Fundamentals Exam 3

Sleep assessment

Systematic evaluation of a patient’s sleep patterns, quality, and factors affecting rest

Sleep history

Includes usual bedtime, wake time, sleep duration, naps, and perceived sleep quality

Sleep quality

Patient’s subjective feeling of how restful and restorative sleep is

Sleep quantity

Total amount of sleep obtained (hours per night)

Sleep disturbances

Problems that interfere with normal sleep (e.g., insomnia, sleep apnea)

Insomnia

Difficulty falling asleep, staying asleep, or waking too early

Sleep apnea

Disorder characterized by repeated pauses in breathing during sleep

Snoring

Noisy breathing during sleep; may indicate airway obstruction

Daytime sleepiness

Feeling excessively tired during the day, often due to poor sleep

Sleep diary

Record of sleep patterns over time used to identify issues

Polysomnography

Diagnostic test that records brain waves, oxygen levels, heart rate, and breathing during sleep

Sleep hygiene

Practices that promote consistent, uninterrupted sleep

Comfortable sleep environment

Cool, dark, quiet room that supports rest

Relaxation techniques

Activities like deep breathing, reading, or meditation before bed

Physical activity

Regular exercise that promotes better sleep (not right before bedtime)

Limiting caffeine

Avoiding stimulants several hours before sleep

Limiting screen time

Reducing exposure to phones/TV before bed

Bedtime routine

Consistent pre-sleep activities that signal the body to rest

Factors That Prevent Good Sleep Habits

stress and anxiety

pain

noise

light exposure

irregular sleep schedule

caffeine intake

alcohol use

medications

illness

night shift

Circadian rhythm

Body’s internal clock regulating sleep-wake cycles

Sleep stages

Cycles of NREM and REM sleep that restore the body and mind

REM sleep

Stage associated with dreaming and cognitive restoration

NREM sleep

Deep, restorative sleep that supports physical recovery

Adults sleep needs

Typically 7–9 hours per night

healthy sleep habits

Avoid heavy meals before bed

consistency-Maintaining regular sleep habits to support overall health

limit naps- short naps less than 30mins

use bed only for sleep

Stage I pressure ulcer

Intact skin with non-blanchable redness; may be warm, firm, or painful

Stage II pressure ulcer

Partial-thickness skin loss; appears as blister or shallow open ulcer

Stage III pressure ulcer

Full-thickness skin loss; subcutaneous fat visible, no bone/tendon exposed

Stage IV pressure ulcer

Full-thickness tissue loss with exposed bone, tendon, or muscle

Unstageable ulcer

Covered with slough or eschar, depth cannot be determined

Deep tissue injury

Purple/maroon discoloration indicating underlying tissue damage

Prevention of Pressure Ulcers

Repositioning

Pressure redistribution (Use of special mattresses, cushions, or padding)

Skin assessment

Keep skin clean and dry

Nutrition support

Mobility promotion (Encouraging movement)

Reduce friction and shear (Proper positioning and use of lift devices)

Debridement

Removal of dead tissue to promote healing

Infection control

Monitoring for signs of infection and using antibiotics if needed

Treatment of Pressure Ulcers

Moist wound healing- Keeping wound environment moist (not dry)

Pain management

Positioning

wound care

debridment

infection control

Transparent film dressing

Used for Stage I; protects skin and allows visualization

Hydrocolloid dressing

Used for Stage II; maintains moist environment

Foam dressing

Used for Stage II–III; absorbs drainage and cushions

Alginate dressing

Used for Stage III–IV with heavy drainage

Hydrogel dressing

Used for dry wounds to add moisture

Gauze dressing

Used for packing deep wounds

Risk Factors for Pressure Ulcers

Immobility → Inability to change position independently

Poor nutrition → Lack of protein and calories delays healing

Moisture → From incontinence, sweat, or wound drainage

Decreased sensation → Reduced ability to feel pain/pressure

Advanced age → Thinner, more fragile skin

Chronic illness → Conditions like diabetes or vascular disease

Decreased circulation → Limits oxygen and nutrient deliver

Braden Scale

Tool used to assess risk for pressure ulcer development

Braden Scale categories

Sensory perception, moisture, activity, mobility, nutrition, friction/shear

Purpose of Braden Scale

Identifies patients at risk so prevention can begin early

Scoring

Lower score = higher risk for pressure ulcers

FICA Model

Tool used for spiritual assessment in nursing care

F (Faith/Beliefs)

Ask about patient’s spiritual beliefs or faith

I (Importance)

Determine how spirituality influences coping and decisions

C (Community)

Identify spiritual or religious support systems

A (Address in care)

Incorporate spiritual needs into care plan

Therapeutic Communication Strategies

Active listening → Fully focusing on what the patient is saying

Open-ended questions → Encouraging patients to express thoughts and feelings

Empathy → Understanding and sharing patient’s feelings

Presence → Being physically and emotionally available

Silence → Allowing time for reflection and expression

Nonjudgmental attitude → Respecting beliefs without imposing personal views

Clarification → Ensuring understanding of patient’s statements

Nursing Interventions for Spiritual Needs

Provide privacy → Allow time for prayer, meditation, or reflection

Facilitate spiritual practices → Support rituals or religious customs

Refer to chaplain → Connect patient with spiritual care providers

Respect beliefs → Honor cultural and religious preferences

Encourage expression → Let patients discuss fears, meaning, and purpose

Support hope → Help patients find meaning and comfort

Create safe environment → Encourage open discussion of spirituality

Avoid imposing beliefs → Maintain professional boundaries

SERT

spiritual

existential

religous

theological

5 P’s — Sexual history components

partners, Practices, Protection from STIs, Past STIs, Pregnancy plans

Partners — What to assess

Number, gender, type of relationships

Practices — What to assess

Type of sexual activity (oral, vaginal, anal)

Protection — What to assess

Condom use, STI prevention methods

Past STIs — What to assess

History of STIs, testing, treatment

Pregnancy plans — What to assess

Desire for pregnancy, contraception use

Sexual health education — Key topics

STI prevention, contraception, consent, healthy relationships

Safe sex education

Condom use, regular STI testing, limiting partners

Patient teaching — Communication approach

Nonjudgmental, open-ended questions, ensure privacy

Post-mortem nursing care — Key actions

Clean body, remove tubes/IVs (unless autopsy), position flat with hands folded, close eyes/mouth, allow family time, respect cultural practices

Rigor mortis — Timing

Begins 2–12 hours after death

Pain management — Acute vs chronic

Acute: ↑ HR, BP, RR, visible distress
Chronic: VS stable, may not show pain, focus on preventing breakthrough pain

Opioids — Examples & uses

Morphine (gold standard), Dilaudid (potent), Fentanyl (short acting/patch), Methadone (long acting)

Palliative care

Focuses on symptom relief and quality of life at any stage of illness

Hospice care

End-of-life care for patients with ~6 months or less to live, no curative treatment

Palliative vs Hospice — Key difference

Palliative = can be with curative treatment
Hospice = comfort care only, end of life

Signs of dying — Physical

↓ appetite, ↓ urine output, cool extremities, cyanosis, ↑ sleep, loss of swallow reflex

Signs of dying — Respiratory

Cheyne-Stokes respirations, death rattle

Signs of dying — Mental

Withdrawal, decreased communication, confusion, hallucinations, agitation

End-of-life nursing interventions

Do not force feed, provide oral care, reposition frequently, manage symptoms, assume patient can hear

Grief

Emotional response to loss (physical, emotional, spiritual)

Bereavement

State of having lost a loved one

Mourning

Expression of grief influenced by culture/religion

Kubler-Ross stages of grief

Denial, anger, bargaining, depression, acceptance

Grief — Key concept

Not linear, highly individual, can last months to years

Complicated grief — Risk factors

Sudden death, prolonged illness, lack of support, unresolved conflict

Grief nursing interventions

Active listening, presence, validate feelings, encourage expression, provide support resources

Therapeutic communication for grief

“I’m so sorry,” “Tell me more,” offer presence

Clear liquid diet

Used post-op/illness; includes broth, clear juice, gelatin

Full liquid diet

More calories than clear; includes milk, cream soups, pudding

Pureed diet

For swallowing issues; blended foods, thick consistency

Dysphagia diet

Prevents aspiration; thickened liquids, soft foods

Low sodium diet — Indication

HTN, heart failure; limit sodium (~2g/day)

Low potassium diet Foods

Avoid bananas, oranges, potatoes

High potassium diet Foods

Bananas, oranges, spinach, milk

Nutritional status — Assessment

Weight, BMI, labs, intake history

Signs of malnutrition

Weight loss, weakness, poor wound healing

Safety with eating

Assess swallowing, aspiration risk, positioning

Promote nutrition — Nursing actions

Small frequent meals, assist feeding, pleasant environment

Enhance intake

Offer favorite foods, manage nausea, oral care

Calorie counting

Tracking daily caloric intake to meet nutritional needs

Basic calorie guideline

Varies by age, gender, activity level

Infants — Needs

High fat, breast milk/formula

Children — Needs

Balanced diet for growth

Adolescents — Needs

Increased calories, protein

Adults — Needs

Balanced diet, prevent chronic disease