Exam 1; comfort, mobility, sleep

Circadian Rhythms

Rhythm that completes a full cycle every 24 hours. (fluctuations in a person's HR, BP, temp, hormone secretions, metabolism, and performance and mood depends in part on circadian rhythms.)

Interventions for sleep disorders (Taylor, pg 1130)

SLEEP APNEA =apply CPAP (delivers positive pressure to keep airway open) Mild OSA/obstructive sleep apnea =MAD (mandibular advancement device: custom-made oral appliance)

Transmission

Conduction of pain sensations from the site of an injury or inflammation along clear and unclear pathways to the spinal cord and then on to higher centers. The endings of A-δ fibers detect thermal and mechanical injury, allow relatively quick localization of pain, and are responsible for a rapid reflex withdrawal from the painful stimulus. Unmyelinated C fibers are slow impulse conductors and respond to mechanical, thermal, and chemical stimuli. They produce poorly localized and often aching or burning pain. A-beta (β) fibers are the largest of the fibers and respond to touch, movement, and vibration but do not normally transmit pain.

Trandsuction

Conversion of painful stimuli into electrical impulses that travel from the periphery to the spinal cord at the dorsal horn. Additionally, when the threshold of perception for pain has been reached and when there is injured tissue, it is believed that the injured tissue releases chemicals that excite or activate nerve endings. Other substances are also released that stimulate nociceptors or pain receptors. These include: -Bradykinin, a powerful vasodilator that increases capillary permeability and constricts smooth muscle, plays an important role in the chemistry of pain at the site of an injury even before the pain message gets to the brain. It also triggers the release of histamine and, in combination with it, produces the redness, swelling, and pain typically observed when an inflammation is present. -Prostaglandins are important hormone-like substances that send additional pain stimuli to the CNS. -Substance P sensitizes receptors on nerves to feel pain and also increases the rate of firing of nerves.

Mobility Concept

Factors that facilitate or impair movement of the body

NREM (non-rapid eye movement)

(75% of total sleep) 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.

Categories of Pain

-Acute (protective temporary usually self limiting and resolves with tissue healing, short term) -Chronic (not protective, ongoing, occurs frequently, long term, and persisting beyond tissue healing) -Nociceptive (arises from damaged to or inflammation of tissue other than that of the peripheral and CNS. Somatic; joints, tendons, muscles, nerves, ligaments, bones, blood vessels, nerves, tissue and visceral pain; internal) --->NEUROPATHIC (arises from abnormal or damaged pain nerves. Intense shooting, burning, pins and needles. Unlike nociceptive pain, neuropathic pain may occur in the absence of tissue damage and inflammation, even when acute neuropathic pain serves no useful purpose. -Hyperexcitable nerve endings in the periphery can become damaged, leading to abnormal reorganization of the nervous system called neuroplasticity -peripheral sensitization: a key peripheral mechanism of neuropathic pain that occurs when there are changes in the number and location of ion channels; in particular, sodium channels abnormally accumulate in injured nociceptors, producing a lower nerve depolarization threshold, ectopic discharges, and an increase in the response to stimuli -Allodynia, or pain from a normally nonnoxious stimulus (e.g., touch), is one such type of abnormal sensation and a common feature of neuropathic pain. In patients with allodynia, the mere weight of clothing or bedsheets on the skin can be excruciatingly painful)

Mobility Antecedents

-Adequate energy -Muscle strength -Underlying skeletal stability -Joint function -Neuromuscular coordination -Age

47. Teaching learning post op hip replacement, assessment. (med-surg 1148)

-Assess patient for pain using a standard pain intensity scale. (Pain is expected after a surgical procedure because of the surgical trauma and tissue response. Muscle spasms occur after total hip replacements. Immobility causes discomfort at pressure points.) -Pain characteristics may help to determine the cause of discomfort. Pain may be due to complications (hematoma, infection, dislocation). Pain is an individual experience—it means different things to different people. Acknowledge existence of pain; inform patient of available analgesic agents or muscle relaxants. Use pain-modifying techniques. Administer analgesic agents as prescribed. Change position within prescribed limits. Modify environment. Notify primary provider about persistent pain. The nurse can reduce the stress experienced by patient by communicating concern and availability of assistance to help the patient deal with the pain. Patient will require parenteral opioids during the first 24-48 hours and then will progress to oral analgesic agents. The use of pillows to provide adequate support and relief of pressure on bony prominences assists in minimizing pain. Interactions with others, distractions, and sensory overload or deprivation may affect pain experience. Surgical intervention may be necessary if pain is due to hematoma or excessive edema. Evaluate and record discomfort and effectiveness of pain-modifying techniques. Effectiveness of action is based on experience; data provide a baseline about pain experiences, pain management, and pain relief.

Pain Scales Assessments (Med-Surg, pg 232-233)

-COMFORT Scale (used to assess pain and distress in critically ill pediatric patients, relies on six behavioral and two physiologic factors that determine the level of analgesia needed to adequately relieve pain in these children) -CRIES pain scale (neonates and infants from 0 to 6 months) -FLACC Scale (face, legs, activity, cry, consolability. for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain, rates each of the five categories on a 0-to-2 scale) -Wong-Baker FACES Pain Rating Scale (recommended for persons aged 3 years and older and cognitively impaired pts. Pick the face that represents how they feel) -0-10 numeric rating scale (NRS) (you should know this one already) -Checklist of nonverbal indicators -Verbal descriptor scale (VDS) (uses different words or phrases to describe the intensity of pain, such as "no pain, mild pain, moderate pain, severe pain, very severe pain, and worst possible pain." The patient is asked to select the phrase that best describes pain intensity.) -VIsual Analog Scale (VAS) (10-cm line with word anchors at the extremes, such as "no pain" on one end and "pain as bad as it could be" or "worst possible pain" on the other end. Patients are asked to make a mark on the line to indicate intensity of pain, and the length of the mark from "no pain" is measured and recorded in centimeters or millimeters.) -Oucher Pain Scale -PAINAD Scale (The Pain Assessment in Advanced Dementia- used for cognitively impaired pts -relies on observation of five specific items: breathing, vocalization, facial expression, body language, and consolability) -FPS-R (faces pain scale revised) (Has six faces to make it consistent with other scales using the 0 to 10 metric. The faces range from a neutral facial expression to one of intense pain and are numbered 0, 2, 4, 6, 8, and 10.) -Payen Behavioral Pain Scale

Factors affecting sleep (select all question!)

-Developmental considerations (age, weight) -Motivation (partying to stay awake or wanting to sleep) -Culture (including bedtime rituals, habits like drinking tea) -Lifestyle Habits (night shifts, watching tv shows) -Physical Activity/Exercise (excessive exercise can decrease the quality of sleep, moderate exercise promotes sleep) -Dietary Habits (alcohol intake, caffeine containing beverages, smoking, snacking with carbs before bed) -Environmental Factors (cool dark room, nightlight, normal noise volumes) -Psychological Stress (illness, stress, and various life situations tends to disturb sleep) -Ilness (major: epilepsy, gastric secretions, liver failure, end stage renal disease, pain, exc.) -Medications (Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications..... timing is a factor!)

Antecedents of Comfort

-Effective circulatory system -Able to discern from comfort to discomfort -Without noxious stimuli -Intact neurological/sensory system

39. Intervention ambulation

-Gait belt (The gait belt is used to help the patient stand and provides stabilization during pivoting. Gait belts also allow the nurse to assist in ambulating patients who have leg strength, can cooperate, and require minimal assistance. Do not use gait belts on patients with abdominal or thoracic incisions ) -Stand-assist and repositioning aids (These devices can be freestanding or attached to the bed or wheelchair. Other aids have a pull bar to assist the patient to stand, and then a seat unfolds under the patient. After the patient sits on the seat, the device can be wheeled to the toilet, chair, shower, or bed.) -Lateral-assist devices (reduce patient-surface friction during side-to-side transfers. Roller boards, slide boards, transfer boards, inflatable mattresses, and friction-reducing lateral-assist devices are examples of these devices, which make transfers safer and more comfortable for the patient.) -Friction-reducing sheets (can be used under patients to prevent skin shearing when moving patients in bed and when assisting with lateral transfers. Their use reduces friction and the force required to move patients.) -Mechanical lateral-assist devices (include specialized stretchers and eliminate the need to slide the patient manually. Some devices are motorized, whereas others use a hand crank.) -Transfer Chairs (can convert into stretchers are available. These are useful with patients who have no weight-bearing capacity, cannot follow directions, and/or cannot cooperate.) Powered Stand-Assist and Repositioning Lifts (These devices can be used with patients who can bear weight on at least one leg, can follow directions, and are cooperative. A simple sling is placed around the patient's back and under the arms. The device mechanically assists the patient to stand, without any assistance from the nurse.) -Powered Full-Body Lifts. (These devices are used with patients who cannot bear any weight to move them out of bed, into and out of a chair, and to a commode or stretcher. A full-body sling is placed under the patient's body, including head and torso, then the sling is attached to the lift.)

Mobility Attributes

-Gross simple movements -Fine complex movements -Coordination -Synchronized efforts of musculoskeletal and nervous systems

40. Types of Exercises

-Isotonic exercise involves muscle shortening and active movement. Examples include carrying out ADLs, independently performing range-of-motion exercises, and swimming, walking, jogging, and bicycling. Potential benefits include increased muscle mass, tone, and strength; improved joint mobility; increased cardiac and respiratory function; increased circulation; and increased osteoblastic or bone-building activity. These benefits do not occur when the nurse or family member performs passive range-of-motion exercises for a patient because the patient's muscles do not exert effort. Therefore, although still beneficial, the overall potential benefits are reduced. -Isometric exercise involves muscle contraction without shortening (i.e., there is no movement or only a minimum shortening of muscle fibers). Examples include contractions of the quadriceps and gluteal muscles, such as what occurs when holding a Yoga pose. Potential benefits are increased muscle mass, tone, and strength; increased circulation to the exercised body part; and increased osteoblastic activity. Nurses should encourage both isotonic and isometric exercises for hospitalized patients with limited mobility. -Isokinetic exercise involves muscle contractions with resistance. The resistance is provided at a constant rate by an external device, which has a capacity for variable resistance. Examples include rehabilitative exercises for knee and elbow injuries and lifting weights. Using the device, the person takes the muscles and joint through a complete range of motion without stopping, meeting resistance at every point. A continuous passive motion (CPM) device used postoperatively after joint surgery (knee replacement, anterior cruciate ligament [ACL] repair) performs these same type exercises passively for the patient.

Gate Control Theory- Interventions (Taylor, pg 1154 and 1171)

-Massage (with or without analgesic ointments or liniments containing menthol) -Application of heat or cold, or both intermittently -Acupressure -Transcutaneous electrical nerve stimulation (TENS) Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to close the gate, thus blocking pain impulses from that area.

Attributes of Sleep

-NREM -REM -sleep scale

Pharmacological interventions for types of pain (Taylor, 1173 and power point)

-Opioid analgesics (all controlled substances; e.g., morphine, codeine, oxycodone, meperidine, hydromorphone, methadone) ------->act on the CNS to inhibit activity of ascending nociceptive pathways -Nonopioid analgesics (acetaminophen and nonsteroidal anti-inflammatory drugs [NSAIDs]-- decrease pain by inhibiting cyclo-oxygenase, which is an enzyme involved in production of prostaglandin.) -Adjuvant analgesics (anticonvulsants, antidepressants, multipurpose drugs) -Local anesthetics (block nerve conduction when applied to nerve fibers.)

Opioid (Taylor, pg 1174)

-Opioids, formerly called narcotic analgesics, are generally considered the major class of analgesics used in the management of moderate to severe pain because of their effectiveness. In sufficient dosage, they are considered capable of relieving pain of virtually every nature. Opioids produce analgesia by attaching to opioid receptors in the brain. -Opioid receptor sites are further classified as mu, delta, and kappa types. The difference in opioid effects is related to their interaction with these three opioid types of receptors. Opioids that produce analgesia (agonists) can compete for binding sites on the receptors with opioids that do not produce analgesia (antagonists). -The most common side effects associated with opioid use are sedation, nausea, and constipation. Respiratory depression is a commonly feared side effect of opioid use.

Assessment and tx of pain (the joint commission standards)

-Patients have the right to appropriate assessment and management of their pain. -Initial assessment and ongoing assessment of the existence of pain should also include the nature and intensity of the pain in all patients. -Assessment results should be recorded in a manner that promotes regular reassessment and follow-up. -Staff, including new clinical staff, must be oriented and competent in assessment and management of pain. -The effect of oral analgesics must be evaluated 45 to 60 minutes after they are administered. -IV analgesics should be reevaluated 15 to 30 minutes after administration. -Policies and procedures that support prescription or ordering of pain medications must be in place. -Pain must be managed so that it does not interfere with a patient's participation in rehabilitation. -Patients and families require education about effective pain management. -Discharge planning should address the patient's needs for management of pain symptoms. -Data must be collected to monitor the appropriateness and effectiveness of the facility's pain management plan.

36. body mechanics (Taylor, 1043 & 1059-1060)

-Practice good posture -Avoid twisting, lifting above waist level, and reaching up for any length of time -Push objects rather than pull them -Keep load close to your body when lifting -Lift with the large leg muscles, not the back muscles -Squat while keeping the back straight when it is necessary to pick something up off the floor -Bend your knees and tighten abdominal muscles when lifting -Avoid overreaching or a forward flexion position -Use a wide base of support -Adjust height of chair using a footstool to position knees higher than hips -Adjust height of work area to avoid stress on back -Avoid bending, twisting, and lifting heavy objects -Avoid prolonged standing and repetitive tasks -Avoid work involving continuous vibrations -Use lumbar support in straight back chair with arm rests -When standing for any length of time, rest one foot on a small stool or box to relieve lumbar lordosis

42. Nursing Interventions for individuals experiencing altered mobility (med-surg, 183-185)

-Relieving pressure (push ups, one half push ups, moving side to side, and shifting) -Positioning the patient (Patients should be positioned laterally, prone, and dorsally in sequence unless a position is not tolerated or is contraindicated. Generally, those who experience discomfort after 30 to 60 minutes of lying prone need to be repositioned. The recumbent position is preferred to the semi-Fowler position because of increased supporting body surface area in this position. Patients able to shift their weight every 15 to 20 minutes and move independently may change total position every 2 to 4 hours. Indications for routine repositioning every 2 hours or more frequently include loss of sensation, paralysis, coma, and edema.) -Use pressure-relieving devices (This is particularly important for patients who cannot get out of bed and who are at high risk for pressure ulcer development. These devices are designed to provide support for specific body areas or to distribute pressure evenly.) -Improving mobility (The patient is encouraged to remain active and is ambulated whenever possible) -Improving sensory perception (Strategies to improve cognition and sensory perception may include stimulating the patient to increase awareness of self in the environment, encouraging the patient to participate in self-care, or supporting the patient's efforts toward active compensation for loss of sensation (e.g., a patient with paraplegia lifting up from the sitting position every 15 minutes) -Improving tissue perfusion (Massage of erythematous areas is avoided because damage to the capillaries and deep tissue may occur) -Improving nutritional status -reducing friction and shear -minimizing irritating moisture -promoting pressure ulcer healing -preventing recurrence ....for details refer to pg 185!

Attributes of Comfort

-Reports being comfortable -Reports pain scale 0 -Relaxed facial expression and body posture -VS WNL for baseline

Nursing processes to promote normal sleep

-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

Identify when sleep imbalance (negative consequence) is developing or has developed. (concept map)

-Slowed response -Fatigue -Irritability -Altered thoughts -Psychosis

Antecedents of Sleep

-age predictor -eustress (normal stress) -adequate daytime functioning -normal upper airway physiologoy -normal circadian rhythm -sufficient time

Barriers to pain control (med serg, pg 224) *select all that apply*

-breakthrough pain: a transitory increase in pain that occurs on a background of otherwise controlled persistent pain. -ceiling effect: an analgesic dose above which further dose increments produce no change in effect. -opioid tolerant: denotes a person who has taken opioids long enough at doses high enough to develop tolerance to many of the opioid's effects, including analgesia and sedation. -tolerance: a process characterized by decreasing effects of a drug at its previous dose, or the need for a higher dose of drug to maintain an effect -fear of myths or misconceptions and lack of knowledge about the use of opioid analgesics.

Exemplars for Pain

-phantom limb pain -nerve root compression -degenerative disc disease -osteoarthritis -post op athroplasty -wound care and dressing changes -procedural pain

Parasomnias (select all question!)

Are patterns of waking behavior that appear during sleep. examples: -Somnambulism (sleep walking) -sleep talking -sleep terrors/nightmares -RBD (rem behavior disorder -acting out dreams while asleep) -nocturnal erections (remember the P) -Enuresis (bed wetting) -Bruxism (grinding teeth) -sleep related eating disorder (cooking or eating foods)

Comparison of Effects of Exercise and Immobility on Body Systems (Taylor, 1048: Table 32-4)

CARDIOVASCULAR -->effects of exercise ↑Efficiency of heart ↓Resting heart rate and blood pressure ↑Blood flow and oxygenation of all body parts -->effects of immobility ↑Cardiac workload ↑Risk for orthostatic hypotension ↑Risk for venous thrombosis RESPIRATORY -->effects of exercise ↑Depth of respiration ↑Respiratory rate ↑Gas exchange at alveolar level ↑Rate of carbon dioxide excretion -->effects of immobility ↓Depth of respiration ↓Rate of respiration Pooling of secretions Impaired gas exchange GASTROINTESTINAL -->effects of exercise ↑Appetite ↑Intestinal tone -->effects of immobility Disturbance in appetite Altered protein metabolism Altered digestion and utilization of nutrients ↓Peristalsis URINARY -->effects of exercise ↑Blood flow to kidneys ↑Efficiency in maintaining fluid and acid-base balance ↑Efficiency in excreting body wastes -->effects of immobility ↑Urinary stasis ↑Risk for renal calculi ↓Bladder muscle tone MUSCULOSKELETAL -->effects of exercise ↑Muscle efficiency ↑Coordination ↑Efficiency of nerve impulse transmission -->effects of immobility ↓Muscle size, tone, and strength ↓Joint mobility, flexibility Bone demineralization ↓Endurance, stability ↑Risk for contracture formation METABOLIC -->effects of exercise ↑Efficiency of metabolic system ↑Efficiency of body temperature regulation -->effects of immobility ↑Risk for electrolyte imbalance Altered exchange of nutrients and gases INTEGUMENT -->effects of exercise Improved tone, color, and turgor, resulting from improved circulation -->effects of immobility ↑Risk for skin breakdown and formation of pressure ulcers PSYCHOLOGICAL WELL BEING -->effects of exercise Energy, vitality, general well-being Improved sleep Improved appearance Improved self-concept Positive health behaviors -->effects of immobility ↑Sense of powerlessness ↓Self-concept ↓Social interaction ↓Sensory stimulation Altered sleep-wake pattern ↑Risk for depression Risk for learned helplessness

Sleep deprivation causes and risks (Taylor, pg 1132)

DEFINITION Decrease in the amount, consistency, or quality of sleep. It may result from decreased REM sleep or NREM sleep. The effects of sleep deprivation become increasingly apparent after 30 hours of continual wakefulness. CAUSES/RISKS -shorter periods of sleep -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. -The possibility of a causal relationship between sleep deprivation and obesity, cancer, diabetes, and cardiovascular conditions.

Signs and Symptoms of Sleep Disorders (Taylor, pg 1129)

DYSSOMNIAS -Insomnia (difficulty falling asleep, intermittent sleep, or early awakening from sleep. It is the most common of all sleep disorders.) -Hypersomnia (excessive sleep, particularly during the day. Naps do not usually relieve their symptoms. When they awake, they are often disoriented, irritated, restless, and have slower speech and thinking processes.) -Narcolepsy (uncontrollable desire to sleep. A person with narcolepsy can literally fall asleep standing up, while driving a car, in the middle of a conversation, or while swimming. sleep attacks, cataplexy, hypnagogic, hallucinations, sleep onset REM periods, sleep paralysis) -*Sleep apnea (absence of breathing while sleeping; snoring. 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. Most common in middle-aged men who are obese and have short, thick necks, women and people of other ages may also experience it. Obstructive sleep apnea (OSA) can result when the airway is occluded because of the collapse of the hypopharynx (Fig. 33-3) or from other structural abnormalities such as enlarged tonsils and adenoids, a deviated nasal septum, and thyroid enlargement. Narrowing of nasal passageways caused by allergic rhinitis or nasal polyps is another factor contributing to OSA. Clinical information and polysomnography can confirm the diagnosis of sleep apnea. Definitive tx involves use of CPAP.) -Restless leg syndrome (cannot lie still and report unpleasant creeping, crawling, or tingling sensations in the legs.) -Sleep deprivation (decrease in the amount, consistency, or quality of sleep) PARASOMNIAS -Somnambulism (sleep walking) -sleep terrors/nightmares RBD (rem behavior disorder -acting out dreams while asleep) -nocturnal erections (remember the P) -Enuresis (bed wetting) -Bruxism (grinding teeth) -sleep related eating disorder (cooking or eating foods)

48. Teaching learning post op hip replacement, assessment. (med-surg 1153)

Discuss with patient the following methods to reduce pain: Periodic rest Distraction and relaxation techniques Medication therapy (e.g., nonsteroidal anti-inflammatory drugs, opioid analgesic agents): actions of medications, administration, schedule, side effects Instruct patient in the following: Keeping incision clean and dry Cleansing incision daily with soap and water and changing the dressing Recognizing signs of wound infection (e.g., pain, increased redness, swelling, purulent drainage, fever) Explain that sutures or staples will be removed 10 to 14 days after surgery. Educate patient about the following: Safe use of assistive devices Weight-bearing limits How to change positions frequently Limitations on hip flexion and adduction (e.g., avoid acute flexion and crossing legs) How to stand without flexing hip acutely Avoidance of low-seated chairs Sleeping with pillow between legs to prevent adduction Gradual increase in activities and participation in prescribed exercise regimen Use of important medications such as warfarin (Coumadin) and aspirin Assess home environment for physical barriers. Instruct patient to use elevated toilet seat and to use reachers to aid in dressing. Encourage patient to accept assistance with activities of daily living during early convalescence until mobility and strength improve. Arrange services and accommodations to address the patient's disability or illness, as appropriate. Assess patient for development of potential problems, and instruct patient to report signs of potential complications: Dislocation of prosthesis (e.g., increased pain, shortening of leg, inability to move leg, popping sensation in hip, abnormal rotation) Deep vein thrombosis (e.g., calf pain, swelling, redness) Wound infection (e.g., pain, increased redness, swelling, purulent drainage, fever) Pulmonary emboli (e.g., shortness of breath, tachypnea, pleuritic chest pain) Discuss with patient the need to continue regular health care (routine physical examinations) and screenings.

RAS (reticular activating system)

During sleep, the RAS experiences few stimuli from the cerebral cortex and the periphery of the body. Wakefulness occurs when this system is activated with stimuli from the cerebral cortex and from periphery sensory organs and cells. Alarm clock example. Sensations such as pain, pressure, and noise produce wakefulness by means of peripheral organs and cells.

Harmful Effects of Unrelieved Pain

ENDOCRINE ↑ Adrenocorticotrophic hormone (ACTH), ↑ cortisol, ↑ antidiuretic hormone (ADH), ↑ epinephrine, ↑ norepinephrine, ↑ growth hormone (GH), ↑ catecholamines, ↑ renin, ↑ angiotensin II, ↑ aldosterone, ↑ glucagon, ↑ interleukin-1; ↓ insulin, ↓ testosterone METABOLIC Gluconeogenesis, hepatic glycogenolysis, hyperglycemia, glucose intolerance, insulin resistance, muscle protein catabolism, ↑ lipolysis CARDIOVASCULAR ↑ Heart rate, ↑ cardiac workload, ↑ peripheral vascular resistance, ↑ systemic vascular resistance, hypertension, ↑ coronary vascular resistance, ↑ myocardial oxygen consumption, hypercoagulation, deep vein thrombosis RESPIRATORY ↓ Flows and volumes, atelectasis, shunting, hypoxemia, ↓ cough, sputum retention, infection GENITOURINARY ↓ Urinary output, urinary retention, fluid overload, hypokalemia GASTROINTESTINAL ↓ Gastric and bowel motility MUSCULOSKELETAL Muscle spasm, impaired muscle function, fatigue, immobility COGNITIVE Reduction in cognitive function, mental confusion IMMUNE Depression of immune response DEVELOPMENTAL ↑ Behavioral and physiologic responses to pain, altered temperaments, higher somatization; possible altered development of the pain system, ↑ vulnerability to stress disorders, addictive behavior, and anxiety states FUTURE PAIN Debilitating chronic pain syndromes: postmastectomy pain, postthoracotomy pain, phantom pain, postherpetic neuralgia QUALITY OF LIFE Sleeplessness, anxiety, fear, hopelessness, ↑ thoughts of suicide

REM (rapid eye movement)

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

Physical Assessment for sufficient rest

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. Other sleep characteristics to assess include restlessness, sleep postures, and sleep activities such as snoring or leg jerking

Pain Classifications

LOCATIONS -cutaneous pain: superficial pain usually involving the skin or subcutaneous tissue -somatic pain: pain originating in structures in the body's external wall -visceral pain: pain originating in the internal organs in the thorax, cranium, or abdomen MODE OF TRANSMISSION -referred pain: pain can originate in one part of the body but be perceived in an area distant from its point of origin. ETIOLOGY -nociceptive pain: pain from a normal process that results in noxious stimuli being perceived as painful -neuropathic pain: pain that results as a direct consequence of a lesion or disease affecting abnormal functioning of the peripheral nervous system (PNS) or central nervous system (CNS) -intractable: severe pain that is extremely resistant to relief measures -phantom pain: sensation of pain without demonstrable physiologic or pathologic substance; commonly observed after the amputation of a limb -psychogenic pain: pain for which no physical cause can be identified

Nursing processes for infants, toddler, and adults experiencing sleep imbalance and to promote normal sleep. (Taylor, pg 1133: box 33-2)

NEWBORNS/INFANTS Sleep Pattern---> Newborn: Sleeps an average of 16 hours/24 hours; averages about 4 hours at a time. Each infant's sleep pattern is unique. On average, infants sleep 10 to 12 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. Implications---> -Teach parents to position infant on the back (less than 1yo only). -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. TODDLERS Sleep Pattern---> Need for sleep declines as this stage progresses. May initially sleep 12 hours at night with two naps during the day and end this stage sleeping 8 to 10 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. 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. PRESCHOOLERS Sleep Pattern---> Children in this stage generally sleep 9 to 16 hours at night, with 12 hours being the average. 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. 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. SCHOOL AGED CHILDREN Sleep Pattern---> Younger school-aged children may require 10 to 12 hours nightly, whereas older children in this stage may average 8 to 10 hours. Sleep needs usually increase when physical growth peaks. 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. ADOLESCENTS Sleep Pattern---> Sleep needs of teenagers vary widely, but the average requirement is 9 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. 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 average amount of sleep required is 8 hours, but in fact, many young adults require less sleep. 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. 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 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. 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. OLDER ADULTS Sleep Pattern---> An average of 7 to 9 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. Elderly people 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. 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 people 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 people to discuss sleep concerns with their physicians.

38. Assessment for common mobility disorders (hip fx)

Maintain neutral positioning of hip. (Prevents stress at the site of fixation.) Use trochanter roll; roll to uninjured side. (Minimizes external rotation.) Place pillow between legs when turning. (Supports leg; prevents adduction.) Instruct and assist in position changes and transfers. (Encourages patient's active participation while preventing stress on hip fixation.) Instruct in and supervise isometric and quadriceps and gluteal setting exercises. (Strengthens muscles needed for walking.) Encourage the use of trapeze. (Strengthens shoulder and arm muscles necessary for use of ambulatory aids.) In consultation with physical therapist, instruct in and supervise progressive safe ambulation within limitations of weight-bearing prescription. (Amount of weight bearing depends on the patient's condition, fracture stability, and fixation device; ambulatory aids are used to assist the patient with non-weight-bearing and partial-weight-bearing ambulation.) Offer encouragement and support exercise regimen. (Reconditioning exercises can be uncomfortable and fatiguing; encouragement helps patient comply with the program.) Instruct in and supervise safe use of ambulatory aids. (Prevents injury from unsafe use.)

Classification of Pain (Med 227, table 12-2)

NOCICEPTIVE PAIN ((Most responsive to nonopioids, opioids, and local anesthetics)) -->Somatic Pain: Arises from bone joint, muscle, skin, or connective tissue. It is usually described as aching or throbbing in quality and is well localized. -Examples: Surgical, trauma; wound and burn pain; cancer pain (tumor growth) and pain associated with bony metastases; labor pain (cervical changes and uterine contractions); osteoarthritis and rheumatoid arthritis pain; osteoporosis pain; pain of Ehlers-Danlos syndrome; ankylosing spondylitis -->Visceral Pain: Arises from visceral organs, such as the GI tract and pancreas. This may be subdivided: Tumor involvement of the organ capsule that causes aching and fairly well-localized pain Obstruction of hollow viscus, which causes intermittent cramping and poorly localized pain Examples: Organ-involved cancer pain; ulcerative colitis; irritable bowel syndrome; Crohn's disease; pancreatitis NEUROPATHIC PAIN ((Adjuvant analgesic agents, such as antidepressants, anticonvulsants, and local anesthetics, but there is wide variability in terms of efficacy and adverse-effect profiles.)) -->Centrally Generated Pain -Deafferentation pain: Injury to either the peripheral or central nervous system; burning pain below the level of a spinal cord lesion reflects injury to the central nervous system. -Examples: Phantom pain as a result of peripheral nerve damage; poststroke pain; pain following spinal cord injury -Sympathetically maintained pain: Associated with dysregulation of the autonomic nervous system -Example: Complex regional pain syndrome -->Peripherally Generated Pain -Painful polyneuropathies: Pain is felt along the distribution of many peripheral nerves. -Examples: Diabetic neuropathy; postherpetic neuralgia; alcohol-nutritional neuropathy; some types of neck, shoulder, and back pain; pain of Guillain-Barré syndrome -Painful mononeuropathies: Usually associated with a known peripheral nerve injury; pain is felt at least partly along the distribution of the damaged nerve. -Examples: Nerve root compression, nerve entrapment; trigeminal neuralgia; some types of neck, shoulder, and back pain MIXED PAIN ((Adjuvant analgesic agents, such as antidepressants, anticonvulsants, and local anesthetics, but there is wide variability in terms of efficacy and adverse-effect profiles.)) -->No identified categories -Examples: Fibromyalgia; some types of neck, shoulder, and back pain; some headaches; pain associated with HIV; some myofascial pain; pain associated with Lyme disease **study this chart

Nonopioid Analgesics

Nonopioid analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), are usually the drugs of choice for both acute and persistent moderate chronic pain. The simplest dosage schedules and least invasive pain management modalities should be used first. Many times, these drugs alone can provide adequate pain relief. Many of these medications are over-the-counter (OTC) products, whereas some are available by prescription only. Some can cause gastric side effects, but these symptoms may be preventable if the drug is taken with food or antacids.

Sleep Hygiene

Nonpharmacologic recommendations that help a person get a better night's sleep.

Implementing a plan of care for pain relief outcomes (Taylor, pg 1168)

Nursing interventions include establishing a trusting nurse-patient relationship, manipulating factors that affect the pain experience, initiating nonpharmacologic pain relief measures, managing pharmacologic interventions, reviewing additional pain control measures, ensuring ethical and legal responsibility to relieve pain, and teaching the patient about pain.

45. Osteoporosis Diagnostics (Med-surg pg 1171)

Osteoporosis is diagnosed by dual-energy x-ray absorptiometry (DEXA), which provides information about BMD at the spine and hip (see Chapter 39). The DEXA scan data are analyzed and reported as T-scores (the number of standard deviations above or below the average BMD value for a 30-year-old healthy Caucasian woman). T-scores that are gender specific for men are not yet available. Baseline DEXA testing is recommended for all women older than 65 years, for women who are postmenopausal older than 50 years with osteoporosis risk factors, and for all people who have had a fracture thought to occur as a consequence of osteoporosis (Cosman et al., 2014). BMD studies are also useful in assessing response to therapy and are recommended 3 months post any osteoporotic fracture. There is no evidence to support basic screening of men or for the optimal time interval to repeat studies following a normal baseline report. Fracture risk can be estimated using the World Health Organization (WHO) Fracture Risk Assessment Tool (FRAX). Treatment is now reserved for those with a 10-year risk of more than 3% for hip fracture or 20% risk for other major fractures. The risks scores are based on BMD, personal and family history of fractures, body mass index, gender, age, and secondary factors such as medication use, smoking, and history of rheumatoid disease. Laboratory studies (e.g., serum calcium, serum phosphate, serum alkaline phosphatase [ALP], urine calcium excretion, urinary hydroxyproline excretion, hematocrit, erythrocyte sedimentation rate [ESR]), and x-ray studies are used to exclude other possible disorders (e.g., multiple myeloma, osteomalacia, hyperparathyroidism, malignancy) that contribute to bone loss. In men, low testosterone levels may be part of the cause. Osteoporosis is the most prevalent bone disease in the world.

Interventions for pain (exemplars)- pharmacological and non pharmacological

PHANTOM LIMB PAIN -(pharm)beta-blockers may relieve dull, burning discomfort; anticonvulsants control stabbing and cramping pain; and tricyclic antidepressants may not only alleviate phantom limb pain. -(nonpharm)mirror therapy, massage, biofeedback, acupuncture, repositioning, TENS, guided imagery, and virtual reality (med serg pg 1216) -nerve root compression DEGENERATIVE DISC DISEASE -(nonpharm) The goals of treatment are to rest and immobilize the cervical spine to give the soft tissues time to heal and to reduce inflammation in the supporting tissues and the affected nerve roots in the cervical spine. It also reduces inflammation and edema in soft tissues around the disc, relieving pressure on the nerve roots. Proper positioning on a firm mattress may bring dramatic relief from pain. The cervical spine may be rested and immobilized by a cervical collar, cervical traction, or a brace. A collar allows maximal opening of the intervertebral foramina and holds the head in a neutral or slightly flexed position. The patient may have to wear the collar 24 hours a day during the acute phase. The skin under the collar is inspected for irritation. After the patient is free of pain, cervical isometric exercises are started to strengthen the neck muscles. -(pharm) OSTEOARTHRITIS -(pharm) directed toward symptom management and pain control acetaminophen initially, COX-2 enzyme blockers for GI coplication pts, or opioids and intra-articular corticosteroids. -(nonpharm) exercise, especially in the form of cardiovascular aerobic exercise and lower extremity strength training, has been found to prevent OA progression and decrease symptoms of OA. Along with exercise, weight loss, which in turn decreases excess load on the joint, can also be extremely beneficial. Occupational and physical therapy can help the patient adopt self-management strategies -OSTEOPEROSIS (pg 1169) -post op athro plasty -WOUND CARE AND DRESSING -procedural pain

Modulation of Pain

Process by which the sensation of pain is inhibited or modified -neuromodulators: endogenous opioid chemical regulators that appear to have analgesic activity and alter pain perception -endorphins: morphine-like substances released by the body that appear to alter the perception of pain -dynorphin: the endorphin having the most potent analgesic effect -enkephalins: opioids that are widespread throughout the brain and dorsal horn of the spinal cord and are believed to reduce pain sensation by inhibiting the release of substance P.

35. ROM

Range-of-motion exercises may be active (performed by the patient under the supervision of the nurse), assisted (with the nurse helping if the patient cannot do the exercise independently), or passive (performed by the nurse). Unless otherwise prescribed, a joint should be moved through its range of motion three times, at least two times a day. The joint to be exercised is supported, the bones above the joint are stabilized, and the body part distal to the joint is moved through the range of motion of the joint. For example, the humerus must be stabilized while the radius and ulna are moved through their range of motion at the elbow joint.

Comfort Concept

State of physical ease

Sleep Concept

State of rest accompanied by natural altered consciousness

49. Types of traction (med 1139)

Straight or running traction applies the pulling force in a straight line with the body part resting on the bed. The countertraction is provided by the patient's body and movement can alter the traction provided. Buck's extension traction is an example of straight traction. Balanced suspension traction supports the affected extremity off the bed and allows for some patient movement without disruption of the line of pull. With this traction, the countertraction is produced by devices such as slings or splints. Traction may be applied to the skin (skin traction) or directly to the bony skeleton (skeletal traction). The mode of application is determined by the purpose of the traction. Traction can be applied with the hands (manual traction). This is temporary traction that may be used when applying a cast, giving skin care under a Buck's extension foam boot, or adjusting the traction apparatus. skin traction may be prescribed for short-term use to stabilize a fractured leg, control muscle spasms, and immobilize an area before surgery. The pulling force is applied by weights that are attached to the client with Velcro, tape, straps, boots, or cuffs. The amount of weight applied must not exceed the tolerance of the skin. No more than 2 to 3.5 kg (4.5 to 8 lb) of traction can be used on an extremity. Pelvic traction is usually limited to 4.5 to 9 kg (10 to 20 lb), depending on the weight of the patient. Types of skin traction used for adults include Buck's extension traction (applied to the lower leg) (described next), the chin halter strap (occasionally used to treat chronic neck pain), and the pelvic belt (sometimes used to treat lower back pain). Buck's extension traction (unilateral or bilateral) is skin traction to the lower leg. The pull is exerted in one plane when partial or temporary immobilization is desired (see Fig. 40-5). It is used as a temporary measure to overcome muscle spasms and promote immobilization of hip fractures in adult patients waiting for more definitive treatment such as surgery

Breakthrough pain (BTP)

Temporary flare-up of moderate to severe pain that occurs even when the patient is taking around-the-clock medication for persistent pain. As many as 50% to 90% of cancer patients experience breakthrough pain. This pain is often not diagnosed correctly and is frequently undertreated. Breakthrough pain can be classified as incident pain (e.g., pain caused by movement), idiopathic (spontaneous pain due to an unknown cause), or end-of-dose pain, when the pain occurs before the next dose of analgesic is due.

Pain Process

The four specific physiologic processes involved in nociception (the ability to feel painful stimuli) include: -transduction -transmission -perception -modulation of pain ATI also states: pain threshold and pain tolerance.

37. Age related changes in mobility (Taylor 428)

The greatest threat to the health of older adults is loss of the physiologic reserve of the various organ systems. When illness occurs, increased physical and emotional stress places an older adult at risk for complex reactions. An older adult is more likely to develop complications and to recover more slowly. For instance, an older patient with a hip fracture is at high risk for pneumonia and skin breakdown because of immobility, a decreased ability to expel pulmonary secretions, and thinner, more fragile skin.

50. Consequence of immobility and pathophysiology of the heart (Taylor 1051)

The primary and serious effects of immobility on the cardiovascular system include increased cardiac workload, orthostatic hypotension, and venous stasis, with resulting venous thrombosis. Immobility results in an increased workload for the heart. With immobility, the skeletal muscles that normally compress valves in the leg veins and help to pump the blood back to the right side of the heart do not adequately contract. There is less resistance offered by the blood vessels and blood pools in the veins, thus increasing the venous blood pressure and changing the distribution of blood in the immobile person. As a result, the heart rate, cardiac output, and stroke volume increase. Immobility predisposes the patient to thrombi formation because of venous stasis, especially in the legs, where normal muscular activity helps move blood toward the central circulatory system. During periods of immobility, calcium leaves the bones and enters the blood, where it influences blood coagulation, leading to an increased risk of thrombus formation. A person who is immobile is more susceptible to developing orthostatic hypotension. The normal neurovascular adjustments that occur to maintain systemic blood pressure with position changes are not used during periods of inactivity and become inoperative. A drop in blood pressure may occur as a result of a lack of vasoconstriction when changing from a supine to an upright position. The person tends to feel weak and faint when this condition occurs. See Chapter 24 for additional discussion of orthostatic hypotension.

Perception of Pain

The sensory process that occurs when a stimulus for pain is present. It includes the person's interpretation of the pain. The physiology of perception of pain continues to be studied but can be targeted by mind-body therapies, such as distraction and imagery, which are based on the belief that brain processes can strongly influence pain perception Pain threshold: amount of stimulation required before a person experiences the sensation of pain Tolerance: amount of pain a person is willing to bare.

The Gate Control Theory of Pain

The theory states that certain nerve fibers, those of small diameter, conduct excitatory pain stimuli toward the brain, but nerve fibers of a large diameter appear to inhibit the transmission of pain impulses from the spinal cord to the brain. There is a gating mechanism that is believed by some to be located in substantia gelatinosa cells in the dorsal horn of the spinal cord. The exciting and inhibiting signals at the gate in the spinal cord determine the impulses that eventually reach the brain. Thus, only a limited amount of sensory information can be processed by the nervous system at any given moment. When too much information is sent through, certain cells in the spinal column interrupt the signal as if closing a gate. The brain can also influence the gating mechanism. Past experiences and learned behaviors, which are interpreted by the brain, regulate or adjust the eventual behavioral responses to pain. Thus, the gating mechanism appears to be influenced by the amount of activity in large and small afferent fibers in addition to nerve impulses that descend from the brain. This helps explain why different people interpret similar painful stimuli differently. Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to close the gate, thus blocking pain impulses from that area.

44. Neurological injury and transport of patient (Taylor, 1072)

When a patient has a spinal injury or is recovering from neck, back, or spinal surgery, it is often necessary to keep the body in straight alignment when turning the patient. Two or three nurses can accomplish this safely by logrolling a patient (Fig. 32-21). Do not try to logroll the patient without enough help. Do not twist the patient's head, spine, shoulders, knees, or hips while logrolling.

Responses to Pain: physical and behavioral

The three types of responses to pain are physiologic, behavioral, and affective. Behavioral (Voluntary) Responses -Moving away from painful stimuli -Grimacing, moaning, and crying -Restlessness -Protecting the painful area and refusing to move Physiologic (Involuntary) Responses (Typical Sympathetic Responses When Pain Is Moderate and Superficial) -Increased blood pressure* -Increased pulse and respiratory rates* -Pupil dilation -Muscle tension and rigidity -Pallor (peripheral vasoconstriction) -Increased adrenalin output -Increased blood glucose (Typical Parasympathetic Responses When Pain Is Severe and Deep) -Nausea and vomiting -Fainting or unconsciousness -Decreased blood pressure -Decreased pulse rate -Prostration -Rapid and irregular breathing Affective (Psychological) Responses -Exaggerated weeping and restlessness -Withdrawal -Stoicism -Anxiety -Depression -Fear -Anger -Anorexia -Fatigue -Hopelessness -Powerlessness

PCA pump (patient-controlled analgesia)

This method of analgesia therapy may be used to manage acute and chronic pain in a health care facility or the home. It is used less frequently with cancer pain, for which oral medication is the preferred route. This device is most commonly used to deliver analgesics intravenously, subcutaneously, or via the epidural route. The most frequently prescribed drugs for PCA administration are morphine, fentanyl, and hydromorphone. The proper selection of patients for PCA is vital for a positive experience. Suitable candidates for this type of delivery system include people who are alert and capable of controlling the unit. (Should not be used for confused older patients, infants and very young children, cognitively impaired patients, patients with conditions for which oversedation poses a significant health risk (e.g., asthma and sleep apnea), and patients who are taking other medications that potentiate opioids... also unauthorized family who push for pt may cause oversedation, respiratory depression, or death.)

Physiology of Sleep

Two systems in the brainstem, the reticular activating system (RAS) and the bulbar synchronizing region, are believed to work together to control the cyclic nature of sleep. The RAS extends upward through the medulla, the pons, the midbrain, and into the hypothalamus. It facilitates reflex and voluntary movements as well as cortical activities related to a state of alertness. The RAS comprises many nerve cells and fibers. The fibers have connections that relay impulses into the cerebral cortex and spinal cord. Various neurotransmitters are involved with the sleeping process. Norepinephrine and acetylcholine—in addition to dopamine, serotonin, and histamine—are involved with excitation. Gamma-aminobutyric acid (GABA) appears to be necessary for inhibition. However, research has yet to prove exactly how biochemical changes and hormones function in sleep.

Assisting with ROM exercises

Unless contraindicated, encourage active, active-assistive, or passive range-of-motion exercises regularly and include them in the patient's plan of care. In active exercise, the patient independently moves joints through their full range of motion (isotonic exercise). In active-assistive exercise, the nurse may provide minimal support, whereas in passive exercise, the patient is unable to move independently, and the nurse moves each joint through its range of motion. Both active and passive exercises improve joint mobility and increase circulation to the affected part, but only active exercise increases muscle mass, tone, and strength and improves cardiac and respiratory functioning. It is also helpful to teach isometric exercises to patients to increase muscle mass, tone, and strength. -Teach the patient what exercise is being undertaken, why, and how it will be done. A show-and-tell technique is often helpful. -Avoid overexertion and continuing exercises to the point that the patient develops fatigue. The exercises are not meant to exhaust or tax the patient. It may be necessary to delay certain exercises until the patient's condition allows. -Avoid neck hyperextension and attempts to achieve full range of motion in all joints with older patients. These movements may prove painful. Encourage adequate range of motion in those joints necessary to perform ADLs. -Start gradually and work slowly. All movements should be smooth and rhythmic. Irregular and jerky movements are uncomfortable for patients. -Move each joint until there is resistance but not pain. Report uncomfortable reactions and stop exercises until further instructions are obtained. -While exercising joints, use a variety of support measures to prevent muscle strain or injury to the patient, as demonstrated in Figure 32-22: -Cupping: placing a cupped hand under the joint to support it (e.g., under the elbow) -Cradling: supporting the joint with one hand while cradling the distal portion of the extremity with the remaining arm (e.g., the calf or forearm might be cradled while the knee or elbow is supported) -Supporting the joint by holding the adjacent distal and proximal muscular areas (indicated when a joint is painful); grasping muscle groups or major tendons is likely to cause injury to the tissues -Return the joint to a neutral position, that is, its normal position of alignment, when finishing each exercise. -Keep friction at a minimum when moving extremities to avoid injuring the skin. -Use range-of-motion exercises twice a day, and do the exercises regularly to build up muscle and joint capabilities. Perform each exercise two to five times. It is possible to perform many of the exercises when the patient is being bathed as part of that procedure. Encourage routine tasks such as eating, dressing, self-bathing, and writing to help to put certain joints through range of motion. -Expect the patient's respiratory and heart rate to increase during exercising, which is good. These rates should return to usual resting levels within 3 minutes. If they do not, the exercises are probably too strenuous for the patient. -Use passive exercises as necessary, but encourage active exercises of the same kind when the patient is able to do so independently. Exercises should continue at home after a period of hospitalization, as necessary.

Analyze conditions which place an individual at risk for sleep imbalance (pg 1133)

Usual sleep-wakefulness pattern: Recent changes -usual sleeping and waking times -number of hours of undisturbed sleep -quality of sleep -number and duration of naps Effect of sleep pattern on everyday functioning -energy level (ability to perform ADLs) Sleep Aids -means of relaxing before bedtime -bedtime rituals -sleep enviornment -pharmacological aids Sleep disturbances and contributing factors -nature of sleep disturbance -onset of disturbance -causes (physical, psycho-social, med related) -severity -symptoms -interventions attempted and results

Focused Assessment: Factors to Assess (Taylor, pg 1133: box 33-1)

Usual sleep-wakefulness pattern: Recent changes -usual sleeping and waking times -number of hours of undisturbed sleep -quality of sleep -number of duration of naps Effect of sleep pattern on everyday functioning -Energy level (ability to perform activities of daily living) Sleep aids -Means of relaxing before bedtime -Bedtime rituals -Sleep environment -Pharmacologic aids Sleep disturbances and contributing factors -Nature of the sleep disturbance -Onset of disturbance -Causes (physical, psychosocial, medicine related) -Severity -Symptoms -Interventions attempted and results

WHO (world health organization) 3 step pain relief ladder (Taylor, pg 1178)

a three-step analgesic ladder that recommends the appropriate progression of drugs and dosages that should be used to manage chronic pain effectively. Step 1: Nonopioid, +/- adjuvant (to suppress side effect) Step 2: Opioid for mild to moderate pain +/- nonopioid, +/- adjuvant Step 3: Opioid for moderate to severe pain, +/- nonopioid, +/- adjuvant

NSAIDs

have an anti-inflammatory effect. Individual responses to NSAIDs vary, but these agents are contraindicated in patients with bleeding disorders (their action may interfere with platelet function) or probable infections (NSAIDs can mask the signs of an infection). Potential for gastric bleeding if certain risk factors are present and the caution that NSAIDs should be taken for the shortest times needed.