Week 9/ Test 3 - Mobility

Metabolic assessment of immobilized patient

*REMINDER!* Metabolism: chemical processes that occur within a living organism in order to maintain life Use *anthropometric measurements* to evaluate muscle atrophy. Analyze intake and output records for fluid balance. Dehydration and edema increase the rate of skin breakdown in a patient who is immobilized. Monitoring laboratory data such as levels of electrolytes, serum protein (albumin and total protein), and blood urea nitrogen (BUN) aid the nurse in determining metabolic functioning. Monitoring food intake and elimination patterns and assessing wound healing help to determine altered gastrointestinal functioning and potential metabolic problems.

Respiratory effects of immobility

- Atelectasis (bronchi/bronchioles fill with fluid & alveoli/air sacs in lung become deflated or possibly filled with alveolar fluid) - Hypostatic pneumonia (pneumonia occuring from fluid buildup in lungs)

Metabolic effects of immobility

- Endocrine (hormonal / gastrin, secretin, etc.) - Calcium absorption - GI function (peristalsis, etc)

Fowler's position

- Head of bed elevated 45-60 degrees - Patient's knees slightly elevated without pressure to restrict circulation in lower legs. The following are common trouble areas for patient in supported Fowler's position: •Increased cervical flexion because pillow at head is too thick and head thrusts forward. •Extension of knees, allowing pt to slide to foot of bed. •Pressure on posterior aspect of knees, decreasing circulation to feet. •External rotation of hips. •Arms hanging unsupported at patient's sides. •Unsupported feet or pressure on heels. •Unprotected pressure points at sacrum and heels. •Increased shearing force on back and heels when head of the bed raised greater than 60 degrees.

Drugs & substances affecting sleep

- Hypnotics - Diuretics - Narcotics - Antidepressants - Alcohol - Caffeine - Beta-blockers - Anticonvulsants Sleepiness, insomnia, & fatigue often result as a direct effect of commonly prescribed medications.

Skeletal effects of immobility

- Impaired calcium absorption - Joint abnormalities

Mobility nursing diagnoses

- Impaired physical mobility - Risk for disuse syndrome - Ineffective airway clearance - Ineffective coping - Impaired urinary elimination - Risk for impaired skin integrity - Social isolation During immobilization some patients experience decreased social interaction & stimuli. Frequently use the call bell to request minor physical attention when real need is greater socialization. Nursing diagnoses for health needs in developmental areas reflect changes from patient's normal activities. Immobility also leads to multiple complications (e.g., renal calculi, DVT, pulmonary emboli, or pneumonia). If these conditions develop, collaborate with the hc provider or NP for prescribed therapy.

Critical thinking (hygiene)

- Integrate nursing knowledge. - Consider developmental and cultural influences. - Think creatively. - Be nonjudgmental and confident. - Draw on your own experiences. - Rely on professional standards. Apply the elements of critical thinking as you use the nursing process to meet patients' hygiene needs. As your experience and knowledge grow, your comfort and expertise in meeting the individualized hygiene needs of your patients increase.

Nature of pain

- Involves physical, emotional, and cognitive components - Pain is subjective and individualized - Reduces quality of life - Not measurable objectively - May lead to serious physical, psychological, social, and financial consequences Always remember pt is one experiencing pain. Pain is whatever pt states it is. Not responsibility of pts to prove that they are in pain; nurse's responsibility to accept their report. If pts are having difficulty expressing pain, does not mean they are not in pain.

Musculoskeletal effects of mobility

- Loss of endurance - Loss of muscle mass - Decreased stability and balance

Muscular effects of immobility

- Loss of muscle mass - Muscle atrophy

Developmental changes in adults experiencing immobility

- Physiological systems are at risk - Changes in family and social structures All physiological systems are at risk. Role of the adult often changes with regard to family or social structure. Some adults lose jobs, which affects self-concept.

Integumentary effects of immobility

- Pressure ulcer - Ischemia

Assessment findings that indicate pneumonia

- Productive cough with greenish-yellow sputum - Fever - Pain on breathing; - Crackles, wheezes, and dyspnea.

How to assess sleep disorders:

- Through the pt's eyes - Sleep assessment - Sleep history

Urinary elimination effects of immobility

- Urinary stasis (urinary retention) - Renal calculi (kidney stones due to waste buildup)

Implementation: Hygiene

- Use caring to reduce anxiety, promote comfort. - Administer meds for symptoms before hygiene. - Be alert for patient's anxiety or fear. - Assist & prepare pts to perform hygiene as independently as possible. - Discuss signs & symptoms of problems. - Inform pts about community resources. - Consider normal grooming routines, and individualize care - Bathing and skin care

Equipment needed for shampooing

- brush - comb - shampoo board - shampoo - conditioner (optional) - hydrogen peroxide (optional) - towels (three or more) - waterproof pad - hair dryer - basin of very warm water - clean gloves (if needed) or shampoo cap

Equipment needed for denture care

- soft-bristle toothbrush or denture toothbrush - denture-cleaning agent or toothpaste - denture adhesive (optional) - glass of water - emesis basin or sink - washcloth - clean gloves - denture cup (if dentures stored after cleaning)

Characteristic of pain

- timing - location - severity When a pt is in pain, conduct a focused physical & neurological exam & observe for nonverbal responses to pain. Examine painful area to see if palpation or manipulation of site increases pain. Ask questions to determine onset, duration, & time sequence of pain. Ask a pt to describe or point to all areas of discomfort in order to assess pain location. To localize pain specifically, have patient trace area from most severe point outward. One of most subjective & therefore most useful characteristics for reporting pain is its severity. Purpose of using a pain scale is to identify pain intensity over time so that effectiveness of pain interventions can be evaluated.

Factors influencing sleep

-Drugs and substances (Hypnotics, diuretics, narcotics, antidepressants, alcohol, caffeine, beta-blockers, anticonvulsants) -Lifestyle (Work schedule, social activities, routines) -Usual sleep patterns (May be disrupted by social activity or work schedule) - Emotional stress (Worries, physical health, death, losses) - Environment (Noise, routines) - Exercise and fatigue (Moderate exercise and fatigue cause a restful sleep) - Food and calorie intake (Time of day, caffeine, nicotine, alcohol. ) A number of factors affect quality & quantity of sleep. Often, several factors contribute to a sleep disorder. Physiological, psychological, & environmental factors inhibit sleep.

Diagnoses

1) impaired physical mobility 2) risk for disuse syndrome. The diagnosis of impaired physical mobility applies to patient who has some limitation but is not completely immobile. The diagnosis of risk for disuse syndrome applies to the patient who is immobile and at risk for multisystem problems because of inactivity.

Physiology of Pain

4 physiological processes of normal pain: 1) transduction 2) transmission 3) perception 4) modulation. Pt who is experiencing pain cannot discriminate between these 4 factors. Understanding each process helps nurse recognize factors that cause pain, symptoms that accompany it, & rationale for selected therapies. Pain processes require an intact NS & spinal cord. Common factors that disrupt pain process includes trauma, drugs, tumor growth, & metabolic disorders.

Insomnia

A *symptom* pts experience when they have chronic difficulty falling asleep. According to ICSD-2, includes: - Adjustment sleep disorder (acute insomnia) - Inadequate sleep hygiene - Behavioral insomnia of childhood - Insomnia caused by medical condition Most common sleep disorder

Back rub

A back rub or back massage usually follows a patient's bath. It promotes relaxation, relieves muscular tension, and decreases perception of pain.

Embolus

A dislodged venous thrombus that can travel through the circulatory system to the lungs and impair circulation and oxygenation, resulting in tachycardia and shortness of breath. Venous emboli that travel to the lungs are sometimes life threatening. More than 90% of all pulmonary emboli begin in the deep veins of the lower extremities.

Narcolepsy

A dysfunction of mechanisms that regulate sleep & waking states. Includes: - cataplexy (sudden, brief loss of voluntary muscle tone triggered by strong emotions such as laughter, sadness, anger. Can occur during day.) - sleep paralysis. During day, person suddenly feels overwhelming wave of sleepiness & falls asleep; REM sleep occurs within 15 mins of falling asleep.

Planning: Set priorities based on assistance required, extent of problems, nature of diagnoses (Hygiene)

A patient's condition influences your priorities for hygiene care. Timing is also important in planning hygiene care. Being interrupted in the middle of a bath often frustrates and embarrasses a patient. Assess for cultural preferences on time of day or who may assist patient in hygiene care.

Developmental stage (hygiene)

A patient's developmental stage affects the ability of the patient to perform hygiene care and the type of care needed. Changes throughout the life span effect the skin, feet and nails, mouth, hair, and senses.

Addiction

A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations

Sleep deprivation

A problem many patients experience as a result of dyssomnia (inability to sleep). Caused by: - Emotional stress - Medications - Environmental disturbances, Symptoms Causes include fever, difficulty breathing, pain, emotional stress, medications, and disturbances in the health care setting. Long work schedules & rotations make hc providers prone. Hospitalization makes pts prone to sleep deprivation caused by environmental noises & interruptions for care.

Be alert for patient's anxiety or fear.

A soft, gentle voice while conversing with patients relieves fears or concerns. Consider the stress that hygiene care can cause and be alert for any cues of embarrassment or anxiety. Some patients fear pain or are frightened about falling or sustaining injury associated with hygiene care.

Drug tolerance

A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time

Physical dependence

A state of adaptation that is manifested by a drug class-specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist Experiencing a physical dependency does not imply addiction, and drug tolerance in and of itself is not the same as addiction.

Perineural local anesthetic infusion

A surgeon places the tip of an unsutured catheter near a nerve or groups of nerves and the catheter exits from the surgical wound.

Surgical or recovery bed

A surgical, recovery, or postoperative bed is a modified version of the open bed. The top bed linen is arranged for easy transfer of the patient from a stretcher to the bed. The top sheets and spread are not tucked or mitered at the corners. Instead, they are folded to one side or to the bottom third of the bed. This makes patient transfer into the bed easier.

Trapeze bar

A triangular device that hangs down from a securely fastened overhead bar that is attached to bed frame. Allows patient to pull with upper extremities to raise trunk off the bed, assist in transfer from bed to wheelchair, or perform upper arm exercises. It increases independence, maintains upper body strength, and decreases shearing action from sliding across or up & down in bed.

ABC's of pain management

A-Ask, Assess B-Believe C-Choose appropriate medication D-Deliver the medication in a timely, logical, coordinated fashion E-Empower the patient Using the ABCs of pain management is an effective way to manage pain.

A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when: A. you compare assessed pain w/baseline pain. B. body language is incongruent with reports of pain relief. C. family members report that pain has subsided. D. vital signs have returned to baseline.

A. you compare assessed pain w/baseline pain.

The American Academy of Sleep Medicine

AASM Intnl Classification of Sleep Disorders version 2 (ICSD-2), classifies sleep disorders into 8 major categories: 1) Insomnias - Chronic difficulty falling asleep, frequent awakenings, or short nonrestorative sleep - Assoc. with many medical, neurological, & psychiatric sleep disorders 2) Sleep-Related Breathing Disorders - Changes in respirations during sleep. 3) Hypersomnias of Central Origin -Sleep disturbances that result in daytime sleepiness & are not caused by disturbed sleep or alterations in circadian rhythms. 4) Parasomnias - Undesirable behaviors that occur usually during sleep (bed-wetting, sleep walking, terror, eating disorders) 5) Circadian Rhythm Sleep Disorders - Misalignment between timing of sleep & individual desires or societal norm. 6) Sleep-Related Movement Disorders - RLS, periodic limb mvmts, bruxism (teeth grinding) - Simple stereotyped movements disturb sleep. 7) Isolated Symptoms, Apparently Normal Variants, and Unresolved Issues. - Sleep-related symptoms that fall between normal and abnormal sleep. 8) Other sleep disorders - Do not fit into other categories

American Dental Association (ADA)

ADA guidelines for effective oral hygiene include: - Brush teeth at least 2x/ day with ADA-approved fluoride toothpaste. - Brush all tooth surfaces thoroughly. - To prevent cross-contamination, teach pts to avoid sharing toothbrushes w/ family members or drinking directly from a bottle of mouthwash. - Instruct pts to obtain a new toothbrush every 3 months or following a cold or upper respiratory infection to minimize growth of microbes. According to ADA recommendations, flossing once a day is sufficient.

Clinical guidelines available to manage pain

ANA (2005) upholds that pain assessment & management is within the scope of every nurse's practice. - Guidelines available through American Pain Society (APS) on mgmt of pain in primary care setting; sickle cell pain; cancer pain in adults & children; & pain in osteoarthritis, rheumatoid arthritis, & juvenile chronic arthritis. Sigma Theta Tau International offers guidelines for the older adult on their website (www.geriatricpain.org). The National Guidelines Clearinghouse (www.guideline.gov) posts a variety of pain-management guidelines.

Nursing Pain Diagnoses

Activity intolerance Anxiety Fatigue Insomnia Impaired social interaction Ineffective coping Impaired physical mobility

Adjuvants

Adjuvants and co-analgesics are drugs used to treat other conditions, but they also have analgesic qualities that were originally unknown/ not original intent of drug (tricyclic antidepressants and anticonvulsants). "tricyclic" meaning a group that of meds that all work in a similar way

Hygeine

Affects patients' comfort, safety, & well-being. When people ill, oftentimes require assistance with self-care. Variety of personal, social, & cultural factors influence hygiene practices. Integrate other nursing activities during hygiene care, including assessment & interventions such as ROM exercises, application of dressings, or inspection & care of IV sites. Preserve as much of patient's independence as possible, assess ability to perform hygiene care, ensure privacy, convey respect, & foster physical comfort.

Systemic effectss of immobility

All body systems work more efficiently with some form of movement. Exercise has positive outcomes for all major systems of the body. When there is an alteration in mobility, each body system is at risk for impairment. The severity of the impairment depends on the patient's overall health, degree and length of immobility, and age.

Sleep environment

All pts require a sleeping environment with a comfortable room temp & proper ventilation, minimal sources of noise, a comfortable bed, & proper lighting. Eliminate distracting noise so the bedroom is as quiet as possible. In the home the television, telephone, or intermittent chiming of a clock often disrupts a pt's sleep. Pts vary in regard to amt of light they prefer at night.

Feet, hands & nails

All require special attention to prevent infection, odor, & injury. Condition of a pt's hands & feet influences ability to perform hygiene care. Normal nail is transparent, smooth, and convex, with a pink nail bed and a translucent white tip. Hc providers should not wear artificial nails because harbor bacteria & can become invaded by fungus. Any condition that interferes with hand movement impairs patient's self-care abilities. Foot pain often changes patient's gait, causing strain on different joints & muscle groups. Without ability to bear weight, ambulate, or manipulate hands, patient is at risk for losing self-care ability.

Assessing gait

Allows you to draw conclusions about balance, posture, safety, and ability to walk without assistance. Mechanics of gait involve coordination of: - skeletal system - neurological system - muscular system

Hearing aid

Amplifies sounds in a controlled manner; Aid receives normal low-intensity sound inputs & delivers them to pt's ear as louder output. Three popular types of hearing aids. 1) An in-the-canal (ITC) aid: Newest, smallest, and least visible and fits entirely in the ear canal. 2) An in-the-ear (ITE, or intraaural) aid: fits into external auditory canal & allows for more fine tuning. 3) A behind-the-ear (BTE, or postaural) aid: hooks around & behind ear. Largest of three aids & is useful for pts with rapidly progressing hearing loss or manual dexterity difficulties or those who find partial ear occlusion intolerable. Digital hearing aids (D): Remove background noise & beneficial to people with mild to severe hearing loss.

Nursing (pain) diagnoses

An accurate nursing diagnosis may be made only after you perform a complete assessment. Development of accurate nursing diagnoses for a pt in pain results from thorough data collection and analysis. Nursing diagnosis focuses on specific nature of a pt's pain to identify most useful types of interventions for alleviating it & improving pt's function. Accurate identification of related factors is necessary in choosing appropriate nursing interventions. Extent to which pain affects a pt's function & general state of health determines whether other nursing diagnoses are relevant.

Transduction

An activated nociceptor converts energy produced by stimuli into electrical energy. Begins in periphery when a pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential. Once transduction is complete, transmission of pain impulse begins.

PCA IV

An established and properly functioning intravenous catheter is needed for intravenous PCA. Check the IV line and PCA device per institutional policy to ensure proper functioning.

TENS

Another form of cutaneous stimulation is transcutaneous electrical nerve stimulation (TENS), involving stimulation of the skin with a mild electrical current passed through external electrodes.

Pain concept map

Another strategy for planning care is using a concept map. Pts who are in pain frequently have interrelated problems. As one problem gets worse, other aspects of a pt's level of health also change. A concept map helps you determine how nursing diagnoses are interrelated & linked to pt's medical diagnosis.

Nursing Sleep Diagnoses Examples

Anxiety Ineffective Breathing Patterns Acute Confusion Compromised Family Coping Ineffective Coping Insomnia Fatigue Sleep Deprivation Readiness for Enhanced Sleep

Scientific Knowledge Base - Hygiene

Apply knowledge of pathophysiology to provide preventive hygiene care. •Requires an understanding of A&P of skin, nails, oral cavity, eyes, ears, & nose •Skin and mucosal cells exchange oxygen, nutrients, & fluids with underlying blood vessels. •The cells require adequate nutrition, hydration, and circulation to resist injury and disease. •Good hygiene techniques promote the normal structure and function of these tissues. Recognize disease states that create changes in the integument, oral cavity, and sensory organs. Use time spent providing hygiene care to identify abnormalities and initiate appropriate actions to prevent further injury to sensitive tissues.

Nursing process: Assessment

Apply nursing process & use critical thinking approach in care of patients. Nursing process provides clinical decision-making approach to develop individualized plan of care. See through the patient's eyes Mobility •Range of motion Planes of the body •Sagittal •Transverse •Frontal

More physiological responses - pain

As pain impulses ascend the spinal cord toward the brainstem and thalamus, the fight-or-flight stress response stimulates the Autonomic (automatic) NS. ANS includes: parasympathetic & sympathetic NS. Parasympathetic NS: Controls homeostasis and the body at rest (including digestion). Continuous, severe, or deep pain typically involving visceral organs activates PNS. Sympathetic NS: Stress stimulates SNS which produces physiological responses (BP, HR, RR, epinephrine, norepinephrine, etc.) Sustained physiological responses to pain sometimes seriously harm individuals. Except in cases of severe traumatic pain, which causes a person to go into shock, most people adapt to their pain reflexively, & their physical signs return to normal baseline. Note that normal is not the same for each individual. Thus pts in pain do not always have changes in their vital signs. Changes in vital signs more often indicate problems other than pain.

Reticular activating system (RAS)

Ascending RAS located in upper brainstem. Receives stimuli: - sensory stimuli (visual, auditory, pain, & tactile) - cerebral cortex activity stimuli (emotions or thought processes) Arousal, wakefulness, & maintenance of consciousness result from neurons in RAS. These neurons release neurotransmitters called catecholamines such as the hormone norepinephrine.

Aggrivating & precipitating pain factors

Ask a pt to describe activities that cause or aggravate pain such as physical movement, positions, drinking coffee or alcohol, urination, swallowing, eating food, or psychological stress. Also ask pts to demonstrate actions that cause a painful response such as coughing or turning a certain way. Some symptoms (depression, anxiety, fatigue, sedation, anorexia, sleep disruption, spiritual distress, and guilt) cause worsening of pain or may be aggravated by pain.

Bedtime routines - sleep assessment

Ask patients what they do to prepare for sleep.

Assess self-care ability (hygiene)

Assess a patient's physical and cognitive ability to perform basic hygiene measures.

Hygiene care practices

Assessment of hygiene practices reveals a patient's preferences for grooming. Ask what makes a patient feel most comfortable during a bath or other hygiene measures. Some patients present risks that require more attentive and rigorous hygiene care. Assessment should include a review of a patient's medical and surgical history, medications, and the specific risk factors that the patient presents.

Data clusters

Assessment reveals clusters of data that indicate whether a patient is at risk or if an actual problem exists. The clusters of data include defining characteristics that support the diagnostic label and probable cause of the diagnosis. Locating the probable cause of the diagnosis (based on assessment data) is important to planning patient-centered goals and subsequent nursing interventions that will best help the patient. It is critical that nursing assessment activities identify and cluster defining characteristics that ultimately support the nursing diagnosis selected.

Hypostatic pneumonia

At some point in development of respiratory complications, there is decline in pt's ability to cough productively. Distribution of mucus in bronchi increases, particularly when pt is in supine, prone, or lateral position. Mucus accumulates in dependent regions of airways. Hypostatic pneumonia frequently results because mucus is an excellent place for bacteria to grow.

Follow these guidelines from the American Society for Pain Management Nurses:

Avoid administration of partial doses at more frequent intervals so as to not underdose a patient with small, frequent, ineffective doses from within a range (e.g., giving oxycodone 10 mg q 2 hours when the order reads oxycodone 10 to 20 mg q 3 hours PRN). Avoid making a patient wait a full time interval after giving a partial dose within the allowed range. Wait until peak effect of the first dose has been reached before giving a subsequent dose.

When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true? A. Chronic pain is psychological in nature. B. Patients are the best judges of their pain. C. Regular use of narcotic analgesics leads to drug addiction. D. Amount of pain is reflective of actual tissue damage.

B. Patients are the best judges of their pain.

A young girl with long hair is experiencing a problem with matting. The most appropriate action to take would be: A. cutting the matted hair away. B. braiding the hair to reduce tangles. C. using a grease-type product to tame the hair. D. keeping the hair oil free by applying powder every morning.

B. braiding the hair to reduce tangles. Rationale: Braiding helps to avoid repeated tangles; however, patients need to unbraid hair periodically and comb it to ensure good hygiene.

You are caring for a non-English-speaking male patient. When preparing to assist him with personal hygiene, you should: A. use soap and water on all types of skin. B. ensure that culture and ethnicity influence hygiene practices. C. shave facial hair to make the patient more comfortable. D. know that all patients need to be bathed daily

B. ensure that culture and ethnicity influence hygiene practices. Rationale: When caring for patients from different cultures, learn as much as possible from them or their family about preferred hygiene practices.

A patient suffers from sleep pattern disturbance. To promote adequate sleep, the most important nursing intervention is: A. administering a sleep aid. B. synchronizing the medication, treatment, and vital signs schedule. C. encouraging the patient to exercise immediately before sleep. D. discussing with the patient the benefits of beginning a long-term nighttime medication regimen.

B. synchronizing the medication, treatment, and vital signs schedule.

Pain is not a number

Because pain is not static but dynamic, accurate assessment requires you to monitor pain on a regular basis along with other vital signs. Some institutions treat pain as the fifth vital sign. Pain assessment is not simply a number. Relying solely on a number fails to capture the multidimensionality of pain and may be unsafe, particularly when the number fails to reflect the entire pain experience, or when the patient does not understand the use of the selected pain rating scale.

Bed rest needs

Bed rest does not guarantee a pt will feel rested. Some still have emotional worries that prevent complete relaxation. Nurses frequently care for pts on bed rest to reduce physical & psychological demands on body in a variety of hc settings. Always be aware of a pt's need for rest. Lack of rest for long periods causes illness or worsening of existing illness.

Promoting bedtime routine (implementation)

Bedtime routines relax pts in preparation for sleep. Always important for persons to go to sleep when feel fatigued or sleepy. A consistent bedtime routine (e.g., same hour for bedtime, snack, or quiet activity) helps young children avoid delaying sleep. Adults need to avoid excessive mental stimulation just before bedtime.

Bone calcium

Bones store calcium & release it into the circulation as needed. Patients with decreased calcium regulation & metabolism, & immobility, are at risk for developing osteoporosis and pathological fractures (fractures caused by weakened bone tissue).

Hair & Scalp care

Brushing and combing: •Distributes oil •Prevents tangling, as does braiding •Obtain permission before braiding or cutting. •Combing is more effective than use of pediculicidal shampoos in the case of head lice Appearance & feeling of well-being often depend on the way the hair looks and feels. Frequent brushing helps keep hair clean and distributes oil evenly along hair shafts. Combing prevents hair from tangling. Encourage pts to maintain routine hair care & provide help for patients with limited mobility or weakness & those who are confused or weakened by illness. When caring for patients from different cultures, learn as much as possible from them or family about preferred hair care practices. Long hair easily becomes matted when a patient is confined to bed, even for a short period. When lacerations or incisions involve the scalp, blood and topical medications also cause tangling. Frequent brushing and combing keep long hair neatly groomed. Braiding helps to avoid repeated tangles; however, patients need to unbraid hair periodically and comb it to ensure good hygiene.

Dermis

Bundles of collagen & elastic fibers form the thicker dermis that underlies & supports the epidermis. Nerve fibers, blood vessels, sweat glands, sebaceous glands, & hair follicles run through the dermal layers. Sebaceous glands secrete sebum Sebum: - an oily, odorous fluid, in hair follicles. - softens & lubricates skin & slows water loss from skin when humidity is low. - More important, has bactericidal action.

A nurse is evaluating teaching on a client who has a new prescription for a sequential compression device. Which of the following client statements should indicate to the nurse the client understands the teaching? A) "With this thing on, my leg muscles won't get weak." B) "This device will keep me from getting sores on my skin." C) "This thing will keep the blood pumping through my leg" D) "This device is going to keep my joints in good shape."

C) "This thing will keep the blood pumping through my leg" SCDs: - Improve bloodflow to legs - Prevents clots - Compresses joints - Prevents atrophy *FIND OUT MORE FROM BOOK!!!!*

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A) Inject a mouth rinse into the center of the client's mouth B) Place 2 fingers in the client's open mouth C) Turn the client's head to the side. D) Brush the client's teeth once a day

C) Turn the client's head to the side.

A 4-year-old pediatric patient resists going to sleep. To assist this patient, the best action to take would be: A. adding a daytime nap. B. allowing the child to sleep longer in the morning. C. maintaining the child's home sleep routine. D. offering the child a bedtime snack.

C. maintaining the child's home sleep routine.

Peripheral NS vs Central NS

CNS includes brain & spinal cord PNS includes all nerves that branch out from brain & spinal cord & extend to other parts of body including muscles & organs.

Renal calculi

Calcium stones lodged in renal pelvis or passed through ureters. Immobilized pts at risk for because frequently have hypercalcemia ( ^ Ca in bs) As period of immobility continues, fluid intake often diminishes. When combined with other problems such as fever, risk for dehydration increases. As a result, urinary output declines on or about fifth or sixth day after immobilization, & urine becomes concentrated. This increases risk for calculi formation & infection. Immobilization --> bone resorption --> hypercalcemia --> decreased fluid intake --> dehydration --> decreased urinary output --> urine becomes concentration --> calculi & UTI

Cancer

Can be acute or chronic Normal (nociceptive), resulting from stimulus of an undamaged nerve and/or neuropathic, arising from abnormal or damaged pain nerves. A pt senses pain at the actual site of the tumor or distant to the site, called referred pain. Always completely assess reports of new pain by a pt with existing pain.

Restless leg syndrome (RLS)

Can occur before sleep onset. Symptoms include recurrent, rhythmical movements of the feet and legs. Pts feel itching sensation deep in muscles. Relief comes only from moving legs, which prevents relaxation & subsequent sleep.

Sleep disorders

Can result in 1 of 3 problems: - insomnia - abnormal movements or sensation during sleep or when awakening at night - excessive daytime sleepiness

Cancer pain & chronic noncancer pain mgmt

Cancer pain is either chronic or acute. The prevalence of pain varies amongst cancer patients. A review of research spanning 40 yrs shows the prevalence of pain ranging from: - 64% in patients with metastatic, advanced or terminal phases of the disease - 59% in patients on anticancer treatment - 33% in patients after curative treatment. Many patients with cancer experience breakthrough cancer pain (BTCP), a transient worsening of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain.

Cardiovascular assessment of immobilized patient

Cardiovascular nursing assessment of patient who is immobilized includes BP monitoring, evaluation of apical and peripheral pulses, & observation for signs of venous stasis. To assess for a deep vein thrombosis (DVT), remove patient's elastic stockings and/or sequential compression devices (SCDs) every 8 hours (or according to agency policy) & observe calves for redness, warmth, & tenderness. Measure bilateral calf circumference and record it daily as an alternative assessment for DVT. Because DVTs also occur in the thigh, take thigh measurements daily if the patient is prone to thrombosis.

Emotional stress affecting sleep

Causes a person to be tense & often leads to frustration when sleep does not occur. Also causes a person to try too hard to fall asleep, to awaken frequently during the sleep cycle, or to oversleep. Continued stress causes poor sleep habits. Older pts frequently experience losses that lead to emotional stress (such as retirement, physical impairment, or death of a loved one). Older adults & other individuals who experience depressive mood problems experience delays in falling asleep, earlier appearance of REM sleep, frequent or early awakening, feelings of sleeping poorly, & daytime sleepiness.

Chronic pain

Chronic pain affects a pt's activity (eating, sleeping, socialization), thinking (confusion, forgetfulness), or emotions (anger, depression, irritability) & quality of life & productivity.

Idiopathic

Chronic pain without identifiable physical or psychological cause

Basic eye care

Cleaning the eyes involves simply washing with a clean washcloth moistened in water

Perineal care

Cleansing patients' genital and anal areas is called perineal care. It usually occurs as part of a complete bed bath. Patients most in need of perineal care include those at greatest risk for acquiring an infection. Encourage patients to perform their own perineal care. Do not let embarrassment cause you to overlook the patient's hygiene needs. When staffing levels permit, use a gender-congruent caregiver. Stress the importance of perineal care in preventing skin breakdown and infection. Be alert for complaints of burning during urination or localized soreness, excoriation (chronic skin-picking), or pain in perineum. Inspect vaginal & perineal areas and pt's bed linen for signs of discharge, & use sense of smell to detect abnormal odors. Risk factors for skin breakdown in perineal area: - urinary or fecal incontinence - rectal & perineal surgical dressings - indwelling urinary catheters - morbid obesity

Behavioral repsonses to pain

Clenching teeth, facial grimacing, holding or guarding painful part, & bent posture are common indications of acute pain. Some pts choose not to report pain if believe that it inconveniences others or if it signals loss of self-control. Others endure severe pain without asking for assistance. Be familiar with behavioral responses to pain.

Cold & heat

Cold and heat applications relieve pain and promote healing.

Nursing Diagnoses (Hygiene)

Common diagnoses associated with hygiene: •Activity intolerance •Bathing self-care deficit •Dressing self-care deficit •Impaired physical mobility •Impaired oral mucous membrane •Ineffective health maintenance •Risk for infection Use the patients' actual alteration or the alteration for which they are at risk. Thorough assessment of a hygiene status and self-care abilities identifies clusters of risk factors or defining characteristics that support actual or at-risk hygiene-related diagnoses. Identification of defining characteristics or risk factors leads you to select the NANDA-I diagnostic label that best communicates the individual patient's situation. Accurate selection of nursing diagnoses requires critical thinking to identify actual or potential problems. Be thorough in assessment to reveal all appropriate defining characteristics or risk factors so you can make an accurate diagnosis. Use patient's actual alteration or alteration for which the patient is at risk to determine focus of nursing interventions. Completing a nursing diagnosis requires identification of the related factor (for an actual diagnosis or optional for a Risk diagnosis), which will guide your selection of nursing interventions. If the patient is at risk for a problem, take preventive measures.

Heparin therapy for DVT prophylaxis

Common dosage: 5000 units subcut 2 hr before surgery & repeated every 8-12 hr until patient fully mobile or discharged.

Holistic approaches

Common holistic health approaches include wellness education, regular exercise, rest, attention to good hygiene practices and nutrition, & mgmt of interpersonal relationships. Pts actively participate in their own well-being whenever possible

Assess oral cavities (hygiene)

Common oral cavity problems include receding gum tissue, inflamed gums (gingivitis), a coated tongue, glossitis (inflamed tongue), discolored teeth (particularly along gum margins), dental caries, missing teeth, and halitosis (foul-smelling breath).

Description of sleeping problems (assessment)

Conduct a more detailed history when a pt has a sleep problem. This ensures that you provide appropriate therapeutic care. Open-ended questions help a patient describe a problem more fully. Ask specific questions related to the sleep problem A general description of problem followed by more focused questions usually reveals specific characteristics useful in planning therapies. To begin, you need to understand nature of sleep problem, its signs & symptoms, its onset & duration, its severity, any predisposing factors or causes, & overall effect on pt. Proper questioning helps to determine type of sleep disturbance & nature of problem.

HTN

Connections between heart disease, sleep, & sleep disorders exist. Sleep-related breathing disorders linked to increased incidence of nocturnal angina (chest pain), increased hr, electrocardiogram changes, high bp, & risk of heart diseases & stroke.

Contact lenses

Contact lenses correct refractive errors of the eye or abnormalities in the shape of the cornea. Care includes proper cleaning and disinfection, insertion and removal, and storage. When pts require help to clean their contact lenses, first perform hand hygiene, & then clean & disinfect lenses with appropriate contact lens solution.

Integumentary assessment of immobilized patient

Continually assess the patient's skin for breakdown and color changes such as pallor or redness. Consistently use a standardized tool such as the Braden Scale. Frequent skin assessment, which can be as often as every hour, are based on patients mobility, hydration, and physiological status is essential to promptly identify changes in patients' skin and underlying tissues.

Topical analgesics

Creams, ointments, patches Commonly used topical agents include NSAID products (ketoprofen patch) and capsaicin.

A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first? A) Arms B) Feet C) Chest D) Face

D) Face Rationale: Should be head to toe, progressing downward.

A patient has just undergone an appendectomy. When discussing with the patient several pain-relief interventions, the most appropriate recommendation would be: A. adjunctive therapy. B. nonopioids. C. NSAIDs. D. PCA pain management.

D. PCA pain management.

During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift. This condition is known as: A. cataplexy. B. insomnia. C. narcolepsy. D. sleep apnea.

D. sleep apnea.

Damage to CNS

Damage to any component of CNS that regulates voluntary movement results in impaired body alignment, balance, & mobility. Trauma from head injury; ischemia from stroke or brain attack (cerebrovascular accident [CVA]); or bacterial infection (i.e. meningitis), can damage cerebellum or motor strip in cerebral cortex. Damage to cerebellum causes problems with balance, & motor impairment is directly related to amount of destruction of motor strip

ROM alteration - Shoulder

Deltoid is strongest muscle controlling shoulder, & is in complete elongation in normal position. No other muscle exerts full strength when in complete elongation. Patients with limited movement in shoulder have difficulty moving arms.

Sleep history

Description of sleeping problems, usual sleep pattern, current life events, physical and psychological illness, emotional and mental status, bedtime routines, bedtime environment, behaviors of sleep deprivation A poor night's sleep for a pt often starts a vicious cycle of anticipatory anxiety. Usually pts are the best resource for describing sleep problems & how they represent a change from their usual sleep & waking patterns. In addition, bed partners are able to provide info about pts' sleep patterns that helps reveal nature of certain sleep disorders. When caring for children, seek info about sleep patterns from parents or guardians because they are usually a reliable source of information. When pt has a sleep problem, conduct a complete sleep history. Diagnosing sleep problems depends on identifying factors that impair sleep.

Reducing cardiac workload

Design interventions to reduce cardiac workload, which is increased by immobility. A primary intervention is to discourage patient from using Valsalva maneuver. This increases intrathoracic pressure, which in turn decreases venous return and cardiac output. When the strain is released, venous return & cardiac output immediately increase, & systolic bp & pulse pressure rise. Teach patient to breathe out while moving side-to-side or up in bed.

Physical & Psychological illness - sleep assessment

Determine whether pt has any preexisting health problems that interfere with sleep. A history of psychiatric problems also makes a difference. If pt has recently had surgery, expect them to experience some sleep disturbance. Pts usually awaken frequently during first night after surgery & receive little deep or REM sleep. Depending on type of surgery, takes several days to months for a normal sleep cycle to return.

Nursing process: Planning

Develop goals and expected outcomes to assist the patient in achieving his or her highest level of mobility and reducing the hazards of immobility. Set priorities when planning care to ensure that immediate needs are met first. This is particularly important when patients have multiple diagnoses. Plan therapies according to severity of risks to the patient; individualize the plan according to the patient's developmental stage, level of health, and lifestyle. Do not overlook potential complications. Care of patient experiencing alterations in mobility requires team approach. Nurses often delegate some interventions to NAP Collab with other hc team members, such as physical or occupational therapists, when essential In anticipation of patient's discharge from institution, make referrals or consult case manager or discharge planner to ensure patient's needs are met at home.

Procedure pain mgmt

Diagnostic and treatment procedures potentially produce pain and anxiety, both of which should be assessed and treated before a procedure begins.

Sim's Position

Differs from side-lying position in distribution of patient's weight. Patient places weight on anterior ileum, humerus, & clavicle. Trouble points common in Sims' position include the following: •Lateral flexion of the neck. •Internal rotation, adduction, or lack of support to the shoulders and hips. •Lack of foot support. •Lack of protection for pressure points at ileum, humerus, clavicle, knees, & ankles.

Signs & symptoms

Discuss any signs and symptoms of hygiene problems

Sleep apnea

Disorder characterized by lack of airflow through nose & mouth for periods of 10+ secs during sleep. Three types are known: central, obstructive, and mixed. According to ICSD-2, includes: - Primary central sleep apnea - Central sleep apnea caused by medical condition - Obstructive sleep apnea syndromes - Excessive daytime sleepiness Treatment: - Therapy for underlying cardiac or respiratory complications - Emotional problems that occur as result of symptoms of this disorder.

Nocturia

Disrupts the sleep cycle.

Distraction

Distraction directs a patient's attention to something other than pain and thus reduces awareness of it.

Adverse effects of epidural analgesics

Do not administer supplemental doses of opioids or sedative/hypnotics because of possible additive central nervous system adverse effects. To minimize bleeding risks and the potential for hematoma formation, anticoagulant and antiplatelet medications should not be administered until safe use can be verified with a pain specialist. The patient needs to receive thorough education about epidural analgesia in terms of the action of the medication and its advantages and disadvantages.

Local anesthesia

Do not place eutectic mixture of local anesthetics (EMLA) around the eyes, the tympanic membrane, or over large skin surfaces (body may absorb too much) EMLA: Homogenous mixture that melts or solidifies at single temp that is lower than melting point of any of the components The Lidoderm patch is a topical analgesic effective for cutaneous neuropathic pain, such as postherpetic neuralgia (complication of shingles in which pain lasts longer than the shingles do), in adults. Place three patches, cut to size, on and around the pain site using a 12-hour on, 12-hour off schedule. Hc providers often use local anesthesia during brief surgical procedures such as removal of a skin lesion or suturing a wound by applying local anesthetics topically on skin and mucous membranes or by injecting them subcutaneously or intradermally to anesthetize a body part.

Orthostatic hypotension - what is it? what are symptoms?

Drop in BP > 20mm Hg systolic , or 10 mmHg diastolic . Symptoms: - dizziness - light-headedness - nausea - tachycardia - pallor - fainting when patient changes from supine to standing Symptoms in immobilized patient: - decreased circulating fluid volume - pooling of blood in the lower extremities - decreased autonomic (automatic/regulatory/fight-or-flight) response *These are especially evident in the older adult.

Xerostomia

Dry mouth. Occurs when strong sympathetic nervous system stimulation almost completely inhibits the release of saliva.

Evaluate hygiene interventions through pt's eyes

During assessment, collected info about pt's expectations of care. Both during & after hygiene determine from the pt if care is being provided in an acceptable manner. Being aware of and addressing a pt's expectations and any concerns fosters a caring therapeutic relationship.

Psychosocial assessment of immobilized patient

During psychosocial assessment, focus on patient's emotional state, behavior, and sleep-wake cycle.

Effective communication - pain

Effective communication among pt, family, & professional caregivers is essential to achieve adequate pain management. Recognition of subjective nature of pain & respect for pt in pain is demonstrated when a nurse accepts McCaffery's classic definition: "Pain is whatever the experiencing person says it is, existing whenever he says it does."

Effective pain management

Effective pain management: - improves quality of life - reduces physical discomfort - promotes earlier mobilization & return to previous baseline functional activity levels - results in fewer hospital and clinic visits - decreases hospital lengths of stay, resulting in lower hc costs.

ROM alterations - Elbow

Elbow functions optimally at 90* angle. Elbow fixed in full extension is disabling & limits pt's independence

ROM alterations - Fingers & thumbs

Enable patient to perform ADLs & activities requiring fine-motor skills (ex: carpentry, needlework, drawing, and painting). The functional position of fingers & thumb is slight flexion of thumb in opposition to fingers.

Breathing techniques for respiratory pts

Encourage patient to deep breathe & cough every 1 - 2 hours. Teach alert patients to deep breathe or yawn every 1 hour, or to use an incentive spirometer. Instruct patient to take in 3 deep breaths & cough with the 3rd exhalation.

Enoxiparin therapy for DVT prophylaxis

Enoxaparin (Lovenox): a low-molecular-weight heparin Common dosage: 30-40 mg subcut 2 hr before surgery & continued every 8-12 hr throughout postoperative period.

Adequate fluid intake

Ensure patients who are immobile take adequate fluid intake. Unless medical contraindication, adult needs to drink 1100 -1400 mL of noncaffeinated fluids daily. Helps keep mucociliary clearance normal.

Points to ensure safe, individualized care:

Ensuring pt safety is essential role of professional nurse. To ensure pt safety, communicate clearly with members of hc team, assess & incorporate pt's priorities of care & preferences, & use best evidence when making decisions about pt care. When performing skills, remember following points to ensure safe, individualized patient care: • Identify patient using two identifiers. •Always perform hygiene measures moving from cleanest to less clean or dirty areas. Often requires change gloves & perform hand hygiene during care activities. •Use clean gloves when you anticipate contact with nonintact skin or mucous membranes or when there will likely be contact with drainage, secretions, excretions, or blood during hygiene care. •When using water or solutions for hygiene care, be sure to test the temperature to prevent burn injury. •Use principles of body mechanics & safe pt handling in order to avoid injury when performing hygiene care & reduce risk of harm to self or others. You are responsible & accountable for care provided. Give proper direction to NAP to whom you delegate and be sure they are competent with hygiene measures.

Skin primary layers

Epidermis Dermis Subcutaneous tissue As long as skin remains intact & healthy, its physiological function remains optimal. Hygiene practices frequently influence skin status & can have beneficial & negative effects on the skin.

Epinephrine vs norepinephrine

Epinephrine: affects heart Norepinephrine: affects blood vessels

Evaluation: Patient Outcomes (Immobility)

Evaluate effectiveness of specific interventions Evaluate patient's & family's understanding of all teaching provided Evaluate outcomes & response to nursing care & compare patient's actual outcomes with outcomes selected during planning such as his or her ability to maintain or improve body alignment, joint mobility, walking, moving, or transferring. When outcomes not met, consider asking the following questions: •Are there ways we can assist you to increase your activity? •Which activities are you having trouble completing right now? •How do you feel about not being able to dress yourself and make your own meals? •Which exercises do you find most helpful? •What goals for your activity would you like to set now?

Elimination assessment of immobilized patient

Evaluate elimination status on each shift and total intake and output every 24 hours. Inadequate intake and output or fluid and electrolyte imbalances increase the risk for renal system impairment, ranging from recurrent infections to kidney failure. Dehydration also increases the risk for skin breakdown, thrombus formation, respiratory infections, and constipation. Assessment of bowel elimination status includes the adequacy of dietary choices, bowel sounds, and the frequency and consistency of bowel movements.

Patient outcomes

Evaluating the effectiveness of a pain intervention requires you to evaluate for change in the severity and quality of the pain. Also be sure to evaluate after an appropriate period of time. Ask a patient if a medication alleviates the pain when it is peaking. Do not expect the patient to volunteer the information. If patient outcomes are not met, ask the patient: •What is your current pain level? •How far away is your pain level from your goal? •What side effects are you experiencing from your pain medication? •What have you done to help manage your pain? •Describe limitations in function you are experiencing related to uncontrolled pain. •How is your pain limiting or altering your rest and sleep? Effective communication of the assessment of a patient's pain and the response to intervention is facilitated by accurate and thorough documentation.

Assess feet & nails (hygiene)

Examine all skin surfaces of the feet, including the areas between the toes and over the entire sole of the foot.

Hypersomnolence

Excessive sleepiness Many adults in the US have significant sleep problems from inadequacies in quantity or quality of nighttime sleep & experience hypersomnolence on daily basis.

Exercise programs

Exercise programs enhance feelings of well-being and improve endurance, strength, and health. Exercise reduces the risk of many health problems such as cardiovascular disease, diabetes, and osteoporosis. Exercise has many positive health benefits. Assist patients in overcoming barriers to physical activity, and encourage them to perform activities that are within their ability. Take cultural practices into consideration.

Exercise therapy

Exercise: a physical activity for conditioning the body, improving health, and maintaining fitness Nurses use exercise as therapy to correct a deformity or restore the overall body to a maximal state of health.

Eyeglasses

Eyeglasses are expensive. Be careful when cleaning glasses and protect them from breakage or other damage when they are not worn.

Bone firmness

Firmness results from inorganic salts (calcium & phosphate) that are in the bone matrix. Firmness is related to the rigidity of the bone, which is necessary to keep long bones straight & enables bones to withstand weight bearing.

IADLs

Focus in restorative care not only on ADLs that relate to physical self-care, but also on instrumental activities of daily living (IADLs). IADLs: activities necessary to be independent in society. Include such skills as shopping, preparing meals, banking, & taking meds. Work collaboratively with pts & other hc professionals.

Promoting Safety (implementation)

For any pt prone to confusion or falls, safety is critical. •Night light •Beds set lower to the floor •Remove clutter Sleepwalkers unaware of surroundings & slow to react, increasing risk of falls. Do not startle sleepwalkers- gently awaken & lead back to bed. Infants' beds need to be safe. To reduce chance of suffocation, do not place pillows, stuffed toys, or ends of loose blankets in cribs. Loose-fitting plastic mattress covers are dangerous because infants pull over faces & suffocate. Parents need to place infant on back to prevent suffocation. People fall asleep only after feeling comfortable & relaxed.

Bone health in patients with osteoporosis

For patients diagnosed with osteoporosis, early evaluation, consultation, and a team approach are important interventions, especially when they become immobilized. ADLs help a patient maintain independence. Assistive ambulatory devices, adaptive clothing, and safety bars help the patient maintain independence. Patient teaching needs to focus on limiting the severity of the disease through diet and activity.

Administer meds for symptoms before hygiene.

For patients suffering symptoms such as pain or nausea, administering medications to relieve the symptoms before providing hygiene helps to maintain patient comfort during procedures.

Implementation: acute care - respiratory

For respiratory patients, need to frequently fully expand lungs to maintain elastic recoil property. Secretions accumulate in dependent areas of lungs. Often patients with restricted mobility experience weakness; As progresses, cough reflex gradually becomes inefficient. All these factors put patient at risk of developing pneumonia. Stasis of secretions in the lungs is life threatening for an immobilized patient. Variety of nursing interventions are available to expand the lungs, dislodge and mobilize stagnant secretions, and clear the lungs. These interventions help reduce risk of pneumonia. Prevention begins with assessment. Assess patient's respiratory status per agency policy. It is essential to implement pulmonary interventions in all patients, even those who do not have pneumonia. - breathing techniques - fluid intake

Shampooing

Frequency depends on patient routines and hair condition Remind pts in hospitals or extended care facilities that: staying in bed, excess perspiration, or trtmts that leave blood or solutions in the hair require more frequent shampooing. A shower or tub chair facilitates shampooing for pts who are ambulatory & weight bearing & become tired or faint. Handheld shower nozzles allow ps to easily wash hair in tub or shower. Some pts allowed to sit in a chair choose to be shampooed in front of a sink or over a wash basin; Certain conditions (e.g., eye surgery, neck injury) limit bending. In these situations, teach pt and family degree of bending allowed.

Setting Priorities (sleep diagnosis)

Frequently sleep disturbances are the result of other health problems Patients are a helpful resource in determining which interventions hold priority.

Adolescents' sleep patterns

Get ~7½ hrs Shortened sleep time often results in excessive daytime sleepiness, which frequently leads to reduced performance in school, vulnerability to accidents, behavior & mood problems, & increased use of alcohol.

Gingivitis & Dental carries

Gingivitis: Inflammation of the gums Dental carries: Tooth decay Difficulty in chewing develops when surrounding gum tissues become inflamed or infected or when teeth are lost or become loosened. Regular oral hygiene helps to prevent gingivitis and dental caries.

Goals & Outcomes (sleep diagnosis)

Goals and outcomes example: •Follow professional standards •Create a concept map •Collaborate Professional standards are especially important to consider in developing a care plan. As plan care for a pt with sleep disturbances, creation of a concept map is another method for developing holistic pt-centered care. When developing goals & outcomes, important for nurse & pt to collab.

Environment affecting sleep

Good ventilation is essential for restful sleep. Size, firmness, and position of bed affect quality of sleep. If a person usually sleeps with another individual, sleeping alone often causes wakefulness. On the other hand, sleeping with a restless or snoring bed partner disrupts sleep.

Hair

Growth, distribution, & pattern indicate general health status. Hormonal changes, nutrition, emotional stress, physical stress, aging, infection, and other illnesses can affect hair characteristics. Shaft itself is lifeless, & physiological factors do not directly affect it. Hormonal and nutrient deficiencies of the hair follicle cause changes in hair color or condition. Remember to consider ethnic hair variations.

Administration of epidural analgesia

HC provider administers epidural analgesia into the spinal epidural space by inserting a blunt-tip needle into the level of the vertebral interspace nearest to the area requiring analgesia. The hc provider advances the catheter into epidural space, removes needle, & secures remainder of catheter with a dressing while ensuring catheter is taped securely.

Usual sleep pattern (assessment)

Have pts describe their normal sleep patterns. As an adjunct to the sleep history, have the patient and bed partner keep a sleep-wake log for 1 -4 weeks. Ask the following questions to determine a patient's sleep pattern: •What time do you usually get in bed each night? •How much time does it usually take to fall asleep? Do you do anything special to help you fall asleep? •How many times do you awaken during the night? Why? •What time do you typically wake up in the morning? •On average, how many hours do you sleep each night? Pts with sleep problems frequently show patterns drastically different from usual one, or sometimes change is relatively minor.

Health literacy

Health literacy significantly affects a patient's pain experience and understanding of pain management strategies.

Transverse plane

Horizontal line that divides body into upper & lower portions. Movements: - pronation & supination (hands) - internal & external rotation (hips)

Use caring to reduce anxiety, promote comfort

Hygiene is a part of basic patient care. When you use caring practices to perform hygiene measures you will reduce the patient's anxiety and promote comfort and relaxation.

Acute, restorative, & continuing care

Hygiene measures vary by patient needs and health care setting. In the acute care setting, factors such as more frequent diagnostic and treatment plans and the need for more extensive hygiene care resulting from acute illness or injury affect scheduling. In extended care facilities and nursing homes, bathing may be scheduled less frequently.

Implementation: Developmental Changes (Immobilization)

Ideally, patients continue normal development. Nursing care needs to provide mental & physical stimulation, esp for young child. Older pts who are frail or have chronic illnesses are at increased risk for psychosocial hazards of immobility. Maintaining a calendar & clock with large dial, conversing about current events & family members, & encouraging visits from significant others reduce risk of social isolation. Nurses encourage older immobilized patients to perform as many ADLs as independently as possible.

Ears/eyes/nose medical devices

If a patient has oxygen tubing, a feeding tube or a nasotracheal tube, it is essential you care for the area of the skin around the nose or ears underlying the device.

Complete bed bath, shower

If a patient is physically dependent or cognitively impaired, increase the frequency of skin assessment and provide skin care directed toward reducing the risk for skin breakdown. A complete bed bath often exhausts a patient. Assessing heart rate before, during, and after the bath provides a measure of a patient's physical tolerance. In a shower, implement safety measures to prevent fall injuries.

Respiratory changes

Immobile patients are at high risk for developing pulmonary complications •Atelectasis (alveoli collapse due to deflation or fluid) •Hypostatic pneumonia (inflammation of lung from stasis or pooling of secretions) Both decreased oxygenation & prolonged recovery add to patient's discomfort.

Calcium/bone resorption - endocrine system

Immobility causes release of calcium into blood circulation. Normally kidneys excrete excess calcium. However, if kidneys unable to respond appropriately, hypercalcemia (High Ca in bs / No bone Ca) results. Pathological fractures occur if bone resorption (bone breakdown --> release of Ca --> bloodstream) continues as pt remains on bed rest or continues to be immobile.

Assist & prepare pts to perform hygiene as independently as possible.

Implementation also focuses on assisting and preparing patients to be able to perform as much of their hygiene care as they can independently. Teach patients proper hygiene techniques and how their use is associated with better health.

Bones role in mobility & aging

Important for mobilization because they are firm, rigid, & elastic. Aging process changes components of bone, which impacts mobility. Elasticity and skeletal flexibility change with age.

Ask pt's pain level

Important to learn what are a pt's own values & beliefs about mgmt of pain & recognize that pt expectations will influence ability to achieve outcomes in pain mgmt. Asking a pt about their tolerable pain level is a first step in helping a pt regain control. Assessing previous pain experiences & effective home interventions provides a foundation on which you can build. Pts expect nurses to accept their reports of pain & be prompt in meeting their pain needs. When assessing pain, be sensitive to level of discomfort & determine what level will allow your pt to function. Determine the pt's health literacy. During an episode of acute pain, streamline assessment & assess its location, severity, & quality. Collect a more detailed acute pain assessment when patient is more comfortable.

Promoting comfort

In a hospital or extended care setting it is difficult to provide patients with the time needed to rest and sleep. The most effective treatment for sleep disturbances is elimination or correction of factors that disrupt the sleep pattern. When pt's condition demands more frequent monitoring, plan activities to allow extended rest periods.

Controlling physiological disturbances

In a hospital or extended care setting it is difficult to provide patients with the time needed to rest and sleep. The most effective treatment for sleep disturbances is elimination or correction of factors that disrupt the sleep pattern. When pt's condition demands more frequent monitoring, plan activities to allow extended rest periods. Pts with OSA are at risk for complications while in hospital. Surgery & anesthesia disrupt normal sleep patterns. After surgery, pts experience interrupted but deep levels of REM sleep. This deep sleep causes muscle relaxation that leads to OSA. Pts with OSA who are given opioid analgesics after surgery have an increased risk of developing airway obstruction because meds suppress normal arousal mechanisms. Recommend lifestyle changes to pts with OSA that include sleep hygiene, alcohol moderation, smoking cessation, & a weight-loss program. One of most effective therapies is use of a nasal continuous positive airway pressure (CPAP) device at night, which requires a pt to wear a mask over nose. A mask delivers room air at a high pressure. Pts who are hospitalized for extensive diagnostic testing often have difficulty resting or sleeping because of uncertainty about state of health. Giving pts control over their health care minimizes uncertainty and anxiety. Providing personal hygiene improves pt's sense of comfort. As a nurse you will learn to control symptoms of physical illness that disrupt sleep.

Sitz bath & Medicated baths

In addition to cleansing baths, the health care provider may prescribe therapeutic baths, including sitz baths. Medicated baths may be recommended in the home setting. A sitz bath cleans and reduces pain and inflammation of perineal and anal areas. Medicated baths relieve skin irritation and create an antibacterial and drying effect.

Planning: Teamwork & Collab (Hygiene)

In hospital or extended care settings, work closely with NAP who often provide hygiene care. Collab with other health team members as indicated (e.g., work with physical therapy and occupational therapy to enhance the patient's independence with self-care activities). When a patient needs assistance as a result of a self-care limitation, family often becomes a valuable resource to nurse & helps with hygiene measures. Collaborate with community agencies as needed.

Middle & older adults' sleep patterns

In middle age, amt of stage 4 sleep begins to fall—a decline that continues with advancing age. Older adults experience weakening, desynchronized circadian rhythms that alter sleep-wake cycle. Episodes of REM sleep tend to shorten. There is a progressive decrease in stages 3 & 4 NREM sleep; some older adults have almost no stage 4, or deep sleep.

Pain assessment tools

In selecting a tool to be used with a pt, be aware of clinical usefulness, reliability, & validity of tool in that specific pt population. Using right tools & methods helps to avoid errors & ensures selection of right pain interventions. Failure of clinicians to accurately assess a pt's pain, accept findings, & treat report of pain is a common cause of unrelieved pain & suffering. Be aware of possible errors in pain assessment

Acute pain

In the case of acute pain, nonpharmacologic measures should never be used in place of pharmacologic therapies.

Sleep - Critical thinking

In the case of sleep, integrate knowledge from nursing and disciplines such as pharmacology and psychology Successful critical thinking requires synthesis of knowledge, including info gathered from pts, experience, critical thinking attitudes, & intellectual & professional stds. Clinical judgments require you to anticipate info necessary, analyze data, & make decisions regarding pt care. Adapt critical thinking to changing needs of pt. Personal experience with sleep problem & experience with pts prepares you to know effective forms of sleep therapies. Use critical thinking attitudes such as perseverance, confidence, & discipline to complete a comprehensive assessment & develop a plan of care to provide successful mgmt of sleep problem. Professional standards provide valuable guidelines to assess & address needs of pts with sleep disorders.: - the Nursing Scope and Standards of Practice - Clinical Guidelines for the Treatment of Primary Insomnia - "Excessive Sleepiness" in Evidence-based Geriatrics Nursing Protocols for Best Practice

Establishing periods of rest and sleep

In the home, helps to encourage pts to stay physically active during day so more likely to sleep at night. Increasing daytime activity lessens problems with falling asleep.

Current life events - sleep assessment

In your assessment learn if pt is experiencing any changes in lifestyle that disrupt sleep. A person's occupation often offers a clue to the nature of the sleep problem.

Stress reduction (sleep)

Inability to sleep because of emotional stress also makes a person feel irritable & tense. When pts are emotionally upset, encourage them to try not to force sleep. Otherwise insomnia frequently develops, & soon bedtime is associated with inability to relax. Preschoolers have bedtime fears (fear of the dark or strange noises), awaken during the night, or have nightmares. Cultural tradition causes families to approach sleep practices differently.

UTI - what is it? causes? what bacteria involved?

Inappropriate perineal care after bowel movements, particularly in women, increases risk of UT contamination by Escherichia coli bacteria. Another cause of UTI in immobilized pts is use of indwelling urinary catheter.

Stomatitis

Inflammation of oral mucosa. RISK FACTORS: Some treatments, such as chemotherapy, immunosuppressive agents, head & neck radiation, & NG intubation, place pts at higher risk of experiencing stomatitis S/S: Burning, pain, & change in food & fluid tolerance. INTERVENTIONS: -brush with soft toothbrush & floss gently to prevent bleeding of gums. -Normal saline rinses on awakening in morning, after each meal, & at bedtime help clean oral cavity. -Pts can increase the rinses to Q2H if necessary. -Consult with hc provider to obtain topical or oral analgesics for pain control.

SCDs (sequential compression devices)

Inflatable sleeves that fit around legs. Act as muscles that contract to prevent clotting.

Circadian rhythms

Influence pattern of major biological & behavioral functions. Circadian (sleep-wake) rhythms include: - Body temp - HR - BP - Hormone secretion - Sensory acuity - Mood

Inform patients of community resources

Inform patients about available resources in the community for dealing with these problems if they arise. Always use teach back during instruction to confirm patients' understanding.

Muscle abnormalities

Injury & disease lead to many alterations in musculoskeletal function.

The skill of denture care can be delegated to nursing assistive personnel (NAP).

Instruct the NAP to: •Inform nurse of any cracks in dentures. •Inform nurse if the pt complains of oral discomfort. •Inform nurse of any lesions in mouth.

The skill of shampooing hair can be delegated to the NAP.

Instruct the NAP: •About any precautions needed in positioning patient. •To inform nurse if patient reports neck pain. •To inform nurse of any new skin lesions.

Central sleep apnea (CSA)

Involves dysfunction in respiratory control center of brain. Impulse to breathe fails temporarily, & nasal airflow & chest wall mvmt cease. O2 sat of blood falls. Common in pts with brainstem injury, muscular dystrophy, & encephalitis. Less than 10% of sleep apnea is predominantly central in origin. People with CSA tend to awaken during sleep & therefore complain of insomnia & excessive daytime sleepiness (EDS). Mild & intermittent snoring also present.

Polysomnogram

Involves the use of EEG, EMG, and EOG to monitor stages of sleep & wakefulness during nighttime sleep. The Multiple Sleep Latency Test (MSLT) provides objective info about sleepiness & selected aspects of sleep structure by measuring eye mvmt, muscle-tone changes, & brain activity during at least 4 napping opportunities spread throughout day.

Evaluation: Through the patient's eyes (Immobility)

It is essential to have patient's evaluation of plan of care Were goals met, or is more work required? Determine with patient & others involved with care if goals or outcomes established with & for patient have indeed been met What still needs to be achieved from patient's perspective; and construction of a new plan of care. In other words, how have patient's expectations changed and in what ways?

Bed making & cleaning

Keep bed clean & comfortable. Usually make bed in morning after a pt's bath or while they are bathing, in a shower, sitting in a chair eating, or out of the room for procedures or tests. Check bed linen for food particles after meals & for wetness or soiling. Change any linen that becomes soiled or wet. When changing bed linen, follow principles of medical asepsis by keeping soiled linen away from the uniform. To avoid air currents that spread microorganisms, never shake the linen. To avoid transmitting infection, do not place soiled linen on the floor. If clean linen touches the floor or any unclean surface, immediately place it in the dirty linen container. During bed making use safe patient handling procedures. Body mechanics and safe handling are important when turning or repositioning a patient in bed. When patients are confined to bed, organize bed-making activities to conserve time and energy. When possible, make the bed while it is unoccupied. *STUDY THIS: An unoccupied bed can be made as an open or closed bed. In an open bed, the top covers are folded back so it is easy for a patient to get into bed. A closed bed is prepared in a hospital room before a new patient is admitted to that room.*

Denture care

Keep dentures covered in water when they are not worn Store in an enclosed, labeled cup with the cup placed on patient's bedside stand Encourage pts to clean dentures on regular basis to avoid gingival infection and irritation. When pts become disabled, someone else assumes responsibility for denture care. Dentures are pt's personal property and must be handled with care because they break easily. They must be removed at night to rest the gums & prevent bacterial buildup. Discourage patients from removing their dentures and placing them on a napkin or tissue because they could easily be thrown away.

Personal preferences (hygiene)

Knowing patients' personal preferences promotes individualized care.

Critical thinking - pain

Knowledge of pain physiology and the many factors that influence pain help you manage a patient's pain. Critical thinking attitudes & intellectual standards ensure aggressive assessment, creative planning, & thorough evaluation needed to obtain an acceptable level of patient pain relief, while balancing treatment benefits with treatment associated risks. Successful critical thinking requires a synthesis of knowledge, experience, information gathered from patients, critical thinking attitudes, and intellectual and professional standards. To make clinical judgments, anticipate info you need, analyze the data, & make decisions regarding pt care. A pt's condition or situation is always changing. During assessment consider all critical thinking elements that lead to appropriate nursing diagnoses. Successful pain mgmt does not necessarily mean pain elimination but rather attainment of a mutually agreed-on pain-relief goal that allows pts to control their pain instead of the pain controlling them.

Pharmacological approaches to sleep

Liberal use of drugs to manage insomnia is quite common in American culture. Hypnotics: Meds that induce sleep Sedatives: Meds that produce a calming or soothing effect. Benzodiazepines & benzodiazepine-like drugs: Common classifications of drugs used to treat sleep problems. Regular use of any sleep med often leads to tolerance & withdrawal.

Subcutaneous skin layer

Lies just beneath skin; contains blood vessels, nerves, lymph, & loose CT filled with fat cells Fatty tissue functions as a heat insulator for body. Subcut tissue also supports upper skin layers to withstand stresses & pressure without injury & anchors skin loosely to underlying structures such as muscle. Very little subcut tissue underlies oral mucosa.

Circadian rhythm is affected by what?

Light, temp, social activities, & work routines.

Local anesthetic SE's

Local anesthetics cause side effects, depending on their absorption into the circulation. Pruritus or burning of the skin or a localized rash is common after topical applications. Application to vascular mucous membranes increases the chance of systemic effects such as a change in heart rate. The use of local anesthetics in peripheral nerve and epidural infusions (see below) may block motor nerves as well as sensory nerves.

Developmental assessment of immobilized patient

Looks at how immobility affects the normal development of patients across the life span. Design nursing interventions that maintain normal development, provide physical and psychosocial stimuli after identifying a child's developmental needs, and assure the parents that developmental delays are usually temporary. Immobilization of a family member changes family functioning. Immobility has a significant effect on the older adult's levels of health, independence, and functional status. Assessment also includes the patient's home and community to identify factors that are risks to his or her mobility and safety.

Hand rolls

Maintain thumb in slight adduction & in opposition to the fingers, which maintain a functional position.

Musculoskeletal assessment of immobilized patient

Major musculoskeletal abnormalities to identify during nursing assessment include decreased muscle tone and strength, loss of muscle mass, and contractures. Early assessment of ROM is important because it establishes a baseline against which later measurements can be compared to evaluate whether a loss in joint mobility has occurred.

Implementation: Integumentary system (Immobilization)

Major risk to skin from restricted mobility is PUs. Reposition every 1-2 hrs, skin care, & use therapeutic devices to help prevent PUs. Change immobilized pt's position according to activity level, perceptual ability, treatment protocols, & daily routines. Can be necessary to use devices for relieving pressure. Usually time that patient sits uninterrupted in a chair is limited to 1 hr. Repositioning key because uninterrupted pressure causes skin breakdown. Teach patients to shift weight every 15 mins. Chair-bound patients need to have a device for the chair that reduces pressure.

Hypothalamus - sleep

Major sleep center in body is hypothalamus. Secretes hypocretins/orexins (hormones) that promote wakefulness & REM sleep. Prostaglandin D2, L-tryptophan, & growth factors control sleep.

Linens

Many agencies have "nurse servers" either within or just outside a patient's room to store a daily supply of linen. Because of the importance of cost control in health care, avoid bringing excess linen into a pt's room. Once bring linen into a pt's room, if unused, must be laundered before being used. Before making bed, collect necessary bed linens & pt's personal items. This way, all equipment accessible to prepare bed & room. Handle linen properly to minimize the spread of infection. Agency policies provide guidelines for proper way to bag & dispose of soiled linen. After pt is discharged, all bed linen goes to laundry, & housekeeping cleans mattress and bed before clean linen applied.

Nursing Knowledge Base - Personal Hygiene

Many factors influence personal hygiene. Use communication skills to promote the therapeutic relationship. Hygiene care is never routine. During hygiene, assess: •Emotional status •Health promotion practices •Health care education needs No two individuals perform hygiene care in the same manner. Patient care is individualized on basis of learning about their unique hygiene practices & preferences. Individualized hygiene care requires use of therapeutic communication skills to promote the therapeutic relationship. In addition, opportunity provided during hygiene care should be used to assess a patient's health promotion practices, emotional status, & hc education needs. Be aware that developmental changes influence the need and preferences for type of hygiene care.

Herbals

Many patients use herbals and dietary supplements such as echinacea, ginseng, ginkgo biloba, and garlic despite conflicting research evidence supporting their use in pain relief.

Bedtime herbals

Melatonin: neurohormone produced in brain that helps control circadian rhythms & promote sleep. Helpful in improving sleep efficiency & decreasing nighttime awakenings. - Rec. dose: 0.3-1mg 2hrs before bedtime. Valerian: effective in mild insomnia & RLS. Effects release of neurotransmitters & produces very mild sedation. Kava: helps promote sleep in pts with anxiety. Should be used cautiously because of potential toxic effects on liver. Chamomile: herbal tea with mild sedative effect that may be beneficial in promoting sleep.

Nuring process: Assessment (Continued)

Mobility •Gait (a particular manner or style of walking) •Exercise Activity tolerance •Physiological •Emotional •Developmental

Analgesics

Most common & effective method of pain relief. Three types of analgesics: (1) nonopioids, including acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) (2) opioids (traditionally called narcotics) (3) co-analgesics or adjuvants, a variety of medications that enhance analgesics or have analgesic properties that were originally unknown.

Preventing thrombus formation

Most cost-effective way to address DVT is through an aggressive program of prophylaxis. It begins with identification of patients at risk and continues throughout their immobilization. Leg, foot, and ankle exercises; regularly providing fluids; position changes; and patient teaching need to begin when the patient becomes immobile. Heparin or enoxiparin therapy for DVT prophylaxis Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding such as hematuria, bruising, coffee ground-like vomitus or GI aspirate, guaiac-positive stools, and bleeding gums.

Body mechanics

Movement requires body mechanics: coordinated efforts of the musculoskeletal and nervous systems. Nurses pay attention to body mechanics to avoid injury to self and patients.

Music therapy

Music therapy may be useful in treating acute or chronic pain, stress, anxiety, and depression.

Full Sleep Cycle

NREM - 75-80% of night N1 (Stage 1) - lightest level of sleep, lasting a few mins - Decreased physiological activity begins with gradual fall in vitals & metab - Sensory stimuli easily arouse sleeper - If awakened, feel as though daydream occurred N2 (Stage 2) - Sound sleep during which relaxation progresses - Arousal still relatively easy - Brain & muscle activity continue to slow N3 (Stage 3 & 4) - Slow-wave sleep - Deepest sleep stage - Sleeper difficult to arouse & rarely moves - Brain & muscle activity significantly decreased - Vitals lower than during waking hours REM - 20-25% of night REM - Vivid, full-color dreaming - Usually begins 90min after sleep has begun - Autonomic response of rapidly moving eyes, fluctuating HR & RR, and increasing or fluctuating BP. - Atonia - Gastric secretions increase - Very difficult to arouse sleeper - Duration of REM increases with each cycle &avgs 20 mins.

Nail

Nails grow from root of nail bed (a layer of epithelium), which is located in skin at nail groove, hidden by fold of skin called cuticle. Scalelike modification of epidermis forms visible part of nail (nail body), which has a crescent-shaped white area known as the lunula. Under the nail lies a layer of epithelium called the nail bed. Disease causes changes in the shape, thickness, and curvature of the nail.

Normal sleep requirements and patterns

Neonates: 16 hrs a day Infants: 8-10 hrs at night + naps = 15hrs per day Toddlers: Total 12 hrs a day Preschoolers: 12 hrs a night School Age: 9-10 hours Adolescents: Get ~7½ hrs Young Adults: Get 6-8½ hrs Middle & Older Adults: Total number of hrs declines Sleep duration & quality will differ across life span.

Nonopioids

Nonopioids include acetaminophen and NSAIDs. Acetaminophen has no anti-inflammatory or antiplatelet effects. NSAIDs (aspirin and ibuprofen) provide mild to moderate pain relief. Most NSAIDs work on peripheral nerve receptors to reduce transmission of pain stimuli. Long-term use is associated with gastrointestinal (GI)bleeding and renal insufficiency.

Two sleep phases:

Nonrapid Eye Movement (NRM) & Rapid Eye Movement (REM) NREM: People progress through 4 stages of NREM sleep during a typical 90-min sleep cycle - Quality of sleep from stages 1 - 4 become increasingly deep - Stages 1 & 2 are light sleep from which people are easily aroused - Stages 3 & 4 are called slow-wave sleep, from which people are less easily aroused REM: Sleep phase at the end of the 90-minute sleep cycle - Increased brain activity & muscle atonia (lack of tonicity)

Cartilage

Nonvascular, supporting connective tissue. Located chiefly in joints, thorax, trachea, larynx, nose, and ear. Characteristics of the cartilage change with the aging process.

Stages of adult sleep cycle

Normal sleep pattern for adult begins with a pre-sleep period during which person is aware only of a gradually developing sleepiness. This period normally lasts 10-30 minutes; however, if person has difficulty falling asleep, lasts 1+hr. Once asleep, person usually passes through 4 or 5 complete sleep cycles lasting 90-100min (that avgs to about 6-8 hrs of sleep uninterrupted) With each cycle, NREM (3&4) gets shorter & REM gets longer until lasts up to 60 mins during last sleep cycle. Sleep goes through stages 1-4, then reversal from stages4-2 before REM can occur Not all people progress consistently through stages. Sleep becomes more fragmented with aging, and person spends more time in lighter stages

Assess hair & hair care (hygiene)

Normally the hair is clean, shiny, and untangled; and the scalp is clear of lesions. If you suspect pediculosis capitis (head lice), guard against self-infestation by handwashing and using gloves or tongue blades to inspect the patient's hair. Note any loss of hair (alopecia).

Chronic noncancer pain

Not protective, has no purpose, may or may not have an identifiable cause Chronic noncancer pain may be viewed as a disease since it has a distinct pathology that causes changes throughout the NS which may worsen over time. May include: Arthritis, headache, low back pain, or peripheral neuropathy The goal for chronic noncancer pain is to improve functional status with a multimodality plan.

Chronic pain

Not protective, has no purpose, may or may not have an identifiable cause Chronic pain lasts longer than anticipated & can be cancerous or noncancerous. The possible unknown cause of chronic pain frequently leads to psychological depression, and even suicide.

Behaviors of sleep deprivation - sleep assessment

Observe for behaviors such as irritability, disorientation (similar to a drunken state), frequent yawning, and slurred speech. If sleep deprivation has lasted a long time, psychotic behavior such as delusions and paranoia sometimes develop.

Dreams

Occur in NREM and REM sleep Dreams of REM more vivid & elaborate; & some believe they are functionally important to learning, memory processing, & adaptation to stress. Ability to describe a dream & interpret significance sometimes helps resolve personal concerns or fears. Another theory suggests dreams erase certain fantasies or nonsensical memories.

Obstructive sleep apnea (OSA)

Occurs when muscles or structures of oral cavity or throat relax during sleep. Upper airway becomes partially or completely blocked, diminishing nasal airflow (hypopnea) or stopping it (apnea) up to30 secs. 2 major risk factors: obesity & HTN. Excessive daytime sleepiness is most common complaint. Feelings of sleepiness usually most intense on awakening, right before going to sleep, & about 12 hrs after midsleep period. Causes serious decline in arterial O2 sat level.

Modulation

Once brain perceives pain, a protective reflex response occurs that inhibits pain impulse. Release of inhibitory neurotransmitters such as: - endorphins (endogenous opioids) - serotonin - norepinephrine - gamma-aminobutyric acid (GABA) These hinder transmission of pain & help produce analgesic effect. A-delta fibers send sensory impulses to spinal cord, where they synapse with spinal motor neurons. Motor impulses travel via reflex arc along efferent/motor nerve fibers back to a peripheral muscle near site of stimulation, thus bypassing brain. Contraction of muscle leads to a protective withdrawal from source of pain. (Think of how barely feel hot stove before reflexively retracting hand. Thanks, A-delta fibers!)

Complications of epidural analgesia

One of the concerns related to the use of peripheral and epidural anesthetic techniques is the risk of bleeding and subsequent hematoma formation near the injection/insertion site. Safe placement or removal of these injections and catheters is based on knowledge of the patients' coagulation status as well as the timing of administration of anticoagulant or antiplatelet medications. Because the epidural space is a highly vascular area, patients with epidural catheters are at risk for the development of epidural hematomas, which may lead to ischemia of the spinal cord, and if unaddressed, serious neurological complications.

Reducing pain perception and reception

One simple way to promote comfort is to remove or prevent painful stimuli.

Opioids

Opioids are prescribed for moderate to severe pain. They are associated with respiratory depression and adverse effects of nausea, vomiting, constipation, itching, urinary retention, and altered mental processes. Sedation is an adverse effect of opioids that always precedes respiratory depression. One way to maximize pain relief while potentially decreasing opioid use is to administer analgesics around the clock (ATC) rather than on a prn basis. Opioids can cause numerous, but common, side effects Careful assessment and critical thinking is required to safely administer analgesics. When you convert a patient from an intravenous (IV) to an oral form of the same opioid, understand that the dose of the oral opioid is usually much higher than the IV dose because of the first-pass effect. Opioids are usually necessary and effective for acute pain and cancer pain of moderate or severe intensity. Many patients are at higher risk for opioid-related adverse drug events..

Oral cavity (hygiene)

Oral cavity is lined with mucous membranes. Normal oral mucosa is light pink, soft, moist, smooth, and without lesions. Medications, exposure to radiation, and mouth breathing can impair salivary secretion. Floor of mouth and undersurface of tongue are richly supplied with blood vessels. Ulcerations or trauma frequently result in significant bleeding. Several glands within and outside the oral cavity secrete saliva.

Epidermis

Outer layer. Shields underlying tissue. Comprised of several thin layers of epithelial cells. These cells shield underlying tissue against water loss & injury & prevent entry of disease-producing microorganisms. Outermost layer: Stratum corneum -resident bacteria/normal flora on SC do not cause disease but inhibit multiplication of disease-causing microbes Innermost layer: Basal -Generates new cells to replace dead cells that SC sheds.

PCA infusion pumps

PCA infusion pumps are portable, computerized and contain a chamber for a syringe or bag that delivers a small, preset dose of opioid to an IV line. To receive a demand dose, a patient pushes a button attached to the PCA device. The PCA infusion pumps are designed to deliver a specific dose, which is programmed to be available at specific time intervals (usually in the range of 8 to 15 minutes) when the patient activates the delivery button.

Sleep is associated with changes in these systems:

PNS, endocrine, cardiovascular, respiratory, & muscular systems.

Types of pain

Pain can be categorized by duration (chronic or acute) or pathology (cancer or neuropathic). Acute/transient Chronic/Persistent Noncancer Chronic Episode Cancer Idiopathic

Pain clinics/centers

Pain centers treat patients on an inpatient or outpatient basis. A comprehensive pain center treats persons on an inpatient or outpatient basis. Staff members representing all health care disciplines (e.g., nursing, medicine, physical therapy, pastoral care, dietetics) work with patients to find the most effective pain-relief measures. A comprehensive clinic provides not only diverse therapy but also research into new treatments and training for professionals.

Gate-control theory of pain (Melzack and Wall)

Pain has emotional & cognitive components, in addition to a physical sensation. Gating mechanisms in the CNS regulate or block pain impulses. Pain impulses pass through when a gate is open & are blocked when a gate is closed. Closing the gate is the basis for nonpharmacological pain relief interventions. EXAMPLE You banged your knee on a table. Transmission of pain stimulus via nociceptors & excitatory neurotransmittors to the cebrebral cortex occurs just as in the physiology of pain (aka: passes through white matter in spinal column first, to be carried to brain). THEN, you rub your knee which sends a deep touch impulse to the same area in the spinal cord as pain. It interferes with the pain signal by synapsing with an interneuron and creating an inhibitory effect. This changes perception of pain.

Factors influencing pain

Pain is complex and a holistic approach may help to meet the needs of your patient. Pain is not an inevitable part of aging. Likewise, pain perception does not decrease with age. Age-related changes and increased frailty may lead to a less predictable response to analgesics, increased sensitivity to medications, and potential harmful drug effects. The presence of pain in an older adult requires aggressive assessment, diagnosis, and management. It is necessary to address misconceptions about pain management in the very young and in older adults before intervening for a patient.

Patient's expression of pain

Pain is individualistic Pt's self-report of pain is single most reliable indicator of its existence & intensity. If pts sense that you doubt that pain exists, they share little info about pain experience or minimize report. Pts unable to communicate effectively often require special attention during assessment. Although no one tool had sufficient reliability and validity, there are clinical practice recommendations. Pts with cognitive impairments often require insightful assessment approaches involving close observation of vocal response, facial movements (e.g. grimacing, clenched teeth) & body movements (e.g., restlessness, pacing). Also assess social interaction: does the patient avoid conversation? Patients who are critically ill and have a clouded sensorium or presence of nasogastric tubes or artificial airways require specific questions that they can answer with a nod of head or by writing out a response. If pt speaks different language, pain assessment is difficult. A professional interpreter is often necessary.

Pain

Pain is purely subjective. No 2 ppl experience pain in same way, & no 2 painful events create identical responses or feelings in a person. The International Association for the Study of Pain (IASP) defines pain as: "an unpleasant, subjective sensory & emotional experience associated with actual or potential tissue damage, or described in terms of such damage."

Pain management

Pain management should be pt centered, with nurses practicing patient advocacy, pt empowerment, compassion, & respect. Caring for pts in pain requires recognition that pain can & should be relieved.

Perception

Pain stimulus reaches cerebral cortex & person becomes aware of pain. (cerebral cortex = awareness!) Perception of pain: Brain interprets pain quality, & incorporates info from past experience, from knowledge, & from cultural associations of pain. Somatosensory cortex: identifies location & intensity -There is no single pain center Association cortex (primarily limbic system): determines how a person feels about it. As a person becomes aware of pain, a complex reaction occurs.: - Psychological & cognitive factors interact with neurophysiological ones. -Physiological & behavioral responses (reactions) occur after an individual perceives pain.

Teamwork & Collaboration (sleep diagnosis)

Partner closely with the pt and sleep partner When pts have chronic sleep problems, initial referral for a pt is often to a comprehensive sleep center for assessment of problem. Nature of sleep disturbance then determines whether referrals to additional hc providers are necessary.

Prone position

Patient lies face-down or chest-down. Often their head is turned to side; but, if a pillow is under the head, it needs to be thin enough to prevent cervical flexion or extension & maintain alignment of lumbar spine. Assess for & correct any of following potential trouble points with patients in prone position: •Neck hyperextension. •Hyperextension of the lumbar spine. •Plantar flexion of the ankles. •Unprotected pressure points at the chin, elbows, female breasts, hips, knees, and toes.

Side-lying (Lateral) Position

Patient rests on side with major portion of body weight on dependent hip & shoulder. A 30-degree lateral position is recommended for patients at risk for pressure ulcers. Following trouble points common in side-lying position: •Lateral flexion of the neck. •Spinal curves out of normal alignment. •Shoulder and hip joints internally rotated, adducted, or unsupported. •Lack of foot support. •Lack of protection for pressure points at the ear, shoulder, anterior iliac spine, trochanter, and ankles. •Excessive lateral flexion of spine if patient has large hips & pillow is not placed superior to hips at waist.

Supine position

Patients rest on backs. Relationship of body parts is essentially same as in good standing alignment except that body is in horizontal plane. The following are some common trouble areas for patients in the supine position: •Pillow at head that is too thick, increasing cervical flexion. •Head flat on the mattress. •Shoulders unsupported and internally rotated. •Elbows extended. •Thumb not in opposition to the fingers. •Hips externally rotated. •Unsupported feet. •Unprotected pressure points at occipital region of head, vertebrae, coccyx, elbows, and heels.

Head lice

Patients who develop head lice require special considerations. The lice are small, about the size of a sesame seed, thus you need bright light or natural sunlight to see them. Thorough combing is more effective than use of pediculicidal shampoos, which are often toxic and ineffective against resistant lice.

Physical condition (hygiene)

Patients with certain types of physical limitations or disabilities associated with disease and injury lack the physical energy and dexterity to perform hygiene self-care safely. Acute and chronic cognitive impairments, such as stroke, brain injury, psychoses, and dementia, often result in the inability to perform self-care independently. Sensory deficits not only alter a patient's ability to perform care, they also place the patient at risk for injury.

Health beliefs & motivation (hygiene)

Patients' health beliefs predict the likelihood of assuming health promotion behavior such as maintaining good hygiene. Knowledge about the importance of hygiene and its implications for well-being influences hygiene practices, but motivation is key.

Bedtime environment- sleep assessment

Pay special attention to a child's bedtime rituals. Some young children need a special blanket or stuffed animal when going to sleep.

Cultural variables (hygiene)

People from diverse cultures practice different hygiene rituals. Do not express disapproval when caring for patients whose hygiene practices differ from yours.

Implementation: Psychosocial Changes (Immobilization)

People with tendency toward depression or mood swings at greater risk for developing psychosocial effects during bed rest or immobilization. Anticipate changes in patient's psychosocial status, & provide routine & informal socialization. Observe pt's ability to cope with restricted mobility. Provide stimuli to maintain pt's orientation. Plan nursing activities so patient is able to talk & interact with staff. Involve pts in their care whenever possible.

Chest physiotherapy (CPT)

Percussion and positioning is another effective method for preventing pneumonia and keeping the airway clear. CPT helps the patient drain secretions from specific segments of the bronchi and lungs into the trachea so he or she is able to cough and expel them.

Respiratory assessment of immobilized patient

Perform a respiratory assessment at least every 2 hours for patients with restricted activity. Includes inspecting the chest for wall movement and auscultating the lungs for decreased breath sounds, crackles, and wheezes.

Assess skin (hygiene)

Perform an assessment of the skin noting color, texture, thickness, turgor, temperature, and hydration. Be attentive to characteristics of skin problems most influenced by hygiene measures. When caring for patients with dark skin pigmentation, be aware of assessment techniques and skin characteristics unique to highly pigmented skin.

Acute care

Pharmacological pain therapies: Analgesics •Nonopioids •Opioids •Adjuvants/co-analgesics

Placebo

Pharmacologically inactive preparations or procedures that produce no beneficial or therapeutic effect. Professional organizations discourage the use of placebos to treat pain. It is considered unethical and deceitful to administer them. Placebo use jeopardizes the trust between patients and their caregivers. If a placebo is ordered, question the order. Many hc agencies have policies that limit the use of placebos to research only.

Physical illness

Physical illness can cause pain, physical discomfort, anxiety, depression, and sleep disturbances: •Hypertension •Respiratory disorders •Nocturia •Restless leg syndrome (RLS) •American Academy of Sleep Medicine Classification of Sleep Disorders

Sleep patterns during pregnancy

Pregnancy increases need for sleep & rest. But majority of pregnant women describe variations in sleep habits. Estrogen decreases REM sleep.

Trochanter roll

Prevents external rotation of hips when patient is in a supine position. To form a trochanter roll: - Fold cotton bath blanket lengthwise to width that extends from greater trochanter of femur to lower border of popliteal space. - Place blanket under buttocks and roll it counterclockwise until thigh is in neutral position or inward rotation. - When the hip aligned correctly, patella faces directly upward.

Homeostatic Process (Process S)

Primarily regulates length & depth of sleep; & circadian rhythms (Process C: "biological time clocks") These influence: - internal organization of sleep - timing & duration of sleep-wake cycles - operate simultaneously to regulate sleep & wakefulness.

ROM alterations - Knee

Primary function is stability, which is achieved by ROM, ligaments, & muscles. Knees cannot remain stable under weight-bearing conditions unless there is adequate quadriceps power to maintain knee in full extension. An immobile knee joint results in serious disability. Degree of disability depends on position in which knee is stiffened. If it is fixed in full extension, person needs to sit with leg out in front. When knee is flexed, person limps while walking. The greater the flexion, the greater is the limp.

ROM alterations - Wrist

Primary function of wrist is to place hand in slight dorsiflexion (the position of functioning). When wrist is fixed in even a slightly flexed position, grasp is weakened.

Professional standards

Professional standards of care regarding pain management are available as agency policies or through professional organizations such as the American Society for Pain Management Nursing (ASPMN).

Hospice

Programs for end of life care Hospice helps terminally ill patients continue to live at home or in a health care setting in comfort and privacy. Pain control is a priority for hospices. Under the guidance of hospice nurses, families learn to monitor patients' symptoms and become the primary caregivers. Hospice programs help nurses overcome their fears of contributing to a patient's death when administering large doses of opioids. Recent research suggests that moderate opioid dose increases in patients who are terminally ill do not hasten death. The disease, not the opioid, is killing the patient.

Sleep

Proper rest & sleep are as important to health as good nutrition & adequate exercise. Physical & emotional health depend on ability to fulfill these basic human needs. Individuals need different amts of sleep & rest. Without proper amts, ability to concentrate, make judgments, & participate in daily activities decreases; & irritability increases. Identifying & treating pts' sleep pattern disturbances are important goals. To help pts, need to understand nature of sleep, factors influencing it, & pts' sleep habits. Sleep provides healing & restoration. Some pts have preexisting sleep disturbances; other pts develop sleep problems as result of an illness or hospitalization.

Skin functions

Protection, secretion, excretion, temperature regulation, and sensation Often reflects a change in physical condition by alterations in color, thickness, texture, turgor, temperature, and hydration.

Acute/transient pain

Protective, identifiable, short duration; limited emotional response Can threaten a pt's recovery by resulting in prolonged hospitalization, complications from immobility, or delayed rehab. Unrelieved acute pain can progress to chronic pain. Seriously threatens a pt's recovery by hampering pt's ability to become active & involved in self-care. Physical &psychological progress is delayed as long as acute pain persists because a pt focuses all energy on pain relief. A primary nursing goal is to provide pain relief that allows pts to participate in their recovery, prevent complications, & improve functional status.

Partial bed bath

Provide a partial bed bath to patients who are aging, dependent, in need of only partial hygiene, or bedridden and unable to reach all body parts.

Anesthetic

Provide emotional support to patients receiving local or regional anesthesia by explaining the insertion technique and warning patients that they will temporarily lose sensory function within minutes of injection. Motor and autonomic (bowel and bladder control) function may also be quickly lost, depending on the area anesthetized. After administration of a local or regional anesthetic, protect the patient from injury until full sensory and motor function return.

Implementation: acute care - metabolic

Provide high-protein, high-calorie diet with vitamin B and C supplements. body needs protein to repair injured tissue & rebuild depleted protein stores. Give immobilized patient high-protein, high-calorie diet. High-calorie intake provides sufficient fuel to meet metabolic needs and replace subcutaneous tissue. Vitamin C is needed for skin integrity and wound healing Vitamin B complex assists in energy metabolism. If the patient is unable to eat, nutrition must be provided parenterally or enterally.

Bath guidelines

Provide privacy: Close the door and/or pull room curtains around the bathing area. While bathing the patient, expose only the areas being bathed by using proper draping. Maintain safety: Keep side rails up when away from the patient's bedside when patients are dependent or unconscious. Maintain warmth: Keep room warm because pt is partially uncovered & easily chilled. Wet skin causes an excess loss of heat through evaporation. Keep pt covered, exposing only the body part being washed during the bath. Promote independence: Encourage the patient to participate in as many of the bathing activities as possible. Offer assistance when needed. Anticipate needs: •Bring new set of clothes & hygiene products to bedside or bathroom. •Teach pts to follow general rules for skin health. Encourage to routinely inspect their skin for changes in color or texture & report abnormalities to hc provider. •Instruct pts to handle skin gently, avoiding excessive rubbing. •Stress safety concerns such as failing to adjust or check the water temperature, cutting nails too close to the skin, & slipping on wet surfaces. •Ensure that pts understand healthy/intact skin & tissues protect from infection. Reinforce infection control practice, including proper hand hygiene.

Nasal care

Pt usually removes secretions from the nose by gently blowing into a soft tissue. If pt unable to remove nasal secretions, help by using a wet washcloth or a cotton-tipped applicator moistened in water or saline. Never insert the applicator beyond the length of the cotton tip. When NG, feeding, or endotracheal tubes inserted through pt's nose, change tape anchoring tube at least 1x/ day.

Emotion & mental status - sleep assessment

Pt's emotions & mental status affect ability to sleep. When a sleep disturbance is related to an emotional problem, key is to treat primary problem; its resolution often improves sleep.

Implementation: Elimination System (Immobilization)

Pts need 2000-3000 mL fluids/day to help prevent renal calculi & UTI. Nursing interventions - Adequate hydration: - At least 1100-1400 mL noncaffeinated fluids daily. - Helps prevent urinary stasis, renal calculi, and UTI without causing bladder distension - Monitor I&O to ensure fluid balance maintained. - Record frequency & consistency of bowel mvmts. - Provide diet rich in fluids, fruits, vegs, & fiber to facilitate normal peristalsis.

Influence of pain on ADLs

Pts who live with daily pain or who have prolonged pain during a hospitalization are less able to participate in routine activities, which results in physical deconditioning. Ask a pt whether pain interferes with sleep. Pain may impair ability to maintain normal sexual relations, threatens a person's ability to work, performing various activities. Include an assessment of effect of pain on social activities. Some pain is so debilitating that pt becomes too exhausted to socialize. Identify a pt's normal social activities, extent to which activities have been disrupted, and desire to participate in these activities.

Artificial eyes

Pts with artificial eyes have had an enucleation (removal) of an entire eyeball as a result of tumor growth, severe infection, or eye trauma. Some artificial eyes are permanently implanted, whereas others must be removed for cleaning. At times pts require assistance in prosthesis removal and cleaning. To remove an artificial eye, retract lower eyelid and exert slight pressure just below the eye. This action causes artificial eye to rise from socket because suction holding eye in place has been broken. Artificial eye is usually made of glass or plastic. Warm normal saline cleans the prosthesis effectively. Also clean the edges of the eye socket and surrounding tissues with soft gauze moistened in saline or clean tap water. To reinsert the eye, retract the upper and lower lids and gently slip the eye into the socket, fitting it neatly under the upper eyelid. Store an artificial eye in a labeled container filled with tap water or saline.

First step in assessing body alignment

Put patient at ease so they do not assume unnatural or rigid positions If immobile or unconscious, remove pillows & positioning supports from bed, and place pt in supine position

Implementation: Musculoskeletal System (Immobilization)

ROM exercises: Prevent excessive muscle atrophy & joint contractures. Help maintain musculoskeletal function. Passive ROM: - Used if pt unable to move part/ all of body. - Perform for all immobilized joints while bathing pt. - At least 2-3 times/day. Active ROM: - If one extremity paralyzed, teach pt to put each joint independently through ROM. - Pts on bed rest need active ROM exercises incorporated into daily schedules. - Teach patients to integrate exercises during ADLs. Continuous Passive Motion ROM: - Some orthopedic conditions require more frequent passive ROM exercises to restore the function of injured joint after surgery. - Pts with such conditions use automatic equipment (CPM) for passive ROM exercises.

Prevention of work-related musculoskeletal issues

Rate of work-related injury in health care settings is on the rise. Most of these injuries occur as a result of overexertion, which results in back injuries and other musculoskeletal problems. Back injuries are often the direct result of improper lifting and bending. Get help, if necessary, before starting a lifting task, and follow correct lifting procedures. The most common back injury is strain on the lumbar muscle group, which includes the muscles around the lumbar vertebrae. Nurses and other hc staff are esp at risk for injury to lumbar muscles when lifting, transferring, or positioning immobilized patients. Be aware of agency policies & protocols that protect staff and patients from injury. Current evidence supports that using mechanical or other ergonomic assistive devices is the safest way to reposition and lift patients who are unable to do these activities themselves.

Unique pain response

Recognizing a pt's unique response to pain is important in assessing success of pain management therapies. Encourage your pts to accept pain-relieving measures so they remain active and continue to maintain daily activities. Pt's ability to tolerate pain significantly influences your perceptions of degree of patient's discomfort. Pts who have a low pain tolerance (level of pain a person is willing to accept) are sometimes inaccurately perceived as complainers. Lack of pain expression does not indicate that a patient is not experiencing pain. Teach pts importance of reporting pain sooner than later to facilitate better control & optimal functional status.

Oral hygiene

Regular oral hygiene includes: brushing, flossing, and rinsing Brushing removes particles, plaque, and bacteria; massages the gums; and relieves unpleasant odors and tastes. Flossing removes tartar at the gum line. Rinsing removes particles and excess toothpaste. Prevents & controls plaque-associated oral diseases. Older adults in particular require good oral care. Complete oral hygiene enhances well-being and comfort and stimulates the appetite.

Relaxation

Relaxation and guided imagery allow patients to alter affective-motivational and cognitive pain perception. Relaxation is mental and physical freedom from tension or stress that provides individuals a sense of self-control.

2010 Patient Protection and Affordable Care Act

Required the Department of Health and Human Services to obtain support of Institute of Medicine (IOM) in conducting an extensive examination of pain as a public health problem. The results of the IOM study were released in the 2011 report, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research." This report acknowledges tragic epidemic of pain in US & calls for major coordinated efforts to develop safe effective preventive & management strategies.

TJC pain standard

Requires hc providers to assess all pts for pain on a regular basis. Many hc institutions have added pain as the fifth vital sign.

Nursing Sleep Diagnoses

Review assessment data, looking for clusters of data that include defining characteristics for a sleep pattern disturbance or other health problem. If you identify a sleep problem, specify condition, such as insomnia or sleep deprivation. By specifying sleep disturbance diagnosis, able to design more effective interventions. Assessment also identifies related factor or probable cause of a sleep disturbance such as a noisy environment or a high intake of caffeinated beverages in evening.

Foot & nail care

Routine care of nails involves soaking hands & feet to soften cuticles & layers of horny cells, thorough cleaning, drying, & proper trimming. *** The one exception is patients with diabetes mellitus or peripheral vascular disease. They are at risk for tissue ulceration or infection because soaking causes skin softening or maceration (wrinkling, sogginess) of tissue. Certain conditions place patients with diabetes at increased risk for amputation. Observe for changes that indicate peripheral neuropathy (disease of nerves that connect CNS to muscles, skin, organs) or vascular insufficiency. Before implementing nail care, check agency policy to determine if an order is necessary.

Ear care

Routine ear care involves cleaning the ear with the end of a moistened washcloth rotated gently into the ear canal. Gentle, downward retraction at the entrance of the ear canal usually causes visible cerumen to loosen and slip out. You can usually remove excessive or impacted cerumen by irrigation, which requires a health care provider's order.

SCDs, thromboembolic disease (TED), hose, and leg exercises

SCDs and intermittent pneumatic compression (IPC) are used to prevent blot clots in the lower extremities. Elastic stockings (sometimes called antiembolitic stockings) also aid in maintaining external pressure on the muscles of the lower extremities and thus promote venous return. Proper positioning reduces the patient's risk of thrombus formation because compression of the leg veins is minimized. ROM exercises reduce the risk of contractures and aid in preventing thrombi.

Moving patients

Safety is first priority Ask patient to help as much as possible •To determine what pt able to do alone & how many people needed to help move them in bed, assess determine whether illness contradicts exertion (e.g., cardiovascular disease). Determine if patient comprehends what is expected Determine patient's comfort level • It is important to evaluate your personal strength & knowledge of procedure. Determine if you need assistance in moving the patient • Pt may be too heavy or immobile to move alone.

Atelectasis

Secretions (i.e. mucus) block a bronchiole or a bronchus Distal lung tissue (alveoli) collapses due to deflation or fluid buildup, as existing air is absorbed, producing hypoxia (reduced O2 to body) and dyspnea Site of blockage affects severity of atelectasis. Sometimes entire lung lobe, or a whole lung collapses.

Bed position

Seriously ill pts often remain in bed for a long time. Bed is piece of equipment used most by a hospitalized pt- designed for comfort, safety, and adaptability for changing positions. A typical hospital bed has firm mattress on metal frame that you can raise and lower horizontally. Different bed positions promote patient comfort, minimize symptoms, promote lung expansion, and improve access during certain procedures. Change position of bed usually by using electrical controls incorporated into pt's call light & in a panel on the side or foot of the bed. Also instruct pts & family in proper use of controls. Maintain bed height at lowest horizontal position when patient unattended. Beds contain safety features such as locks on the wheels or casters. Side rails allow patients to move more easily in bed and prevent accidents. Do not use side rails to restrict a patient from moving in bed.

Assumptions about patients in pain

Seriously limit nurse ability to offer pain relief. Biases based on culture, education, & experience influence everyone. Too often nurses allow misconceptions about pain to affect their willingness to intervene. A nurse must accept a pt's report of pain & act according to professional guidelines, standards, position statements, policies & procedures, & evidence-based research findings. To help a pt gain pain relief, important to view experience through pt's eyes. Acknowledging personal prejudices or misconceptions help to address pt problems more professionally.

Mustache & beard care

Shave facial hair after bath or shampoo. When using a razor blade for shaving, skin must be softened to prevent pulling, scraping, or cuts. Shave in direction of hair growth. Use longer strokes on the larger areas of the face. Use short strokes around the chin and lips. Patients prone to bleeding need to use an electric razor. Facial hair of African-Americans tends to be curly and becomes ingrown unless shaved close to the skin. Mustaches and beards require daily grooming. Grooming keeps food particles and mucus from collecting in the hair. Comb out beards gently, and obtain the patient's permission before trimming or shaving off a mustache or beard.

Denture-induced stomatitis

Signs & symptoms can include: - redness & swelling under the dentures - painful red sores on roof of mouth - infection with yeast Candida albicans To prevent: - rinse mouth &dentures after meals - clean carefully and regularly - remove and soak overnight - brush and floss any remaining teeth, - visit a dentist regularly for examination.

Muscle movement and posture

Skeletal muscles are working elements of movement. Movement of bones & joints involves active processes that are carefully integrated to achieve coordination. Skeletal muscles, because of their ability to contract and relax, are the working elements of movement. Anatomical structure and attachment to the skeleton enhance contractile elements of the skeletal muscle.

Parasomnias

Sleep problems more common in children. Include: - sleepwalking (somnambulism) - night terrors - nightmares - bed-wetting (nocturnal enuresis) - body rocking - tooth grinding (bruxism) When adults have these problems, often indicates more serious disorders.

Social practices (hygiene)

Social groups influence hygiene preferences and practices, including the types of hygiene products used and the nature and frequency of personal care practice

Factors influencing hygiene

Social practices Personal preferences Body image Socioeconomic status Health beliefs and motivation Cultural variables Developmental stage Physical condition

Bedtime snacks

Some enjoy bedtime snacks, whereas others cannot sleep after eating. A dairy product such as warm milk or cocoa that contains L-tryptophan is often helpful in promoting sleep. A full meal before bedtime often causes gastrointestinal upset & interferes with ability to fall asleep. Warn pts against drinking or eating foods with caffeine before bedtime.

Patients with special needs

Some pts require special oral hygiene methods. This includes those with: - diabetes - artificial airways - unconscious - chemotherapy Pts with diabetes mellitus & who are on chemotherapy frequently experience periodontal disease. Pts with decreased levels of consciousness need special attention because often do not have gag reflex. Proper oral hygiene requires keeping mucosa moist & removing secretions that contribute to infection. When providing oral hygiene to unconscious pt, need to protect from choking & aspiration.

Physiological states

Specific physiological responses & patterns of brain activity identify each sequence. Instruments that provide info about some structural physiological aspects of sleep.: - the electroencephalogram (EEG), which measures electrical activity in the cerebral cortex, - the electromyogram (EMG), which measures muscle tone - the electrooculogram (EOG), which measures eye movements

Cutaneous stimulaton

Stimulation of the skin through a massage, warm bath, cold application, and TENS may be helpful in reducing pain perception.

What controls circadian rhythm?

Suprachiasmatic nucleus (SCN) nerve cells They are named so because they are located in the hypothalamus directly above optic chiasm which connects brain to eye. SCN controls rhythm of sleep-wake cycle & coordinates it with other circadian rhythms (HR, BP, temp, hormones, acuity, mood)

Body image (hygiene)

Surgery, illness, or a change in emotional or functional status often affects a patient's body image. Discomfort and pain, emotional stress, and fatigue diminish the ability or desire to perform hygiene self-care and require extra effort to promote hygiene and grooming.

Biological clocks

Synchronization of sleep cycle. Biological rhythm of sleep frequently becomes synchronized with other body functions. Explains why some ppl fall asleep at 8 p.m., & others go to bed at midnight or early morning. Different people also function best at different times of the day. Failure to maintain a usual sleep-wake cycle negatively influences pt's overall health.

Oral analgesics

Systemic patient-controlled analgesia (PCA) traditionally involves IV or subcutaneous drug administration. However, a controlled analgesia device for oral medications is available. This device allows patients access to their own oral prn medications, including opioids and other analgesics, antiemetics, and anxiolytics, at the bedside.

Teeth (oral cavity)

Teeth lie in sockets in gum-covered mandible and maxilla They tear & grind ingested food so it can be mixed with saliva & swallowed for digestion. A normal tooth consists of the crown, neck, and root. The enamel-covered crown extends above the gingiva or gum, which normally surrounds the tooth like a tight collar. A constricted portion of the tooth called the neck connects the crown and the root; the root is embedded in the jawbone. The periodontal membrane lies just below the gum margins, surrounds a tooth, and holds it firmly in place. Healthy teeth are white, smooth, shiny, and properly aligned.

Circadian (diurnal) rhythm

The 24-hour, day-night cycle Derived from Latin: circa, "about," and dies, "day". People experience cyclical rhythms as part of everyday life.

ANA

The American Nurses Association (ANA) supports aggressive treatment of pain and suffering, even if it hastens a patient's death.

American Pain Society

The American Pain Society reports that the primary goal in treating chronic noncancer pain with opioids is to increase patients' level of function rather than just to provide pain relief.

International Association for the Study of Pain (IASP)

The IASP "Declaration of Montreal," declared that access to pain mgmt is a fundamental human right (IASP, 2015). Nurses are legally and ethically responsible for managing pain and relieving suffering.

TJC

The Joint Commission requires health care agencies, where permissible, to have range-order policies in place to guide nurses in selecting the most appropriate dose of a medication.

WHO Analgesic Ladder

The World Health Organization (WHO) recommends a three-step approach, the "analgesic ladder" to the management of cancer pain. Treatment begins with NSAIDs and/or adjuvants and progresses to opioids. A bidirectional approach has been suggested in which, in addition to the original step-up approach, a step-down approach would be used for patients with intense acute pain, uncontrolled cancer pain, and breakthrough pain. Another mod includes the addition of a fourth step which recommends neurosurgical and other invasive procedures and also includes mgmt of pediatric pain & acute pain in emergency departments & postoperative situations. All patients on chronic opioid therapy require monitoring and follow-up. Many pts, family members, and hc providers have concerns about the risks of addiction associated with opioid use. Estimates of addiction in patients with chronic persistent pain range from 6% - 10%. Administer analgesics rectally when patients are unable to swallow, have nausea or vomiting, or are near death. When a patient first receives continuous-drip opioids, the IV access needs to be patent and without complications.

Joints

The connections between bones. Each joint is classified according to its structure and degree of mobility. Three classifications of joints: - cartilaginous - fibrous - synovial (hinge joints: shoulder, knee, hip, elbow)

Consider normal grooming routines, and individualize care

The extent, type, and timing or frequency of bathing and the methods used depend on a patient's physical abilities, health problems, and the degree of hygiene required.

Palliative care

The goal of palliative care is to learn how to live life fully with an incurable condition. Many hospitals have palliative care departments to help patients and their family members successfully manage disease. The goal of palliative care is to learn to live life fully with an incurable condition.

Assess eyes, ears, and nose (hygiene)

The healthy eye is not inflamed and is without drainage. Observe for the presence of accumulated cerumen (earwax) or drainage in the ear. Inspect the nares for signs of inflammation, discharge, lesions, edema, and deformity.

Regional anesthesia

The injection or infusion of local anesthetics to block a group of sensory nerve fibers.

Pain tolerance influence on pain

The level of pain a person is willing to accept

Cultural factors influencing pain

The meaning that a person associates with pain affects experience of pain & how one adapts to it. This is often closely associated with a person's cultural background, including age, ethnicity, education, race, and familial factors. Cultural beliefs and values affect how individuals cope with pain. Individuals learn what is expected and accepted by their culture, including how to react to pain. HC providers often mistakenly assume that everyone responds to pain in same way. Different meanings & attitudes are associated with pain across various cultural groups. An understanding of cultural meaning of pain helps you design culturally sensitive care for people with pain. As a nurse, explore impact of cultural differences on a pt's pain experience & make adjustments to plan of care.

Assess hygiene through the patient's eyes

The nursing process provides a clinical decision-making approach for you to develop and implement an individualized plan of care. Explore a patient's viewpoint regarding hygiene care by asking him or her about preferred personal hygiene and grooming practices.

Patient education

The patient needs to receive thorough education about epidural analgesia in terms of the action of the medication and its advantages and disadvantages. Instruct patients about the potential for side effects and to notify their health care provider if side effects develop.

Transmission

The process of sending pain impulse across an afferent/sensory pain nerve fiber (nociceptor). (Neurotransmitters either excite impulses during transmission or inhibit impulses during modulation.) Excitatory neurotransmitters send electrical impulses across synaptic cleft between two nerve fibers. Pain-sensitizing substances surround the pain fibers in extracellular fluid, spreading the pain message & causing an inflammatory response.

Benefits of PCA use

There are many benefits to PCA use. The patient gains control over pain, and pain relief does not depend on nurse availability. Patients also have access to medication when they need it. This decreases anxiety and leads to decreased medication use. Small doses of medications are delivered at short intervals, stabilizing serum drug concentrations for sustained pain relief. Patient preparation and teaching is critical to the safe and effective use of PCA devices.

Pain quality

There is no common or specific pain vocabulary in general use. Pts describe pain in their own way. Assess terms that pts use to describe discomfort & then always use these words consistently to obtain an accurate report.

Assessment (Hygiene)

Through the patient's eyes •Assess patient expectations about hygiene Assess: - Self-care ability - Skin - Feet and nails - Oral cavity - Hair and hair care - Eyes, ears, and nose - Use of sensory aids - Hygiene care practices - Cultural influences - Patients at risk for hygiene problems

Evaluating outcomes

Through the pt eyes Determine whether expected outcomes met: •Are you able to fall asleep within 20 minutes of getting into bed? •Describe how well you sleep when you exercise. •Does the use of quiet music at bedtime help you to relax? •Do you feel rested when you wake up? With regard to sleep, pt is source for evaluating outcomes. Each pt has unique need for sleep & rest. Pt is only one who knows if sleep problems are improved & which interventions or therapies are most successful in promoting sleep. If a nurse has successfully developed a good relationship with pt & a therapeutic plan of care, subtle behaviors often indicate level of pt's satisfaction. Note signs of sleep problems such as lethargy or frequent yawning or position changes in the patient. You are effective in promoting rest & sleep if patient's goals and expectations are met.

Food & Calorie intake affecting sleep

Time of day, caffeine, nicotine, alcohol. Following good eating habits is important for proper sleep. Weight loss or gain influences sleep patterns. Weight gain contributes to OSA because of increased size of the soft tissue structures in the upper airway.

ROM exercises

To ensure adequate joint mobility, teach pt about ROM exercises. When performing passive ROM exercises, stand at side of bed closest to the joint being exercised. Perform passive ROM exercises using a head-to-toe sequence & moving from larger to smaller joints. If an extremity is to be moved or lifted, place a cupped hand under joint to support it, support joint by holding adjacent distal & proximal areas or support joint with one hand & cradle distal portion of extremity with remaining arm.

Behavioral effects of pain

To understand a pt's pain experience, ask pt what pain prevents them from doing. When a pt has pain, assess verbalization, vocal response, facial & body movements, & social interaction. A verbal report of pain is a vital part of assessment. You need to be willing to listen & understand. When a pt is unable to communicate pain, it is especially important for you to be alert for behaviors that indicate pain.

Soap and water vs. Chlorhexidine Gluconate (CHG)

Traditionally, baths have been given using soap and warm water. The question of whether to use bath basins with soap and water is an issue because bath basins provide a reservoir for bacteria and are a possible source of transmission of HAIs. Chlorhexidine Gluconate (CHG) 4% solution in place of standard soap & water in wash basins has been shown to decrease bacterial growth in basins & reduce critical care unit acquired methicillin-resistant Staphylococcus aureus. Another option is use of CHG 2% in impregnated wash cloths. Daily bathing with some form of CHG is becoming more of a standard practice across hospitals.

Sleep assessment tools

Two effective subjective measures of sleep are: - the Epworth Sleepiness Scale (self-rating to indicate how likely they are to fall asleep in certain situations) - the Pittsburgh Sleep Quality Index (self-rating & symptoms-focused) Another brief subjective method is a numeric scale with a 0-10 sleep rating.

2 Types of Peripheral Nerve Fibers

Two types of peripheral nerve fibers conduct painful stimuli: 1) the fast, myelinated A-delta fiber 2) the very small, slow, unmyelinated C fibers. A-delta fibers send sharp, localized, & distinct sensations that specify source of pain & detect intensity. C fibers relay impulses that are poorly localized, visceral, & persistent. Ex: after stepping on a nail, person initially feels sharp, localized pain, which is a result of A-fiber transmission, or first pain. Within a few seconds whole foot aches from C-fiber transmission, or second pain.

Pharmacological approaches - sleep

Use of nonprescription sleeping meds is not advisable. Pts need to learn risks of such drugs. Over long term these drugs lead to further sleep disruption, even when initially seemed effective.

Pain relief measures

Useful to know whether a pt has an effective way of relieving pain, such as changing position, using ritualistic behavior (pacing, rocking, or rubbing), eating, meditating, praying, or applying heat or cold to the painful site. Assessment of relieving factors also includes identification of all the pt's health care providers.

Concomitant symptoms

Usually increase pain severity Include nausea, headache, dizziness, urge to urinate, constipation, depression and restlessness. Certain types of pain have predictable concomitant symptoms.

Gravity

Weight force exerted on the body The force of weight is always directed downward. This is why an unbalanced object falls. Center of gravity usually 55% - 57% of standing height and is in the midline. This is why only using principles of body mechanics in lifting patients often leads to injury of the nurse or health care professional

Socioeconomic status (hygiene)

When a patient lacks socioeconomic resources, it becomes difficult to participate and take a responsible role in health promotion activities such as basic hygiene.

Ears, eyes, and nose

When hygiene care is provided, the eyes, ears, and nose require careful attention. Clean the sensitive sensory tissues in a way that prevents injury and discomfort for a patient, such as by taking care to not get soap in his or her eyes. The sense of smell is an important aid to appetite. In addition, the time you spend with your patient during hygiene provides an excellent opportunity to ask if any changes in vision, hearing, or sense of smell are occurring.

Epidural infusions

When managing epidural infusions, if agency policy allows, connect the catheter to an infusion pump, a port, or reservoir, or cap it off for bolus injections. To reduce the risk of accidental epidural injection of drugs intended for IV use, clearly label the catheter epidural catheter.

Walking

When patient has limited ability to walk, assess activity tolerance, tolerance to upright position (orthostatic hypotension), strength, presence of pain, coordination, & balance to determine amount of assistance needed. Explain how far patient should try to walk, who is going to help, when walk will take place, & why walking is important. Determine with patient how much independence they can assume. Check environment to be sure that there are no obstacles in patient's path. Provide support at waist by using a gait belt so patient's center of gravity remains midline. Patients with hemiplegia (one-sided paralysis) or hemiparesis (one-sided weakness) often need assistance with walking.

Reducing orthostatic hypotension

When patients who are on bed rest or are immobile move to a sitting or standing position, often experience orthostatic hypotension. If symptoms severe enough, patient can faint. Have increased pulse rate, decreased pulse pressure, and drop in BP. Mobilize patient as soon as physical condition allows, even if this only involves dangling at the bedside or moving to a chair. When getting an immobile patient up for the first time, assess the situation using a safe patient-handling algorithm

Protect patient from injury

When pts receive epidural analgesia, initially monitor them as often as every 15 mins, including assessment of vital signs, respiratory effort, and skin color. Once stabilized, monitoring occurs every 1hr in the first 12-24 hrs and then with less frequency if the patient is stable. To minimize bleeding risks & potential for hematoma, anticoagulant & antiplatelet meds should not be administered until safe use can be verified with a pain specialist.

Invasive interventions for pain relief

When severe pain persists despite medical treatment, available invasive interventions include intrathecal implantable pumps or injections, spinal cord and deep brain stimulation, neuroablative procedures (cordotomy, rhizotomy), trigger point injections, cryoablation, and intraspinal medications.

Pain threshold

You gain a useful conceptual framework for pain management by understanding the physiological, emotional, & cognitive influences on the gates. For example, factors such as stress & exercise increase release of endorphins, often raising an individual's pain threshold. Because amount of circulating substances varies with every individual, response to pain varies.

Pediculosis capitis

head lice

Hemiplegia & hemiparesis

hemiplegia: one-sided paralysis hemiparesis: one-sided weakness

Isometric exercises

i.e.: activities that involve muscle tension without muscle shortening Have no beneficial effect on preventing orthostatic hypotension, but improve activity tolerance.

Respiratory disease

ie COPD, emphysema, asthma, allergies, or common cold often interferes with sleep

Time of wake up is defined by what?

intersection of Process S (homeostasis) & Process C (biological clock).

Flow of urine

kidney --> ureter --> bladder --> urethra --> excretion

Dorsiflexion

movement that bends the foot upward at the ankle

Peripheral Nervous System (PNS)

the sensory/afferent and motor/efferent neurons that connect the central nervous system (CNS) to the rest of the body.

Purpose of sleep

• Remains unclear • Physiological and psychological restoration • Maintenance & restoration of biological functions • Conserves energy (muscles relax progressively & BMR lowers) • Protein synthesis & cell division for renewal of tissues (i.e. skin, marrow, gastric mucosa, brain) NREM sleep: - contributes to body tissue restoration. - HR falls to 60bpm or less, which benefits cardiac function. - RR, bp, & muscle tone also decrease - NREM sleep is esp important in children, who experience more stage 4 sleep Deep slow-wave (NREM stage 4) sleep: - body releases human growth hormone for repair & renewal of epithelial & specialized cells (i.e. brain cells) REM sleep: - brain tissue restoration - important for cognitive restoration & memory. - loss of REM leads to confusion & suspicion.

Physiological factors influencing pain

•Age, fatigue, genes, neurological function Fatigue increases perception of pain and can cause problems with sleep and rest Genetic makeup may possibly affect a person's pain threshold or pain tolerance. Any factor that interrupts or influences normal pain reception or perception (spinal cord injury, peripheral neuropathy, neurological disease) can affect the patient's response to pain.

Patient-controlled analgesia

•Allows patient to self-administer with minimal risk of overdose •Maintains a constant plasma level of analgesic

Planning (pain)

•Analyze information from multiple sources. •Apply critical thinking •Adhere to professional standards •Use a concept map •Goals and outcomes •Setting priorities •Teamwork and collaboration A successful plan of care requires a therapeutic relationship with a patient. When managing pain, goals of care promote a patient's optimal function. Determine with pt, realistic expectations for pain relief. Helping pts learn how to manage pain is always a goal of care. When setting priorities in pain management, consider type of pain pt is experiencing & effect that it has on various body functions. Work with pt to select interventions that are appropriate. A comprehensive plan includes a variety of resources from hc team such as advanced practice nurses, doctors of pharmacology (PharmDs), physical therapists, occupational therapists, physicians, social workers, psychologists, and clergy.

Psychological factors influencing pain

•Anxiety •Coping style Anxiety often increases perception of pain, & pain causes feelings of anxiety. Difficult to separate the two sensations. Pharmacological & nonpharmacological approaches to management of anxiety are appropriate; however, anxiolytic medications are not a substitute for analgesia. Pain is a lonely experience that often causes pts to feel a loss of control. Coping style influences the ability to deal with pain. Locus of control: the degree to which people believe they have control over the outcome of events in their life. -Persons with internal loci of control perceive themselves as having control over events in their life & the outcomes such as pain; -persons with external loci of control perceive that other factors in their life, such as nurses, are responsible for outcome of events.

Pain assessment through the pt's eyes

•Ask the patient's pain level •Use ABCs of pain management •Pain is not a number

Social factors influencing pain

•Attention, previous experiences, family and social support, spiritual •Spirituality includes active searching for meaning in situations, with questions such as "Why am I suffering?" Any factor that interrupts or influences normal pain reception or perception (spinal cord injury, peripheral neuropathy, neurological disease) can affect the patient's response to pain. A pt's attention to pain, previous experiences, & social support systems will affect pain experiences. Repeated pain experiences may help pt deal with present pain experience. When in pain, a pt may rely heavily on others for assistance. Increased attention is associated with increased pain, whereas distraction is associated with a diminished pain response. Each person learns from painful experiences. Prior experience does not mean that a person accepts pain more easily in the future. It is crucial to remember that spirituality stretches beyond religion. When experiencing pain, a pt may ask, "Why has God done this to me?"

Pain - knowledge, attitudes, beliefs

•Attitude of health care providers •Malingerer or complainer When there is no obvious source of pain (e.g., the patient with chronic low back pain or neuropathies), health care providers sometimes stereotype pain sufferers as malingerers, complainers, or difficult patients. Nurse's personal opinion about a patient's report of pain affects pain assessment & titration (strength) of opioid doses. Amt of analgesia administered may vary based on whether a pt is grimacing or smiling during nurse's assessment.

Effects of pain on the patient

•Behavioral effects •Influence on activities of daily living (ADLs)

Nonpharmacological pain relief interventions

•Cognitive and behavioral approach •Relaxation and guided imagery •Distraction •Music •Cutaneous stimulation •Cold and heat application •Transcutaneous electrical nerve stimulator (TENS) •Herbals •Reducing pain perception and reception

Safety Guidelines for Nurses (Immobility)

•Communicate clearly with members of the hc team •Assess & incorporate patient's priorities of care & preferences •Use best evidence when making decisions about your patient's care Ensuring pt safety is an essential role of professional nurse. To ensure patient safety, communicate clearly with members of the hc team, access & incorporate patient's priorities of care & preferences, & use the best evidence when making decisions about your patient's care. When performing skills in this chapter, remember following points to ensure safe, individualized patient-centered care: •Determine amt & type of assistance required for safe positioning, including transfer equipment & number of personnel to safely transfer & prevent harm to pt & hc providers. •Raise side rail on side of bed opposite of where you are standing to prevent patient from falling out of bed on that side. •Arrange equipment (e.g., intravenous lines, feeding tube, indwelling catheter) so does not interfere with positioning process. •Evaluate patient for correct body alignment & pressure risks after repositioning.

Health Promotion (sleep)

•Environmental controls •Promoting bedtime routines •Promoting safety •Promoting comfort •Establishing periods of rest and sleep •Stress reduction •Bedtime snacks •Pharmacological approaches Nursing interventions designed to improve quality of a person's rest & sleep are largely focused on health promotion. Pts need adequate sleep and rest to maintain active & productive lifestyles. During times of illness, rest &sleep promotion are important for recovery. In community health and home settings, help pts develop behaviors conducive to rest & relaxation. Pts benefit most from instructions based on info about their homes & lifestyles such as which types of activities promote sleep in a nightshift worker, or how to make home environment more conducive to sleep. They will likely apply info that is useful & valued.

Acute care - sleep

•Environmental controls •Promoting comfort •Establishing periods of rest and sleep •Promoting safety •Stress reduction In a hospital, nurse controls environment in several ways. When planning interventions to promote sleep, consider usual characteristics of pt's home environment & normal lifestyle. Pts in acute care settings have normal rest & sleep routine disrupted, which generally leads to sleep problems. In this setting, nursing interventions focus on controlling factors in environment that disrupt sleep, relieving physiological or psychological disruptions to sleep, & providing for uninterrupted rest & sleep periods for pt.

Evaluate pt outcomes (hygiene)

•Evaluate after each hygiene intervention •Use teach back •If outcomes were not met, revise the care plan Evaluate patient responses to hygiene measures both during and after each particular hygiene intervention. Once a bath is completed, evaluate if the patient feels more comfortable by using a pain scale. Frequently, it takes time for hygiene care to result in an improvement in a patient's condition. To evaluate a patient or family caregiver's ability to perform self-care hygiene measures use teach back. For example, "I want to be sure you are clear about why foot care is so important for you since you have diabetes. Tell me three things you can do to protect your feet from infection?" Another example, "We talked about ways to prevent your skin from drying, describe them for me." If outcomes established for the plan of care are not met, revise the care plan. Continue to apply critical thinking attitudes when considering all evaluation findings. When outcomes are not met, ask questions by involving the patient, to determine appropriate changes in interventions.

Maintaining wellness

•Help patient understand •Health literacy •Patients actively participate in their own well-being whenever possible Pain therapy requires an individualized approach You are responsible for administering & monitoring therapies ordered by hc providers for pain relief & independently providing pain-relief measures that complement those prescribed. Generally try least invasive or safest therapy first, along with previously used successful patient remedies. If you question a medical therapy, consult with hc provider.

Implementation: Restorative & continuing care (Immobility)

•IADLs •ROM exercise •Walking Goal of restorative care for immobile pt is to maximize functional mobility & independence & reduce residual functional deficits such as impaired gait & decreased endurance.

Safety Guidelines for Nursing Skills

•Identify pt with two identifiers. •Move from cleanest to less clean areas. •Use clean gloves for contact with nonintact skin, mucous membranes, secretions, excretions, or blood. •Test temperature of water or solutions. •Use principles of body mechanics & safe pt handling. •Give proper direction to NAP when delegating.

Dependence

•Lack of knowledge and misconceptions about pain and appropriate pain management present significant barriers. •Patients and health care providers often do not understand the differences between physical dependence, addiction, and drug tolerance.

Patient's room environment

•Maintaining comfort •Temperature, noise, lighting, ventilation, odors •Room equipment •Foot Boots •Special Mattress Attempt to make pt's room as comfortable as home. Needs to be safe & large enough to allow pt &visitors to move freely. Removal of barriers along walkways reduces risk of falls. Control room temp, noise, lighting, ventilation, & odors. Keeping the room neat & orderly also contributes to pt's sense of well-being. Although there are variations across hc settings, a typical hospital room contains the following basic pieces of furniture: - over-bed table - bedside stand - chairs - bed. Clean top of over-bed table with antiseptic cleaner before using for meals. Do not place the bed pan or urinal on the over-bed table. The bedside stand for storing the patient's personal possessions and hygiene equipment. The telephone, water pitcher, & drinking cup usually on top of the bedside stand. Each room usually has an over-bed light & floor level night lighting. Other equipment usually found in a pt's room includes: - call light - television set - wall-mounted blood pressure gauge - oxygen & vacuum wall outlets - personal care items.

Key points when teaching patients about hygiene include the following:

•Make any instruction relevant based on your assessment of the patient's knowledge, motivation, preferences, and health beliefs. •Adapt available resources so the patient can comfortably and safely reach and use needed items. •Include safety risks and tips with all instructions. Determine that the patient understands the relationship among healthy and intact skin and tissues, hand hygiene practices, and the prevention of infection.

Health promotion implementation

•Make instructions relevant. •Adapt instruction to patient's facilities and resources. •Teach the patient ways to avoid injury. •Reinforce infection control practices. In primary health care situations educate and counsel patients and caregivers on why proper hygiene techniques are necessary. The hygiene skills described throughout this chapter provide standards for excellent physical care. When caring for patients in primary health care settings, maintain these standards and incorporate adaptations as needed to meet the patient's lifestyle, functional status, living arrangements, and preferences.

Care of ears, eyes, nose

•Medical devices •Basic eye care •Eyeglasses •Contact lenses •Artificial eyes •Ear care •Hearing aid care •Nasal care Give special attention to cleaning eyes, ears, and nose during a routine bath & when drainage or discharge accumulates. Care focuses on: - preventing infection - maintaining normal sensory function

Rest contributes to:

•Mental relaxation •Freedom from anxiety •State of mental, physical, and spiritual activity Rest does not imply inactivity. When rested, people feel rejuvenated, refreshed, and are able to carry out ADLs. Illness & unfamiliar health care routines affect usual rest & sleep patterns of hospitalized pts. It will be important to allow pts periods of rest.

Cardiovascular changes caused by immobility

•Orthostatic hypotension •Increased cardiac workload •Thrombus formation

Nursing process & pain

•Pain management needs to be systematic. •Pain management needs to consider the patient's quality of life. urses approach pain management systematically to understand and treat a patient's pain. Successful management of pain depends on establishing a relationship of trust among health care providers, patient, and family. Pain management extends beyond pain relief, encompassing the patient's quality of life and ability to work productively, enjoy recreation, and function normally in the family and society.

Planning: Goals & Outcomes (Hygiene)

•Partner with the patient and family •Measurable, achievable, individualized Synthesize info from multiple resources. Critical thinking ensures that a patient's plan of care integrates all that is known about the individual patient & key critical thinking elements. In many situations, patients present with multiple nursing diagnoses. Use a concept map to visualize & understand how nursing diagnoses interrelate. Partner with patient & family to identify goals & expected outcomes to develop a mutually agreed upon plan of care based on the patient's nursing diagnoses. Make outcomes measurable and achievable within patient limitations.

Evaluation (pain) through the patient's eyes

•Patients help decide the best times to attempt pain treatments •They are the best judge of whether a pain-relief intervention works For patients with chronic pain, the effect of the pain intervention on the patient's function should be considered when evaluating the patient's perception of his or her response to treatment. If patients state that an intervention is not helpful or even aggravates the discomfort, stop it immediately and seek an alternative. Time and patience are necessary to maximize the effectiveness of pain management. Educate patients about what to expect. For a patient in acute pain, reassure that you will check back frequently to assess for changes in pain level. Continually assess if the character of the patient's pain changes and whether individual interventions are effective. A patient's behavioral responses to pain-relief interventions are not always obvious.

Implementation: Health promotion

•Prevention of work-related musculoskeletal injuries •Exercise •Bone health in patients with osteoporosis Health promo activities include variety of interventions such as education, prevention, and early detection.

Restorative or continuing care (sleep)

•Promoting comfort •Controlling physiological disturbances •Pharmacological approaches

•Nursing implications for local and regional anesthesia

•Provide emotional support •Protect patient from injury •Patient education Provide emotional support to pts receiving local or regional anesthesia by explaining insertion technique & warning pts they will temporarily lose sensory function within minutes of injection. After admin of a local or regional anesthetic, protect pt from injury until full sensory and motor function return. Pts are at risk for injuring an anesthetized body part without knowing it.

Skeletal system

•Provides attachments for muscles & ligaments, protects vital organs, aids in calcium regulation •Provides leverage for mobility •Bones are long, short, flat, or irregular •Joints •Ligaments, tendons, and cartilage

Characteristics of pain continued

•Quality •Aggravating and precipitating factors •Relief measures

Implementation: Acute care - cardiovascular

•Reducing orthostatic hypotension •Reducing cardiac workload •Preventing thrombus formation •SCDs, thromboembolic disease (TED), hose, and leg exercises

Epidural analgesia

•Regional •Administered into epidural space Epidural analgesia effectively treats acute postoperative pain, rib fracture pain, labor and delivery pain, and chronic cancer pain. Epidural analgesia controls or reduces severe pain and reduces a patient's overall opioid requirement, thus minimizing adverse effects. Epidural analgesia is short or long term, depending on a patient's condition and life expectancy.

Sleep regulation

•Regulated by sequence of physiological states integrated by CNS •Hypothalamus •Reticular activating system (RAS) •Homeostatic process (Process S)

Sleep assessment

•Sources for sleep assessment = Patient, family •Tools for sleep assessment Assess pts' sleep patterns by using nursing history to gather info about factors that usually influence sleep. Sleep is a subjective experience. Only the pt is able to report whether it is sufficient & restful. If pt is satisfied with quantity & quality of sleep received, you consider it normal, & nursing history is brief. If a patient admits to or suspects a sleep problem, you need a detailed history & assessment. If a pt has an obvious sleep problem, consider asking if their sleep partner can be approached for further assessment data. When suspecting a sleep problem, assess quality & characteristics of sleep in greater depth by asking patient to describe problem. Includes recent changes in sleep pattern, sleep symptoms experienced during waking hours, use of sleep & other prescribed or OTC meds, diet & intake of substances such as caffeine or alcohol that influence sleep, & recent life events that have affected pt's mental & emotional status. If a pt's sleep is adequate, assess usual bedtime, normal bedtime ritual, preferred environment for sleeping, & usual preferred rising time.

An evidence-based practice protocol for pain management in older adults recommends these guidelines for nonpharmacological therapies:

•Tailor nonpharmacological techniques to the individual. •Cognitive behavioral strategies may not be appropriate for the cognitively impaired. •Physical pain relief strategies focus on promoting comfort & altering physiologic responses to pain & are generally safe & effective.

Safety guidelines - pain

•The patient is the only person who should press the button to administer the pain medication when PCA is used. •Monitor the patient for signs and symptoms of oversedation and respiratory depression. •Monitor for potential side effects of opioid analgesics. To ensure pt safety, communicate clearly with members of hc team, assess and incorporate pt's priorities of care and preferences, and use the best evidence when making decisions about pt's care.

Bathing and skin care

•Therapeutic: sitz, medicated •Complete bed bath, shower •Partial bed bath •Soap and water vs. Chlorhexidine Gluconate (CHG) •Perineal care

Positioning Techniques

•Trochanter roll •Hand roll •Trapeze bar•Supported Fowler's •Supine •Prone •Side-lying •Sims' • Moving patients Pts with impaired nervous, skeletal, or muscular system functioning & increased weakness & fatigability often require help to attain proper body alignment while in bed or sitting. Several positioning devices available for maintaining good body alignment for pts, including: - pillows - positioning boots - ankle-foot orthoses (AFOs) - blankets, - sandbags - hand rolls - splints Following guidelines reduces risk of injury to musculoskeletal system when patient sitting or lying. When joints unsupported, alignment is impaired. If joints not positioned in slightly flexed position, mobility is decreased. During positioning assess for pressure points.

Apply guidelines for individualizing pain therapy, including:

•Use different types of pain-relief measures. •Use measures that patient believes are effective. •Keep an open mind about ways to relieve pain. Keep trying. When efforts at pain relief fail, do not abandon the patient but reassess the situation.

Examples of evaluation questions include:

•What is preventing you from being able to perform your foot care at home? •Which further measures do you think are necessary to keep your mouth feeling clean? •What do you think would help you be more independent with your hygiene?

Nursing implications

•You maintain responsibility for providing emotional support to patients receiving local or regional anesthesia. •After administration of a local anesthetic, protect the patient from injury until full sensory and motor function return. •Nursing implications for managing epidural analgesia are numerous. •Patient education.

Developmental changes in older adults experiencing immobility

- Decreased physical activity - Hormonal changes - Bone reabsorption Progressive loss of total bone mass occurs with older adult. Some of possible causes of this loss include decreased physical activity, hormonal changes, & bone resorption. Older adults often walk more slowly, take smaller steps, & appear less coordinated. Prescribed meds alter sense of balance or affect BP when change position too quickly, increasing risk for falls. Outcomes of fall include possible injury, hospitalization, loss of independence, psychological effects, & possibly death. Older adults often experience functional status changes secondary to hospitalization and altered mobility status.

Developmental changes in adolescents experiencing immobility

- Delay in gaining independence - Delay in accomplishing skills - Social isolation Adolescent stage usually begins with a tremendous increase in growth. When activity level is reduced due to trauma, illness, or surgery, adolescent often behind peers in gaining independence & accomplishing certain skills (such as obtaining driver's license).

Developmental changes in infants, toddlers, & preschoolers experiencing immobility

- Delayed gross motor skills - Delayed intellectual development - Delayed musculoskeletal development Newborn infant's spine is flexed & lacks the anteroposterior curves of the adult. As baby grows, musculoskeletal development permits support of weight for standing & walking. Posture is awkward because head & upper trunk are carried forward. Because body weight is not distributed evenly along a line of gravity, posture is off balance, & falls occur often. Infant, toddler, or preschooler usually immobilized because of trauma or need to correct a congenital skeletal abnormality.

Cardiovascular effects of immobility

- Orthostatic hypotension - Thrombus

Footdrop

A common and debilitating contracture. When footdrop occurs, foot is permanently fixed in plantar flexion. Ambulation is difficult with foot in this position because the patient cannot dorsiflex the foot. Unable to lift toes off ground.

Sagittal plane

A line that passes through body from front to back, dividing it into a left & right side. Movements: - Flexion & extension (ie: fingers & elbows) - Dorsiflexion and plantar flexion (feet) - Extension (i.e.: hip)

Frontal plane

A line that passes through body from side to side & divides it into front and back. Movements: - abduction & adduction (e.g., arms and legs) - eversion & inversion (feet).

You notice a respiratory change in your immobilized postoperative patient. The change you note is most consistent with: A. atelectasis. B. hypertension. C. orthostatic hypotension. D. coagulation of blood.

A. atelectasis. Rationale: Atelectasis is the collapse of alveoli.

Joint contracture

Abnormal & possibly permanent condition characterized by fixation of joint. Important to note that flexor muscles for joints are stronger than extensor muscles & therefore contribute to formation of contractures. Disuse, atrophy, & shortening of muscle fibers cause joint contractures. When contracture occurs, joint cannot achieve full ROM. Contractures sometimes leave a joint or joints in a nonfunctional position, as seen in patients who are permanently curled in a fetal position. Early prevention of contractures is essential.

Depression

Affective disorder characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness out of proportion to reality. Results from worrying about present and future levels of health, finances, &family needs. Because immobilization removes the patient from a daily routine, they have more time to worry about disability. Worrying quickly increases the patient's depression, causing withdrawal. Withdrawn patients often do not want to participate in their own care. Immobility --> depression --> worry --> withdrawal

Immobility & Mobility

Apply scientific principles in the clinical setting to determine safest way to move patients & to understand the effect of immobility on physiological, psychosocial, & developmental aspects of patient care. To determine how to move patients safely, assess their ability to move. Think of mobility as a continuum, with mobility on one end, immobility on the other, and varying degrees of partial immobility between the end points. Some patients move back and forth between mobility and immobility, but for others immobility is absolute and continues indefinitely. Manually lifting and transferring patients contributes to the high incidence of work-related musculoskeletal problems and back injuries in nurses and other health care staff.

Developmental changes & activity tolerance

As infant enters toddler stage, activity level increases, and need for sleep declines. Child entering preschool or primary grades expends mental energy in learning & often requires more rest after school or before strenuous play. The adolescent going through puberty requires more rest because much body energy is expended for growth and hormone changes. Changes still occur through the adult years, but many of them are related to work and lifestyle choices. As the person grows older, activity tolerance changes. Muscle mass reduced, and posture & bone composition change. Changes in the cardiorespiratory system such as decreased maximum heart rate and lung compliance, which affect the intensity of exercise, often occur. As age progresses, some older individuals still exercise but do so at a reduced intensity.

Activity tolerance

Assessment of energy level includes the physiological effects of exercise and activity tolerance. Activity tolerance is the type and amount of exercise or work that a person is able to perform. Assessment of activity tolerance is necessary when planning activity such as walking, ROM exercises, or ADLs. Activity tolerance assessment includes data from physiological, emotional, and developmental domains. As activity begins, monitor patients for symptoms such as: - dyspnea - fatigue - chest pain - change in vital signs A weak or debilitated patient is unable to sustain even slight changes in activity because of the increased demand for energy. When patient experiences decreased activity tolerance, carefully assess how much time they need to recover. Decreasing recovery time indicates improving activity tolerance. People who are depressed, worried, or anxious are frequently unable to tolerate exercise.

ROM

Assessment of patient mobility focuses on ROM, gait, exercise and activity tolerance, and body alignment. Generally assessment of movement starts while patient is lying & proceeds to assessing sitting positions in bed, transfers to chair, & finally walking. This helps to protect patient's safety. ROM is maximum amount of movement available at a joint in one of the three planes of the body: sagittal, transverse, or frontal. Ligaments, muscles, and the nature of the joint limit joint mobility in each of the planes. Ask questions about & physically examine patient for stiffness, swelling, pain, limited movement, & unequal movement. Exercises may be active, passive, or in between. Consider medical plan of care & patient's ability & need for assistance, teaching, or reinforcement before engaging in active ROM exercises. Assessment data from patients with limited joint movements vary based on the area affected: neck, shoulder, elbow, forearm, wrist, fingers and thumb, hip, knee, ankle and foot, and toes.

Effects of muscular deconditioning

Associated with lack of physical activity - often apparent in a matter of days. This cluster of symptoms is often referred to as the "hazards of immobility": •Disuse atrophy •Physiological •Psychological •Social Disuse atrophy: - describes tendency of cells & tissue to reduce in size & function in response to prolonged inactivity resulting from bed rest, trauma, casting, or local nerve damage. - The individual of average weight and height without a chronic illness on bed rest loses muscle strength from baseline levels at a rate of 3% a day. Physiological, Psychological & social effects: - Periods of immobility or prolonged bed rest cause major physiological, psychological, and social effects. - These effects are gradual or immediate and vary from patient to patient. Patient with complete mobility restrictions is continually at risk for the hazards of immobility. When possible, it is imperative that patients, especially older adults, have limited bed rest & that activity is more than bed-to-chair. The deconditioning related to reduced walking increases the risk for patient falls.

When does balance occur?

Balance occurs when all of these happen together: - wide base of support is present - center of gravity falls within the base of support - vertical line falls from center of gravity through base of support.

Lean body mass loss & muscle weakness

Because of protein breakdown, patient loses lean body mass. Reduced muscle mass is unable to sustain activity without increased fatigue. If immobility continues & patient does not exercise, further loss of muscle mass. Muscle weakness always occurs with immobility, and prolonged immobility often leads to disuse atrophy. Muscle atrophy is widely observed response to illness, decreased ADLs, & immobilization. Loss of endurance, decreased muscle mass and strength, and joint instability put patients at risk for falls.

Immobility vs mobility

Bed rest influences mobility Mobility refers to a person's ability to move about freely, and immobility refers to the inability to do so

Bed rest

Bed rest is an intervention that restricts patients to bed for therapeutic reasons. Nurses & hc providers most often prescribe this intervention.

Postural abnormalities

Can cause pain, impair alignment or mobility, or both. Knowledge about characteristics, causes, & treatment of common postural abnormalities is necessary for lifting, transfer, and positioning.

Pressure ulcers

Changes in metabolism during immobility add to harmful effect of pressure on skin. Tissue metab depends on supply of O2 & nutrients to blood, & elim of metabolic wastes from blood. Pressure affects cellular metab by decreasing/ eliminating tissue circulation. Any break in integrity of skin is difficult to heal. Preventing PU less expensive than treating one; preventive nursing interventions imperative. A PU is an impairment of skin that results from prolonged ischemia (decreased blood supply) in tissues. Ischemia develops when pressure on skin greater than pressure inside small peripheral blood vessels supplying blood to the skin. Ulcer characterized initially by inflammation (stage 1 transient or permanent ischemia) & usually forms over a bony prominence.

Metabolic changes caused by immobility

Changes in mobility alter: •Endocrine metabolism •Calcium resorption •Functioning of the GI system Endocrine system helps maintain homeostasis Immobility disrupts normal metabolic functioning: •Decreases metabolic rate •Alters metabolism •Causes GI distrubances

ROM alterations - Lower extremities

Concerned chiefly with locomotion &weight bearing For this reason, stability of hip joint is more important than its mobility. Contractures often fix hip in positions of deformity. Excessive hip abduction makes affected leg appear too short, whereas excessive adduction makes it appear too long. In either case, patient has limited locomotion & walks with obvious limp. Internal & external rotation contractures cause abnormal & unbalanced gait.

Pathological influences on mobility

Congenital or acquired postural abnormalities affect efficiency of musculoskeletal system & body alignment, balance, & appearance. During assessment observe body alignment & ROM - Postural abnormalities - Muscle abnormalities - Damage to central nervous system (CNS) Musculoskeletal trauma - Trauma to the spinal cord also impairs mobility. - Direct trauma to the musculoskeletal area can cause bruises, contusions, sprains, or fractures. Treatment often includes positioning the fractured bone in proper alignment and immobilizing it to promote healing and restore function. Even this temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness.

Musculoskeletal changes caused by immobility

Effects of immobility on musculoskeletal system include perm or temp impairment or permt disability. Sometimes results in loss of endurance, strength, & muscle mass & decreased stability & balance. Muscle effects: •Lean body mass loss •Muscle weakness/ atrophy Skeletal effects • Disuse osteoporosis • Joint contracture • Impaired calcium metabolism • Joint mobility

Psychosocial effects of immobility

Emotional and behavioral responses •Hostility, giddiness, fear, anxiety •Sensory alterations •Altered sleep patterns Changes in coping •Depression, sadness, dejection Impaired mobility can cause social isolation & loneliness Patients with restricted mobility may have depression

ROM alterations - toes

Excessive flexion of toes results in clawing. When this is a permanent deformity, foot is unable to rest flat on floor, and pt is unable to walk properly. Flexion contractures are the most common foot deformity associated with reduced joint mobility.

ROM alteration - Neck

Flexion contracture - causes neck to be permanently flexed with chin close to or touching chest. Develop if joints not moved periodically through their full ROM Contractures cause altered body alignment, changes in visual field, & decreased level of independent functioning.

_____ muscles for joints are stronger than ______ muscles & therefore contribute to formation of _____.

Flexor, extensor, contractures

Friction

Force that occurs in a direction opposite to movement. The greater the surface area of the object that is moved, the greater the friction. Large objects produce greater resistance to movement. This is why nurses need to be aware of the friction that can cause a patient's skin to shear or tear. Shear: The force exerted against the skin while the skin remains stationary and the bony structures move.

Disuse osteoporosis - Causes? What can it lead to? ___% of people who have osteoporosis are ____

Immobilization causes two skeletal changes: - impaired calcium metabolism - joint abnormalities Because immobilization results in bone resorption (breakdown of Ca from bone, putting it in blood), bone tissue is less dense or atrophied, & disuse osteoporosis results. When disuse osteoporosis occurs, patient is at risk for pathological fractures. Approx 80% of people who have osteoporosis are female. Although primary osteoporosis is different in origin from the osteoporosis that results from immobility, it is imperative for nurses to recognize that immobilized patients are at high risk for accelerated bone loss if they have primary osteoporosis.

GI disturbances - endocrine

Impairments of GI functioning caused by decreased mobility vary.: -Difficulty passing stools (constipation) is common - Pseudodiarrhea often results from fecal impaction (accumulation of hardened feces). Over time intestinal function becomes depressed, dehydration occurs, absorption ceases, and fluid & electrolyte disturbances worsen.

Immobilized patients & Basal Metabolic Rate (BMR) - endocrine system

In presence of infectious process, immobilized pts often have increased BMR (metabolism) as result of fever or wound healing, as these have increased cellular O2 requirements.

Urinary stasis

In upright position urine flows out of renal pelvis and into ureters and bladder due to gravitational forces. When patient is recumbent or flat, kidneys and ureters move toward more level plane. Urine formed by kidney needs to enter bladder unaided by gravity. Because peristaltic contractions of ureters are insufficient to overcome gravity, renal pelvis fills before urine enters ureters. Urinary stasis increases risk of UTI and renal calculi. laying flat --> no gravity for urine flow & decreased peristalsis --> renal pelvis fills before urine enters ureters --> urinary stasis --> UTI & calculi

Which body systems are necessary for optimal physical mobility?

Intact musculoskeletal & nervous systems are necessary for optimal physical mobility and functioning. Clinical nursing practice related to mobility and immobility requires incorporation of scientific & nursing knowledge & skills to provide competent care. Mobility is essential for self-defense, ADLs, & recreational activities. Many functions of body depend on mobility.

Long bones

Internal structure of long bones contains bone marrow, participates in RBC production & acts as reservoir for blood. Patients with altered bone marrow function or diminished RBC production fatigue easily because of reduced hemoglobin and oxygen-carrying ability. Less O2 = sleepy! This fatigue decreases their mobility and increases the risk for falling, which impacts a patient's mobility status. Altered bone marrow function --> low RBC prod --> fatigue --> decreased mobility --> increased fall risk --> impacted mobility

ROM alterations - Hand

Most functions of hand are best carried out with forearm in moderate pronation. When the forearm is fixed in a position of full supination, use of hand is limited.

Components of the nature of movement

Nature of Movement: - Body mechanics - Alignment & balance - Gravity - Friction Nurses use info about these components when implementing nursing interventions. Ex: positioning patients, determining the risk of patient falls, and selecting the safest way to move or transfer patients.

Negative nitrogen balance - endocrine system

Nitrogen: end product of amino acid breakdown Nitrogen balance: balance between N intake in food, and N excretion in urea, uric acid, creatinine, & small amt of amino acids. When pt immobile, body often excretes more nitrogen than it ingests in proteins, resulting in negative nitrogen balance. Tissue catabolism causes: Weight loss, decreased muscle mass, & weakness. More N excretion than ingestion --> negative N balance --> tissue catabolism --> weight loss, decreased muscle mass, weakness

Anthropometric measurements

PPT notes: Measures of height, weight, and skinfold thickness. Used to evaluate muscle atrophy during metabolic assessment. My notes: Measure body composition & body size. Body composition: fat mass vs. lean body mass Body size: height, weight, circumference

Body alignment - lying

People who are conscious have voluntary muscle control & normal perception of pressure. As a result, usually assume a position of comfort when lying down. Because ROM, sensation, & circulation are within normal limits, change positions when perceive muscle strain & decreased circulation. Assess body alignment for a pt who is immobilized or bedridden with pt in LATERAL position. Remove positioning supports from the bed except for pillow under the head & support body with adequate mattress. This position allows full view of spine & back, & helps provide other baseline body alignment data such as whether pt able to remain positioned without aid. Vertebrae are aligned, and position does not cause discomfort. Patients with impaired mobility (e.g., traction or arthritis), decreased sensation (e.g., hemiparesis [muscle paralysis on one side] following a CVA), impaired circulation (e.g., diabetes), & lack of voluntary muscle control (e.g., spinal cord injury) are at risk for damage when lying down.

Alignment & balance

Posture. Refers to the positioning of joints, tendons, ligaments, & muscles while standing, sitting, or lying. Body alignment means that the individual's center of gravity is stable. Without balance control, center of gravity is displaced. Individuals require balance for maintaining a static position (e.g., sitting) and moving (e.g., walking). Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. Medications that cause dizziness and prolonged immobility effect balance. Impaired balance is a major threat to mobility and physical safety. Contributes to fear of falling & self-imposed activity restrictions.

Integumentary changes

Pressure ulcers •Inflammation •Ischemia Older adults at greater risk

Nervous system

Regulates movement and posture. The precentral gyrus (motor strip), is the major voluntary motor area. It is in the cerebral cortex. A majority of motor fibers descend from the motor strip and cross at the level of the medulla. Movement is impaired by disorders that alter neurotransmitter production, transfer of impulses from the nerve to the muscle, or activation of muscle.

Body alignment

The condition of joints, tendons, ligaments, and muscles in various body positions. Perform assessment of body alignment with patient standing, sitting, or lying down. This assessment has the following objectives: •Determining normal physiological changes in body alignment resulting from growth & development. •Identifying deviations in body alignment caused by incorrect posture. •Providing opportunities for patients to observe their posture. •Identifying learning needs of patients for maintaining correct body alignment. •Identifying trauma, muscle damage, or nerve dysfunction. •Obtaining infor concerning other factors that contribute to incorrect alignment such as fatigue, malnutrition, and psychological problems.

Endocrine metabolism

The endocrine system is made up of hormone-secreting glands. It maintains & regulates vital functions such as: (1) response to stress and injury (i.e. cortisol, epinephrine, norepinephrine) (2) growth and development (i.e. growth hormone) (3) reproduction (i.e. sex hormones) (4) maintenance of the internal environment (i.e. insulin, temperature, other chemical messengers) (5) energy production, use, and storage (i.e. thyroid hormones)

Thrombus formation in immobile patients - What is it? Virchow's Triad?

Thrombus is accumulation of platelets, fibrin, clotting factors, & the cellular elements of blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel. 3 factors contribute to venous thrombus formation. Referred to as Virchow's triad.: (1) damage to the vessel wall (e.g., injury during surgical procedures) (2) alterations of blood flow (e.g., slow blood flow in calf veins assoc. w bed rest) (3) alterations in blood constituents (e.g., change in clotting factors or increased platelet activity).

Endocrine system & homeostasis

When injury or stress occurs, endocrine system triggers a series of responses aimed at maintaining BP & preserving life. Important in maintaining homeostasis. Immobility disrupts normal metabolic functioning: - decreases the metabolic rate - alters metabolism of carbs, fats, & proteins - causes fluid, electrolyte, & calcium imbalances - causes gastrointestinal disturbances (Ex: decreased appetite & slowing of peristalsis)

Older adults at greater risk for integumentary changes Where are pressure ulcers most prevalent? Where is highest rate of hc assoc. pu?

When patient lies in bed or sits in chair, weight of body is on bony prominences. The longer pressure is applied, longer period of ischemia & therefore greater risk of skin breakdown. Prevalence of pressure ulcers is highest in LT care facilities, with hc assoc. PU being highest in adult ICU.

Assessment - through patient's eyes

When unsure of patient's abilities, begin assessment of mobility with patient in most supportive position, & move to higher levels according to tolerance. Usually nurse assesses for & asks questions about degree of mobility & immobility during physical exam. Convey respect for the patient's preferences, values, and needs when implementing nursing process and designing a plan of care with patient.

Tendons

White, glistening, flexible bands of fibrous tissue connect muscle to bone strong and inelastic

Ligaments

White, shiny, flexible bands of fibrous tissue Bind joints together, or connect 2 bones, or 2 cartilages Aid joint flexibility & support.

Increased cardiac workload

With immobility, caused by less resistance offered by the blood vessels and change in distribution of blood As workload of heart increases, so does cardiac O2 consumption. Therefore, heart works harder & less efficiently during periods of prolonged rest. As immobilization increases, cardiac output falls, further decreasing cardiac efficiency & increasing workload.

ROM alterations - Ankle

Without full ROM of ankle, gait deviations occur. If joint is not stable, person falls. When person relaxes as in sleep or coma, foot relaxes and assumes a position of plantar flexion. As a result, it becomes fixed in plantar flexion (footdrop), which impairs ability to walk independently & increases risk for falls.

Hemiparesis

slight paralysis or weakness affecting one side of the body

Characteristics of correct body alignment for the sitting patient include the following:

•Head is erect. Neck & vertebral column are in straight alignment. •Body weight distributed evenly on buttocks & thighs. •Thighs are parallel & in a horizontal plane. •Both feet supported on floor, & ankles flexed comfortably. (With patients of short stature, use a footstool to ensure that ankles are flexed comfortably.) •2.5-5cm (1-2inch) space between edge of seat & popliteal space on posterior surface of knee. (Ensures no pressure is present on popliteal artery or nerve to decrease circulation or impair nerve function. •Forearms supported on armrest, lap, or on table in front of chair. Particularly important to assess alignment when sitting if patient has muscle weakness, muscle paralysis, or nerve damage. Patients who have these problems have diminished sensation in affected area & are unable to perceive pressure or decreased circulation. Proper alignment while sitting reduces risk of musculoskeletal system damage. Patient with severe respiratory disease sometimes assumes a posture of leaning on table in front of chair in an attempt to breathe more easily. This is called orthopnea.

Characteristics of correct body alignment for the standing patient include the following:

•The head is erect and midline. •When observed posteriorly, shoulders & hips are straight & parallel. •When observed posteriorly, vertebral column is straight. •When observed laterally, head is erect, & spinal curves are aligned in a reversed S pattern. Cervical vertebrae are anteriorly convex, the thoracic vertebrae are posteriorly convex, & lumbar vertebrae are anteriorly convex. •When observed laterally, abdomen is comfortably tucked in, & knees &ankles are slightly flexed. The person appears comfortable & does not seem conscious of flexion of knees or ankles. •Arms hang comfortably at sides. •Feet are slightly apart to achieve a base of support, & toes are pointed forward. •When viewing patient from behind, center of gravity is at midline, and line of gravity extends from middle of the forehead to a midpoint between the feet. Laterally, line of gravity runs vertically from the middle of the skull to the posterior third of the foot.

Urinary elimination changes

•Urinary stasis •Renal calculi •Infection