Foundations CPA 2 BluePrint

Chapter 33:

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Sleep Assessment

History:
- Identify sleep/wakefulness patterns
- Identify effects of these patterns on everyday life
- Assess use of sleep aids
- Assess presence of sleep disturbances and contributing factors
- nature and cause of problem
- accompanying signs and symptom

Sleep Positions

put babies in supine position

SIDS

Sudden Infant Death Syndrome
-infants who sleep in the prone position will increase the risk of SIDS

Patient Safety

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Sleep Hygiene

-restrict the intake of caffeine, nicotine, and alcohol (especially late at night)
-avoid mental and physical activities after 5 pm that are stimulating
-avoid daytime naps
-eating a light carb/protein snack before bed
-avoid high fluid intake in the even

Sleep Promotion

-Prepare a restful environment.
-Promote bedtime rituals; warm bath, light meal
-Offer appropriate snacks at bedtime
-Promote relaxation and comfort.
-Respect normal sleep-wake patterns.
-Schedule nursing care to avoid disturbances.
-Use medications to pr

Sleeping Disorders and Treatments

-Narcolepsy, a person can literally fall asleep while performing ADLs.
-Insomnia is characterized by difficulty falling asleep.
-Sleep apnea is a condition in which a person experiences the absence of breathing during sleep between snores.
-Restless leg s

Medications and Sleep

- Barbiturates, Amphetamines, and antidepressants do NOT increase REM sleep.
-hypnotics induce sleep
-anti-anxiety only relieves anxiety and tension

Side effects to medication for sleep

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Nursing Diagnosis (as the problem and etiology) associated with sleep and sleep disorders

Problem:
-Physical or emotional discomfort or pain
-Changes in bedtime rituals or sleep environment
-Disruption of circadian rhythm
-Exercise and diet before sleep
-Drug dependency and withdrawal
-Symptoms of physical illness
Etiology
-See Page 1136 for e

Factors affecting rest and sleep

-Developmental considerations
-Motivation
-Culture
-Lifestyle and habits
-Physical activity and exercise
-Dietary habits
-Environmental factors
-Psychological Stress
-Illness
-Medications

Classifications of Sleep Disorders:

Dyssomnias
-Insomnia or excessive sleepiness
- Ex. Insomnia, Hypersomnia, Narcolepsy, Sleep apnea, Restless leg syndrome, Sleep deprivation
-Treatment for dyssomnias: Pharmacological Therapy (Sedatives and hypnotics) or Non-pharmacological Therapy (Stimul

Sleep Diary:

-Time patient retires
-Time patient tries to fall asleep
-Approximate time patient falls asleep
-Time of any awakening during the night and resumption of -sleep
-Time of awakening in morning
-Presence of any stressors affecting sleep
-Record of food, drin

Chapter 34:

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Assessment of Pain

General Assessment (pg. 1161)
-Patient's verbalization and description of pain
-Duration of pain
-Location of pain
-Quantity and intensity of pain
-Quality of pain
-Chronology of pain
-Aggravating and alleviating factors
-Physiologic indicators of pain
-B

Pain Relief Measures (Pharmacological and Non-Pharmacological)

Non-Pharmacological:
-Distraction
-Humor
-Music
-Imagery
-Relaxation
-Cutaneous stimulation
-Acupuncture
-Hypnosis
-Biofeedback
-Therapeutic Touch
-Animal-facilitated therapy
Pharmacological:
-Analgesic (Pharmaceutical agent that relieves pain)
-Types: No

Types of Pain

Duration
-Acute
-Rapid in onset, varies in intensity and duration
-Protective in nature
-Chronic
-May be limited, intermittent, or persistent
-Lasts beyond the normal healing period
-Periods of remission or exacerbation are common
Source
-Cutaneous
-Somat

Pain Management: when to contact healthcare provider

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Gate-Control Theory

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Pain and the Joint Commission

look on page 1161!!

Nursing Diagnosis (as the problem and etiology) associated with pain

Consider ...
-Type of pain
-Etiologic factors
-Behavioral, physiologic, affective response
-Other factors affecting pain process

Sources of Pain:

Nociceptive - the normal process that results in noxious stimuli being perceived as painful.
Cutaneous- pain usually involves the skin or subcutaneous tissue.
Somatic - is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, an

Factors affecting pain:

Culture
Ethnic variables
Family, gender, and age variables
Religious beliefs
Environment and support people
Anxiety and other stressors
Past pain experience

Pain Assessment Tools

Pg. 1164-1165; Table 34-4
Comfort Scale
CRIES Pain Scale
FLACC Scale
Wong-Baker FACES Pain Rating Scale
Oucher Pain Scale

Patient's Rights

Patients with pain Bill of Rights (Box 34-3)

Numeric Sedation Scale:

S: sleep, easy to arouse: no action necessary
1: awake and alert; no action necessary
2: occasionally drowsy, but easy to arouse; no action necessary
3: frequently drowsy, drifts off to sleep during conversation; reduce dosage
4: somnolent with minimal or

Nursing Interventions:

-Establish trusting nurse-patient relationship
-Manipulate factors affecting pain experience
-Review additional pain control measures
-Initiate non-pharmacologic and pharmacologic pain relief measures
-Consider ethical and legal responsibility to relieve

Review variables that influence urination

Developmental considerations
-Children
*Toilet training (18-24 months sphincter control)
-Aging
*Nocturia
*Increased frequency, less concentrated
*Urine retention and stasis
*Voluntary control affected by physical problems
*Medication
-Food and fluid inta

Nursing urinary assessment and health history

History
-Question about voiding patterns, habits, past history of problems...
-Duration, severity, and precipitating factors
-Patient's perception of the problem
-Adequacy of patient's self-care behaviors
-How patient has been able to handle the problem
P

Review nursing diagnoses that correctly identify urinary problems

Urinary functioning as the problem ...
-Incontinence - embarrassment, isolation
-Pattern alteration
-Urinary retention
Urinary functioning as the etiology ...
-Anxiety
-Caregiver role strain
-Risk for infection

Review nursing interventions to promote normal urination; facilitating the use of the toilet, bedpan, urinal, and commode; manage urinary incontinence; perform cauterization; assist with urinary
diversions.

Maintaining normal voiding habits
-Schedule
-Urge to void
-Privacy
-Position
-Hygiene
Promoting fluid intake
Strengthening muscle tone - Kegel Exercises
Assisting with toileting

Plan, implement, and evaluate nursing care related to select nursing diagnoses associated with urinary problems.

the patient will:
-produce urine output about equal to fluid intake
-maintain fluid and electrolyte balance
-empty the bladder completely at regular intervals
-report ease of voiding
-maintain skin integrity

Review types of urine specimen's collection devices & procedures for use. Indwelling catheters.

Routine urinalysis
Clean-catch or midstream specimens
Sterile specimens from indwelling catheter
24-hour urine specimen
Specimens from infants and children
A urine specimen from a patient with an indwelling catheter should be obtained from the catheter po

Review nursing considerations for urinary changes with medications (Levodopa, furosemide)

Anticoagulants�Red urine
Diuretics�Pale Yellow urine
Pyridium�Orange to Orange-Red urine
Elavil or B-complex Vitamins�Green or Blue-Green urine
Levodopa or Injectable Iron�Brown or Black urine

Changes for older adults related to the urinary tract system

-the diminished ability of the kidneys to concentrate urine
-decreased bladder muscle tone
-decreased bladder contractility
-neuromuscular problems, degenerative joint problems.

Post-void residual

the amount of urine remaining in the bladder immediately after voiding

Terms:

Anuria- synonymous with kidney shutdown or renal failure. Dysuria- painful or difficult urination.
Glycosuria- presence of sugar in the urine.
Pyuria- pus in the urine.

Diuretics

Cause increased urine production, resulting in the need for increased urination and possibly urge incontinence.

Diseases Associated with Renal Problems

Congenital urinary tract abnormalities
Polycystic kidney disease
Urinary tract infection
Urinary calculi
Hypertension
Diabetes mellitus
Gout
Connective tissue disorders

Measuring Urine Output:

1. Ask patient to void into bedpan, urinal, or specimen container in bed or bathroom.
2. Pour urine into appropriate measuring device.
3. Place calibrated container on flat surface and read at eye level.
4. Note amount of urine voided and record on approp

Risk for Infection:

Sexually active women
Women who use diaphragms for contraception
Postmenopausal women
Individuals with indwelling urinary catheter
Individuals with diabetes mellitus
Increased age

Urinary Incontinence:

-Stress (Increase in intra-abdominal pressure)
-Urge (Urine lost during abrupt and strong desire to void)
-Mixed (Symptoms of urge and stress incontinence present)
-Overflow (Over distention and overflow of bladder)
-Functional (Caused by factors outside

Kegel Exercises

targets the inner muscle that lie under and support the bladder. these muscles can be toned, strengthened, and actually made larger by a regular routine of tightening and relaxing.

Name factors that influence oxygenation.

-Integrity of the airway system to transport air to and from lungs
-Properly functioning alveolar system in lungs (Oxygenate venous blood, Remove carbon dioxide from blood)
-Properly functioning cardiovascular and hematological system (Carry nutrients and

Review age related differences that influence the care of patients with respiratory problems.

-the tissues and airways become less elastic
-respiratory and abdominal muscles are reduced
-chest is unable to stretch as much
-airways collapse more easily

Review essential elements of a respiratory assessment

Pg. 1408.
-Determine why the patient needs nursing care.
-Determine what kind of care is needed to maintain a sufficient intake of air.
-Identify current or potential health deviations.
-Identify actions performed by the patient for meeting respiratory ne

Age related changes in the respiratory system, risk

...

Plan, implement, and evaluate nursing care related to select nursing diagnoses involving oxygenation problems.

-demonstrate improved gas exchange in lungs
-demonstrate a way to cope with causative factors
-preserve cardiopulmonary function by maintaining optimal activity
-demonstrate self care behaviors that provide relief from symptoms and prevent further problem

Review nursing strategies to promote adequate oxygenation and identify their rationale.

Promoting Optimal Function:
Patient Teaching
-Pollution Free Environment
-Allergens
-Air Quality
-Cigarette Smoking
Reducing Anxiety
Maintaining Good Nutrition
-Energy
-Small Meals
-Nutrient Dense
Medication Side Effects
Promoting Comfort:
Positioning
-Hi

Medications associated with respiratory problems

Bronchodilators: open narrowed airways
Nebulizers: disperse fine particles of liquid medication into the deeper passages of the respiratory tract
Meter-dose inhalers: deliver a controlled dose of medication with each compression of the canister
Dry powder

Review safety issues associated with the use of oxygen.

Avoid open flames in patient's room.
Place no smoking signs in conspicuous places.
Check to see electrical equipment in room is in good working order.
Avoid wearing and using synthetic fabrics (builds up static electricity).
Avoid using oils in the area (

Nursing diagnosis associated with oxygenation; used as the problem; used as the etiology

THE PROBLEM
Ineffective Airway Clearance
Ineffective Breathing Pattern
Impaired Gas Exchange
THE ETIOLOGY (directs nursing interventions)
Activity Intolerance R/T SOB
Acute Confusion R/T Impaired Ventilation
Ineffective Health Maintenance R/T Smoking

Identify correctly written nursing diagnosis

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Promoting respiratory self-care

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Hypoxia: signs and symptoms

inadequate amount of oxygen available to the cells

Pulse oximetry; peak expiratory flow

95-100% = "Normal" & <95% = "Abnormal

What organ is the site of gas exchange?

Alveoli

Transport of Respiratory Gases:

-Oxygen is carried in the body via plasma and red blood cells.
-Most oxygen (97%) is carried by red blood cells in the form of oxyhemoglobin.
-Hemoglobin also carries carbon dioxide in the form of carboxyhemoglobin.
-Internal respiration between the circu

Perfusion

the process by which oxygenated capillary blood passes through body tissues.

Dyspnea

difficulty breathing

Hypoventilation

decreased rate or depth of air movement into the lungs

Cardiovascular System:

-Vital for exchange of gases
-Composed of the heart and the blood vessels
The heart is a cone shaped, muscular pump, divided into four hollow chambers The upper chambers, the atria (singular, atrium), receive blood from the veins (the superior and inferio

Wheezes:

continuous, musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors.

Breath Sounds:

Vesicular: low-pitched, soft sound during expiration heard over most of the lungs
Bronchial: high-pitched and longer, heard primarily over the trachea
Bronchovesicular: medium pitch and sound during expiration, heard over the upper anterior chest and inte

Interventions:

Chest Physiotherapy (Percussion, Vibrating, Postural Drainage)
Suctioning
Administration of Inhaled Medication
Supplemental Oxygen
Chest Tubes
Artificial Airways

CPAP-function

provides continuous mild air pressure to keep airways open