Comfort (25%)

Exam 3/NRS100

comfort

a sense of mental, physical, or social well-being

hygiene

practices to preserve health

what are the 4 basic principles of bathing?

privacy, temperature (room, wipes, water), distal to proximal venous return, and change water, wipes PRN

when do you change your gloves during catheter care?

when cleaning the catheter itself (from dirty to clean)

when is foley care done?

twice daily (once a shift) and after every stool incontinence episode

how many wipes are in a pack of foley wipes?

5

what are the foley wipe steps?

1. thigh 

2. thigh 

3. labia, labia 

4. front to back 

5. meatus & foley catheter itself (after changing gloves & hand sanitizer)

Braden score: sensory perception: completely limited (1)

 Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR limited ability to feel pain over most of body

Braden score: sensory perception: very limited (2)

Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of the body

Braden score: sensory perception: slightly limited (3)

Responds to verbal commands, but cannot always communicate discomfort or the need to be turned OR has some sensory impairment which limits ability to feel pain or discomfort over 1 or 2 extremities

Braden score: sensory perception: no impairment (4)

Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice discomfort

Braden score: moisture: constantly moist (1)

 Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

Braden score: moisture: very moist (2)

Skin is often, but not always moist. Linen must be changed at least once a shift.

Braden score: moisture: occasionally moist (3)

Skin is occasionally moist, requiring an extra linen change approximately once a day.

Braden score: moisture: rarely moist (4)

 Skin is usually dry, linen only requires changing at routine intervals.

braden score: activity: bedfast (1)

confined to bed

braden score: activity: chairfast (2)

 Ability to walk severely limited or non-existent. Cannot bear own weight and /or must be assisted into chair or wheelchair

braden score: activity: walks occasionally (3)

Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair

braden score: activity: walk frequently (4)

 Walks outside room at least twice a day and inside room at least once every two hours during waking hours

braden score: mobility : completely limited (1)

 Does not make even slight changes in body or extremity position without assistance

braden score: mobility: very limited(2)

Makes occasional slight changes in body or extremity but unable to make frequent or significant changes independently

braden score: mobility: slightly limited (3)

Makes frequent though slight changes in body or extremity position independently

braden score: mobility: no limitation (4)

 Makes major and frequent changes in position without assistance

braden score: nutrition: very poor (1)

 Never eats a complete meal. Rarely eats more than one of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO and/or maintained on clear liquids or IV's for more than 5 days.

braden score: nutrition: probably inadequate (2)

 Rarely eats a complete meal and generally eats only about 2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement OR receives less than optimum amount of liquid diet or tube feeding.

braden score: nutrition: adequate (3)

: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day). Occasionally will refuse meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs.

braden score: nutrition: excellent (4)

Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

braden score: friction & sheer: problem (1)

Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction

braden score: friction & sheer: potential problems (2)

 Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.

braden score: friction & sheer: no apparent problem (3)

 Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair

when performing bath care, what do you wash first?

face

rest

a condition in which the body is in a decreased state of activity, with the consequent feeling of being refreshed

common sleep disorders: parasomnias

• somnambulism

• somniloquy

• sleep-related-eating disorder

• bruxism

• nocturnal enuresis

  • night terrors

common sleep disorders: dysomnias 

• insomnia 

• narcolepsy (hypersomnia) 

• restless leg syndrome 

• sleep apnea 

Sleep factors :

• physical acitity & exercise

• alcohol &caffeine

• smoking

• illness

• motivation & culture

• dietary factors

• environmental

• stress

• medication 

5th vital sign

pain

what interprets pain

nociceptors (peripheral nerve fibers)

acute pain

rapid onset, pain disappears

chronic pain

lasts beyond normal healing time (1-6 months or longer)

somatic pain

deep, scattered throughout (tendons, bones, nerves, blood vessels)

visceral pain

body organs (commonly produced by disease)

referred pain

transmitted (perceived at a different origin site)

harmful effects of unrelieved pain

1. elevated BP, HR, RR, BS, can be decreased BP/HR too

2. rapid, irregular breathing 

3. depression, anxiety, anger, frustration, dependency 

4. labeled as weak, hypochondriac

   1. fatigue, anorexia, hopelessness, nausea/vomiting

5 stages of grief in order:

denial, anger, bargaining, depression, acceptance

What do you monitor for a patient on a PCA pump?

Pain, sedation, level, LOC, BP, RR, Pulse-ox

Who controls the PCA pump?

patient? (question teacher)

What are the respiration parameters that must met prior to initiation and/or bolus? 

uPOSS </equal to 2

uRR > 8

uPulse oximetry > 92%

(review policy, every hospital is different) 

What are the characteristics of REM Sleep?

• Eye dart back and forth quickly 

• small muscle twitching, such as on the face 

• large muscle immobility, resembling paralysis 

• Respirations irregular; sometimes interspersed with apnea 

• rapid or irregular pulse 

• blood pressure increases or fluctuates 

• increase in gastric secretions 

• metabolism increases 

When does REM Sleep start? and percentage of sleep?

Enters from stage 2 of NREM sleep

difficulty to arousal from sleep

20-25% of sleep

What are the characteristics of NREM stage 1 and %?

• transition stage between wakefulness and sleep

• relaxed but somewhat aware

• involuntary muscle jerking may occur and waken the person

• lasts only minutes

• can easily be aroused

• constitutes only about 5% of total sleep

What are the characteristics of NREM stage 2 and %?

• now in a stage of sleep

• can be aroused with relative ease

• 50% to 55% of sleep

What are the characteristics of NREM stage 3 and %?

• depth of sleep increases, and arousal becomes increasingly difficult 

• composed about 10%

What are the characteristics of NREM stage 4 and %?

• the person reaches the greatest depth called delta sleep 

• arousal is difficult

• 10% of sleep

What are the physiological characteristics of NREM stage 4?

• slow brain waves are recorded on a EEG

• pulse and respiratory rates decrease

• blood pressure decrease

• muscles are relaxed

• metabolism slows and the body temp is low

What is agonist?

a medication that binds to an opioid receptor mimicking the way endogenous substances provide analgesia

What is an agonist-antagonist?

a type of opioid that binds to the kappa opioid receptor site acting as an agonist (capable of producing analgesia) and simultaneously to the mu opioid receptor site acting as an antagonist (reversing mu agonist effects)

What is the definition of “pain”?

“an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”

What is breakthrough pain?

a transitory increase in pain that occurs in the context of otherwise controlled persistent pain (timely acute pain)

What is the difference between nociceptive (physiological) pain and neuropathic (pathophysiological) pain?

nociceptive refers to normal processing of stimuli that damages tissue or perceives potential to do so while neuropathic is the result from abnormal processing of sensory input result of the PNS or CNS being damaged.

What are some considerations for bathing infants?

Use a sponge bath or tub bath to bathe young infants who cannot sit unaided. Support the infant’s body at all times. Ensure appropriate water temperature. Avoid use of talcum powder.

What are some considerations for bathing infants?

Bathe older infants and toddlers at the bedside or in a regular bathtub, depending on their health condition.

What are some considerations for bathing school-age children and adolescents?

Older children may prefer a shower, if available and acceptable for their health condition. Assess whether a shower would be safe. Provide privacy.

How do you promote nutrition to your hospitalized child?

• encourage child to eat their favorite foods

• assist child with eating or drinking; present at mealtimes to promote socialization

• offer small cups of fluids or finger foods

• use bright colored utensils to provide contrast and stimulation

• offer praise

What is therapeutic play in peds?

Therapeutic play is nondirected and focuses on helping the child cope with feelings and fears.

What are some nursing strategies to address hygiene in older adults with impaired oral mucous membranes?

• Floss and brush teeth with fluoride toothpaste twice a day; rinse after meals.

• Brush dentures twice a day and rinse with cool water; remove and rinse dentures and rinse mouth after meals.

•  Avoid mouthwashes with alcohol content.

• Inspect mouth daily for lesions and inflammation.

• Use lubricant on lips.

• Suck on sugar-free candies, chew sugarless gum, use salivary substitutes.

• Continue with dental exams at the dentist every 6 months.

What are some nursing strategies to address hygiene in older adults with impaired physical mobility?

• Use adaptive devices for hygiene such as toothbrush with a large or extended handle, long-handled body sponge, shower chair, and grab bars. •   Provide for safety in the bathroom: use nonslip mats, grab bars.

What are some nursing strategies to address hygiene in older adults with impaired skin integrity?

• Use safe water temperatures to bathe; warm water, not hot.

• Avoid soap; use pH-balanced skin cleansers.

• Shower instead of tub bath.

• Use skin moisturizers and emollients at least daily.

• Bath regularly, but less often (not every day).

What is Sleep in definition?

is a state of rest accompanied by altered consciousness and relative inactivity

What are sleep patterns of newborns and infants?

• newborns sleep an average 16hr/24hr: averages about 4 hours at a time

• infants sleep 12 to 16 hours at night with several naps

• age 8 to 16 weeks infants sleep through the night

• REM is most of their sleep cycle in a young infant

What are some sleep pattern nursing implications for newborns and infants?

• teach parents to position infant on the back

• sleeping in the prone position increases risk for sudden infant death syndrome

• advise parents that eye movements, groaning, grimacing, and moving are normal

• encourage parents to have infant sleep in a separate area in the parent’s bedroom rather than their bed

• caution parents about placing pillows, crib bumpers, quilts, stuffed animals, and etc

What are some toddler sleep patterns?

• need for sleep declines as this stage progresses

• may require two naps during the day

• sleeping 11 to 14 hours a night and napping once durinmg the day at the end stage

• may begin to resist naps and going to bed at night

• move from crib to youth bed or regular bed at around age 2 years

What are some sleep pattern nursing implications for toddlers?

• establish a regular bedtime routine

• advise parents of the value of a routine sleeping pattern with minimal variation

• encourage attention to safety once child moves from crib to bed 

• folding gate might be necessary if they wander 

What are the sleep patterns of preschoolers?

• children in this stage generally sleep 10 to 13 hours at night

• The REM sleep pattern is similar to that of an adult

• daytime napping decreases

• age 5 most children no longer nap

• may resist going to bed

What are some sleep pattern nursing implications of preschoolers?

• Discuss the fact that the stress of beginning school may interrupt normal sleep patterns.

• Advise that a relaxed bedtime routine is most helpful at this stage.

• Inform parents about child’s awareness of the concept of death possibly occurring at this stage.

• Encourage parental presence and support to help alleviate some of the child’s concerns.

What are the sleep patterns of a school-aged child?

• Younger school-aged children may require 9 to 12 hours nightly, whereas older children in this stage may average 9 to 11 hours.

• Sleep needs usually increase when physical growth peaks.

What are some sleep pattern nursing implications of school-aged children?

• Discuss the fact that the stress of beginning school may interrupt normal sleep patterns.

• Advise that a relaxed bedtime routine is most helpful at this stage.

• Inform parents about child’s awareness of the concept of death possibly occurring at this stage.

• Encourage parental presence and support to help alleviate some of the child’s concerns.

What are some self-care behaviors for rest and sleep?

• Follow a regular routine for bedtime and morning awakening

• Accept individual differences in need for sleep.

• Use relaxation exercises to relax before bedtime

•  Avoid caffeine, smoking, and alcohol before bedtime.

• Adjust room preferences

• Eat a small protein and carbohydrate snack before going to bed

• Incorporate periods of regular exercise into each week.

• Use some part of each day for quiet, enjoyable activities such as crafts, hobbies, reading, watching television, listening to music, and visiting with friends.

What are the sleep patterns of a teenager?

• Sleep average requirement is 8 to 10 hours. The growth spurt that normally occurs at this stage may necessitate the need for more sleep; however, the stresses of school, activities, and part-time employment may cause adolescents to have a restless sleep.

• Adolescents tend to go to bed later than younger children and adults, but early morning start times for high school frequently require an early awakening time.

• Many adolescents do not get enough sleep.

What are some sleep pattern nursing implications from teenagers?

• Advise parents that their adolescents’ complaints of fatigue or inability to do well in school may be related to not enough sleep.

• Excessive daytime sleepiness (EDS) may also make the teenager more vulnerable to accidents and behavioral problems.

What are the sleep patterns of a young adults?

• The amount of sleep required is 7 to 9 hours.

• Sleep is affected by many factors: physical health, type of occupation, exercise. Lifestyle demands may interfere with sleep patterns.

• REM sleep averages about 20% of sleep.

What are some sleep pattern nursing implications for young adults?

• Reinforce that developing good sleep habits has a positive effect on health, particularly as a person ages.

• If loss of sleep is a problem, explore lifestyle demands and stress as possible causes.

• Suggest use of relaxation techniques and stress-reduction exercises rather than resorting to medication to induce sleep.

• Sleep medications decrease REM sleep, may be habit forming, and frequently lose their effectiveness over time.

What are the sleep patterns of a middle-aged adult?

• Total sleep time decreases during these years, with a decrease in stage IV sleep.

• The percentage of time spent awake in bed begins to increase. People become more aware of sleep disturbances during this period.

What are some sleep pattern nursing implications for middle-aged adults?

• Encourage adults to investigate consistent sleep difficulties to exclude pathology or anxiety and depression as causes.

• Encourage adults to avoid use of sleep-inducing medication on a regular basis.

What are some sleep patterns of older adults?

• An average of 7 to 8 hours of sleep is usually adequate for this age group.

• Sleep is less sound, and stage IV sleep is absent or considerably decreased. Periods of REM sleep shorten.

• Older adults frequently have great difficulty falling asleep and have more complaints of problems sleeping.

• Decline in physical health, psychological factors, effects of drug therapy (e.g., nocturia), or environmental factors may be implicated as causes of inability to sleep.

What are some sleep pattern nursing implications for older-aged adults?

• A comprehensive nursing assessment and individualized interventions may be effective in the long-term care of this age group.

• Emphasize concern for a safe environment because it is not uncommon for older adults to be temporarily confused and disoriented when they first awake.

• Use pharmacologic sleep aids with extreme caution because of declining physiologic function and concerns about polypharmacy.

• Encourage older adults to discuss sleep concerns with their health care provider.

What is Idiopathic hypersomnia?

characterized by constant or recurrent episodes of extreme sleepiness, particularly during the day.

What is narcolepsy?

is a chronic neurologic disorder characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep.

What is parasomnias?

are episodes or behaviors that occur during arousals from REM sleep or partial arousals from NREM sleep that disturb the patient or others

What is somnambulism?

sleepwalking may range from sitting up in bed to walking around the room or the house to walking outside the house.

What is the Gate control theory?

It describes the transmission of painful stimuli and recognizes a connection between pain and the projection of pain information to the brain

What does pain mean in transduction?

It involves conversion of painful stimuli into electrical impulses that travel from the periphery to the spinal cord at the dorsal horn

What does pain mean in transmission?

Pain sensations from the site of an injury or inflammation are conducted along pathways to the spinal cord and then on to higher centers.

What is pain threshold?

the “minimum intensity of a stimulus that is perceived as painful”

What is modulation?

The process by which the sensation of pain is inhibited or modified

What are neuromodulators?

endogenous opioid compounds, meaning they are naturally present, morphine-like chemical regulators in the spinal cord and brain.

what are endrophins?

produced at neural synapses at various points along the CNS pathway.

what are enkephalins?

what is exacerbation?

pain that is recurring and contains elements of both chronic and acute pain

What is cutaneous pain?

involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain.

What is somatic pain?

involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain.