their ability to inspire and motivate others. · They create intellectually stimulating practice environments and challenge themselves and others to grow personally and professionally, and to learn. · Gifted in creating a common vision, they demonstrate passion for their vision and keep others similarly focused. One of the unique qualities of transformational leaders is their vulnerability. · They communicate honestly and openly, and can express emotions as well as ideas as they share themselves with others. They show concern and care for others and are willing to take risks. They pay attention to process as well as outcomes. · An example of transformational leadership is as follows. Nurse C is troubled by the plight of women and children in the inner city where she lives. She unites with other nurses and health care professionals to design and implement strategies to meet their needs. Within 18 months, a nursing center is funded and running, improving maternal-child outcomes in the area. The founding group of health care professionals continues to meet monthly to dream about future strategies and to support each other in their work. They are proudest of the improved self-esteem and independence in many of the women they serve. · Transformational leaders have a positive and compelling vision, fostering a new culture for nursing practice and patient care. This style of leadership is a key component of organizations that achieve Magnet status.

development - self concept

· certain inborn tendencies, such as temperament, when interacting with social and interpersonal experiences, are crucial in the formation of self-concept. An infant learns that the physical self is different from the environment. If basic needs are met, warmth and affection are experienced, and the caregivers' anxiety is minimized, then the child begins life with positive feelings about self. The child next internalizes (incorporates into self) other people's attitudes toward self, including attitudes directed toward the child's innate tendencies, such as temperament and aggression. This internalization forms the foundation of self-concept. Parents or other direct caregivers play the most influential role; peers play the second most influential role. Later, the child continues to behave in ways that confirm this early self-concept. The child or adult internalizes the standards of society. · Stages in the development of the self include self-awareness (infancy), self-recognition (18 months), self-definition (3 years), and self-concept (6 to 7 years). Psychological conditions that foster healthy development of the self in children include: emotional warmth and acceptance. effective structure and discipline. clearly defined standards and limits, so that children understand what goals, procedures, and conduct are approved. adequately defined roles for both older and younger members of the family. established methods of handling children that produce the desired behavior, discourage misbehavior, and deal with infractions when they occur. encouragement of competence and self-confidence (Fig. 41-3). helping children meet challenges. appropriate role models. a stimulating and responsive environment.

insomnia

· characterized by difficulty falling asleep, intermittent sleep, or difficulty maintaining sleep, despite adequate opportunity and circumstances to sleep · People older than 60 years of age, women (especially after menopause), and people with a history of depression are more likely to experience insomnia. · Many cases of insomnia are related to disruptions in circadian rhythms. This sleep disorder can also occur during periods of stress; in situations involving some change in the normal environment such as shift work; as a result of pain, discomfort, or limited mobility; and as a result of the side effects of medications. · Common medications that may result in insomnia include those taken for hypertension and cardiovascular disease, cold and allergies, attention-deficit hyperactivity disorder (ADHA), and depression · Daytime consequences of insomnia include reports of feeling tired, lethargic, and irritable during the day. Difficulty concentrating is also a common manifestation. Older adults who experience insomnia while in an acute care setting may manifest delirium as a symptom of sleep deprivation. It is a challenge for health care providers to understand the effects of age-related changes on sleep and be alert for the potential complications associated with insomnia in this growing population. · Nonpharmacologic approaches should be attempted initially to resolve the insomnia. Refer to the Teaching About Rest and Sleep discussion. The misuse of alcohol or caffeine can have an adverse effect on sleep; stopping these behaviors may reduce or eliminate the insomnia. Cognitive behavioral therapy (CBT) is a safe, effective means of managing chronic insomnia and may include cognitive therapy, relaxation training, stimulus control therapy, or sleep restriction therapy (Brem, 2015). CBT involves meeting with a therapist and working through maladaptive sleep beliefs. It may also include biofeedback, additional relaxation techniques, and sleep hygiene measures (see Teaching About Rest and Sleep). When used in conjunction with these other complementary therapies, CBT can be very successful (Brem). If, however, nonpharmacologic measures prove ineffective, pharmacologic treatment may be necessary. Refer to the Using Medications to Promote Sleep discussion.

Developmental considerations

· ecause spirituality involves the nonmaterial realm of being, a child must have developed some capacity for abstraction in order to understand the spiritual self. However, this is not to say that spirituality is meaningless for children. For example, David Heller (1985) interviewed 40 children between 4 and 12 years old who were affiliated with one of four major religions (Judaism, Roman Catholicism, Protestantism, or Hinduism) and discovered that the children had definite perceptions of God. Central themes in all the children's descriptions included the following: Notion of a God who works through human intimacy and the interconnectedness of lives Belief that God is involved in self-change and growth and transformations that make the world fresh, alive, and meaningful Attributing to God tremendous and expansive power and then showing considerable anxiety in the face of this power Image of light · As the child matures, life experiences usually influence and mature the child's spiritual beliefs. With advancing years, the tendency to think about life after death prompts some people to re-examine and reaffirm their spiritual beliefs.

transgender

· frequently shortened to trans, is a term that describes a wide range of experiences or identities where gender identification and expression differ from societal expectations that are based on a person's biological sex. For example, a person born biologically male (penis and scrotum) may identify as female (gender). More specifically, transgender is an inclusive term used to describe those who feel that the sex that was assigned to them at birth incompletely describes or fails to describe them. This term includes: People who have a gender expression that differs from their biological sex (according to societal norms) People who are transsexual—that is, people who live full-time as members of a gender that differs from the sex and gender they were assigned at birth People who are intersex—that is, people whose reproductive or sexual anatomy does not fit the typical definition of male or female People who identify outside the female/male binary People who identify as having no gender or multiple genders · For many transgendered people, the solution is to change their bodies, through surgery, hormone therapy, or both, to match their inner feelings; this process is referred to as transitioning. The surgery is frequently referred to as gender affirmation surgery or gender confirmation surgery. The terminology used for the surgery is significant: It reinforces the belief that the surgery is realigning a person with their actual gender. · Teens who are transgender face the reality of puberty, where their body will go through biological changes that betray who they feel they are or who they want to be. Puberty blockers, medications that pause puberty, may be taken to block secondary sex characteristics for a few years. They are generally safe, and their effects are reversible. Exogenous hormones (testosterone or estrogen) may also be administered. When the teen reaches the age of consent and has solidified his or her gender identification, surgery may be a viable, even medically necessary option (WPATH, 2016). Typically, genital surgery requires two mental health evaluations to confirm gender dysphoria, capacity for informed consent, 12 continuous months of hormone use, control of significant medical or mental health concerns, and living in the gender to which a person is transitioning (WPATH, 2011). · Gender binary (male or female identification) is not the only option. Gender fluid describes a person whose gender identification and behaviors shift from time to time, whether within or outside of societal, gender-based expectations. There is an emerging understanding that external genitalia do not always dictate gender identification or gender expression. Some people identify as nonbinary, and may prefer the gender-neutral pronouns they and their rather than him/her or his/her. Each person's experience is individual, and the vocabulary and terms continue to evolve. There is a growing understanding that asking people what their preferred pronouns are is appropriate. For a current glossary, check out the University of California—Davis Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual (LGBTQIA) Resource Center at https://lgbtqia.ucdavis.edu/educated/glossary.html. People experience sexual gratification in many ways; what is considered normal differs from one person to another and among cultures.

Culture

· he manner in which a society perceives sexuality influences the person. Every culture has its own norms regarding sexual identity and behavior. To some degree, culture dictates the choice of sexual partner, duration of sexual intercourse, methods of sexual stimulation, and sexual positions. In some cultures, women may be expected to merely tolerate sex; in others, the woman's participation is encouraged. To gain an appreciation for all the ways that culture can influence sexual expression and health, ask people from different cultures the following questions: What type of dress is appropriate for children, men, and women? How is nudity viewed? What role behaviors and social responsibilities are expected of men and women? Is masturbation acceptable? At what age is genital sexual intimacy appropriate? With whom is it appropriate? What sexual practices are accepted? What are the rules for marriage? Is premarital sex, extramarital sex, or polygamy accepted? · The fact that a practice is common in a culture does not mean that it is healthy or ethical. Female genital mutilation (FGM), for example, includes procedures that intentionally injure or alter the female genital organs for nonmedical reasons. It is a procedure that has no health benefits for girls and women and can cause severe bleeding and problems urinating. Later in life it can cause cysts, infections, and infertility, as well as complications in childbirth and increased risk of newborn deaths. About 200 million girls and women worldwide, primarily in Africa, the Middle East, and Asia, are currently living with the consequences of FGM. The WHO (2018b) writes that: · "FGM is recognized internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person's rights to health, security, and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death" (para. 3). · There are four major types of FGM: Clitoridectomy: partial or total removal of the clitoris and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris) Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris. Other: all other harmful procedures to the female genitalia for nonmedical purposes—for example, pricking, piercing, incising, scraping, and cauterizing the genital area

authoritarian

· involves the leader assuming control over the decisions and activities of the group. It is often an efficient process, yet many people may resent this leadership approach when used regularly. Staff and team members have limited opportunity to contribute suggestions and participate in organizational decisions. High staff turnover and burnout are more common with this style of leadership. · Many experienced nurses are used to working under autocratic leaders because this approach was used in most hospitals in earlier years. It may have evolved from nursing's historical military and religious past, or from the industrial model of command and control prevalent in many organizations. Although some health care workers still respond best to the directive approach, this style of leadership is gradually being replaced by the democratic style of leadership as nurses demand and receive more say in decision making. · Some situations may require an autocratic leadership style. For example, Nurse A discovers that one of her patients is bleeding excessively from his surgical incision. She knows that he needs immediate attention, so she gives specific orders to another team member to attend to the other patients. She tells the RN on her team to call the surgical resident to come as soon as possible. She implements a nursing care plan to prevent further blood loss or complications. Nurse A assumed the autocratic style of leadership in this situation so that all necessary tasks would be accomplished immediately. Although she rarely uses this style, she implemented it effectively in this emergency situation. This example illustrates that leadership is context dependent.

Narcolepsy

· is a condition characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep. Up to 70% of people with narcolepsy also experience cataplexy, the sudden, involuntary loss of skeletal muscle tone lasting from seconds to 1 or 2 minutes (Ruoff & Black, 2014). Additional symptoms include the presence of hallucinations or sleep paralysis (National Heart Lung and Blood Institute [NHLBI], 2010). A person with narcolepsy can literally fall asleep standing up, while driving a car, in the middle of a conversation, or while swimming. People with narcolepsy tend to fall asleep quickly, find it difficult to wake up, sleep fewer hours than others, and sleep restlessly. Symptoms usually appear in susceptible people during adolescence or early adulthood and are usually lifelong (Ruoff & Black). · Because narcolepsy is a rare disorder, diagnosis is lengthy and difficult. Many people with narcolepsy have low hypocretin levels. This is a chemical in the brain that causes alertness and wakefulness. It is unknown at this time what causes this low hypocretin level (NHLBI, 2010; Sateia, 2014). Undiagnosed, a person with narcolepsy is potentially dangerous to self and others. In some countries, a person with a diagnosis of narcolepsy is not permitted to drive a motor vehicle. A sleep study is important to confirm the diagnosis of narcolepsy. At present, there is no cure. However, medications that restore alertness allow near-normal functioning for most patients. · A central nervous system stimulant (e.g., methylphenidate) that causes wakefulness may be used to control narcolepsy. Additional medications such as modafinil, a wakefulness-promoting compound, and sodium oxybate, a sedative used for treating disturbed nocturnal sleep, have proved effective in treating narcoleptic symptoms (Lehne, 2013; Ruoff & Black, 2014). People using such drugs should take them faithfully because with discontinuation of use, the uncontrollable desire to sleep returns. In addition to medications, behavioral therapies may help to control the symptoms of narcolepsy.

obstructive sleep apnea

· is a potentially serious sleep disorder in which the throat muscles intermittently relax and block the airway during sleep, causing breathing to repeatedly stop and start · Adult OSA is characterized by five or more predominantly obstructive respiratory events (the absence of breathing [apnea] or diminished breathing efforts [hypopnea] or respiratory effort-related arousals) during sleep, accompanied by sleepiness, fatigue, insomnia, snoring, subjective nocturnal respiratory disturbance, or observed apnea and associated health disorders (hypertension, coronary artery disease, atrial fibrillation, congestive heart failure, stroke, diabetes, cognitive dysfunction or mood disorder) (Sateia, 2014). OSA (adult) may also be diagnosed based on a frequency of obstructive respiratory events that occur at a rate of ≥15 events per hour, even in the absence of associated symptoms or health disorders alone (Sateia). · OSA (adult) is a common disorder, caused by recurrent collapse of the upper airway during sleep (Fig. 34-3). Breathing may cease for 10 to 20 seconds and possibly as long as 2 minutes. During long periods of apnea, the oxygen level in the blood drops, the pulse usually becomes irregular, and the blood pressure often increases. This decrease in ventilation and associated physiologic response activates the fight-or-flight response of the sympathetic nervous system and the sleeper startles and awakens (Simmons & Pruitt, 2012). · The incidence of OSA (adult) increases with age, excess weight, large neck size, male, and family history and is associated with cardiovascular risk factors, cardiovascular disease, depression, increased risk of motor vehicle accidents, and increased mortality (American Academy of Sleep Medicine, 2016; Maeder, Schoch, & Rickli, 2016). · Clinical information and polysomnography can confirm the diagnosis of sleep apnea. This overnight sleep study also includes a video recording of sleep awakenings and movements. Cardiopulmonary monitoring of the arterial oxygen saturation and an electrocardiogram (ECG) to detect any cardiac arrhythmias can also assist in the diagnosis of OSA. · Adults with OSA may become irritable during the day, fall asleep during monotonous activities, have difficulty concentrating, and exhibit slower reaction times. Alcohol, tobacco, and sleeping pills increase the breathing disruption that occurs in sleep apnea and therefore should be avoided. · The definitive treatment of moderate or severe OSA involves use of a continuous positive airway pressure machine (CPAP). CPAP is noninvasive and consists of a mask connected to an air pump that is worn during sleep. This device delivers positive air pressure that holds the airway open. It can significantly improve the manifestations of OSA, but adherence and inconsistent use of the CPAP device is an issue for many patients. Patients may discontinue use of CPAP because of a sensation of claustrophobia, discomfort exhaling against air inflow, or dryness and skin irritation. Mild OSA can be managed with a custom-made oral appliance (OA), also known as a mandibular advancement device (MAD). These hard, plastic devices are fitted by a dentist or orthodontist based on a mold of the patient's mouth. If a person is unable to tolerate CPAP, an OA is an alternative treatment. Both CPAP and MAD must be used every sleep event to be effective (Agency for Healthcare Research and Quality, 2011). If conservative treatment methods fail, surgery to remove soft tissue at the back of the mouth may be an option. This surgery is not without risks and poses significant postoperative issues for the patient. People who opt for the procedure need continued support and comprehensive teaching, including coping strategies, for the immediate postoperative period. · OSA (pediatric) is defined by the presence of one of these findings: snoring, labored/obstructed breathing, enuresis (urinating during sleep), or daytime consequences (hyperactivity or other neurobehavioral problems, sleepiness, fatigue) (Sateia, 2014). The American Academy of Pediatrics has revised recommendations for diagnosis and treatment of OSA syndrome in children (Marcus et al., 2012). According to these guidelines, children and adolescents with symptoms of OSA, including snoring, should have polysomnography to confirm the diagnosis. Severe complications can occur if this disorder is untreated or ignored. Options for treatment in children include weight loss if obesity is present, adenotonsillectomy (removal of tonsils and adenoids), CPAP, or intranasal corticosteroids (Marcus et al., 2012; Perry et al., 2014). ·

self esteem

· is the need that people have to feel good about themselves and to believe that others hold them in high regard. · Self-esteem is the evaluative and affective component of the self-concept, sometimes termed self-respect, self-approval, or self-worth. · two subsets of esteem needs: (1) self-esteem needs, such as strength, achievement, mastery and competence, confidence in the face of the world, independence, and freedom; and (2) respect needs or the need for esteem from others, such as status, dominance, recognition, attention, importance, and appreciation. · four bases of self-esteem as (1) significance, or the way people feel they are loved and approved of by the people important to them; (2) competence, or the way tasks that are considered important are performed; (3) virtue, or the attainment of moral-ethical standards; and (4) power, the extent to which people influence their own and others' lives. · Three major self-evaluation feelings or affects found in people are (1) pride, based on a positive self-evaluation, (2) guilt, based on behaviors incongruent with ideal self, and (3) shame, associated with low global self-worth. These affects are learned in early childhood within relationships with significant others and maintained through practice.

culture

· person's cultural beliefs and practices can influence rest and sleep. Although developmental stages are similar, children's bedtime rituals, sleeping position and place, and pattern of sleep may vary based on culture. Methods to enhance or foster sleep may also be culturally influenced. · \A cultural orientation toward privacy and quiet makes sleep difficult in a busy special care unit. Sensitivity to a patient's culture must be included in the plan of care for preparing the patient for an evening's sleep.

sleep deprivation

· refers to a decrease in the amount, consistency, or quality of sleep. It may result from decreased REM sleep or NREM sleep. · Total sleep deprivation is rarely seen, other than in experimental settings. · There are many causes, and the manifestations progress from irritability and impaired mental abilities to a total disintegration of personality. In general, the effects of sleep deprivation become increasingly apparent after 30 hours of continual wakefulness. · Partial sleep deprivation may result in loss of concentration, inattention, and impaired information processing, and poses serious safety risks. Excessive daytime sleepiness, a form of partial sleep deprivation, impairs performance at times when people need to be alert. The strange environment of the hospital, physical discomfort and pain, the effects of medications, and the need for 24-hour nursing care may also contribute to sleep deprivation in hospitalized patients. It is unclear whether irreversible damage to body tissue results from prolonged or chronic sleep deprivation. As mentioned earlier in this chapter, recent research has indicated the possibility of a causal relationship between sleep deprivation and obesity, altered healing, depression, cancer, diabetes, and cardiovascular conditions. However, sleep deprivation clearly produces changes in physical and mental functioning, supporting the belief that sleep is essential for well-being. Sleep deprivation may be caused by shorter periods of sleep, which over time can cause impairment. Whether it occurs as a result of a disorder or is due to voluntary sleep curtailment, sleep deprivation has wide-ranging negative consequences for human health and well-being (American Sleep Association, n.d.).

childhood

• An intact body is important to the young child, who fears bodily mutilation. • During middle childhood, a sense of being trusted and loved, of being competent and trustworthy develops. • Differences between self and others are strong. • If invasive procedures are indicated, explain simply to the child what is being done and offer the child support. • Assess the parents' ability to provide the type of developmental environment in which the child's self-concepts can evolve positively. • Dysfunctional family • Too much or too little structure • Sensory perceptual impairments

older adult years

• Declining physical and possibly mental abilities • Multiple losses • Increasing dependency • Impending death • Diminished choices/options • Assess how the older adult is adjusting to effects of aging. • Counsel regarding meaningful use of time. • Explore resources. • Assess depression, substance abuse. • Recognize and value older adults' life experience. • Loss of significant work (retirement); feelings of uselessness • Death of spouse, significant others • Diminished physical attractiveness, strength, overall health • Multiple stressors • Fear of dependency • Change may be more difficult

adolesence

• Development of secondary sex characteristics; rapid body changes • Sense of self is consolidated. • Emphasis on sexual identity • Parental influences on self-concept are often rejected; peers become more important; movement is toward development of own identity. • Assess adolescent's self-knowledge and understanding of body changes. • Counsel adolescent regarding mature and healthy use of independence he or she craves. • Provide anticipatory guidelines regarding hazards to life, health, human functioning. • Inability to accept body • Inability to resolve competing pulls to be both a child and an adult • Unhealthy peer pressure • Identity confusion

infancy

• No self-concept at birth • Beginning differentiation of self and nonself • Teach parents the critical importance of providing consistent and affectionate parenting. • Assess whether the parents have reasonable expectations of the infant: sleeping, eating, other awake behaviors. • Unmet basic human needs • Lack of adequate body and sensory stimulation • Parents' lack of acceptance of the infant's appearance or behavior • Poor match between parent's and child's temperament or needs

adulthood

• Society places emphasis on intactness of body, fitness, energy, sexuality, style, productivity, sophistication, beauty. • Important to meet role expectations well. • Assess how realistic the adult's expectations are and the incentive they provide for growth and development. • Assist patient to deal constructively with negative influences in self-image. • Preretirement counseling. • Inability to fulfill conflicting role expectations • Failure to accept role responsibility (e.g., parenting responsibilities) • Unreasonable expectations • Irreversible body change related to trauma, illness • Unsatisfying job • Failure to develop new goals to give meaning and purpose to life • Multiple stressors