Adults Unit 1 exam

Identify the importance of caring in nursing.

Gain trust of patients to open up and share more to improve patient care and outcomes

Discuss the barriers to caring and building therapeutic relationships and ways to overcome these barriers.

Barriers: Internal and external

Overcoming barriers:

• Practice good self-care practices:

  • Meditation, exercise, journaling, joining burnout programs, etc.

• This will vary among individuals

  • Try out different methods and reflect

• Call for systems changes - eg. address the nursing shortage

What are internal barriers?

compassion fatigue, burnout, personal experiences impacting nurses’ behaviors (i.e. death, break-up, etc.)

what are external barriers?

time constraints with balancing multiple patients, multiple nursing tasks, demands of documentation, etc.

compassion fatigue

fatigue is emotional, physical, spiritual exhaustion of caring for trauma patients creating secondary traumatic stress

secondary traumatic stress

less empathy and desire to work, exhaustion, fatigue, anger, irritability, strained relationships, anxiety, difficulty sleeping (Lombardo & Eyre

Identify ways the nurse can convey caring in their practice.

presence, touch, listening, knowing the patient, spiritual care, relieving symptoms, and family care.

A nurse is caring for a client who is crying. Which of the following uses of touch should the nurse implement to convey caring?

A. Briefly holding the client’s hand

B. A lengthy front-facing hug

C. Rubbing the client’s shoulders

D. Sitting beside the client and touching their thigh

Briefly holding the client’s hand

A nurse needs to use clinical judgment before planning and implementing any touch interventions. What does the nurse need to understand about the use of touch? (Select all that apply.)

A. Some cultures may have specific restrictions about non–skill based touch.

B. Touch is a form of nonverbal communication.

C. Touch reduces only physical pain.

D. Touch can successfully influence a patient’s level of comfort.

E. There is never a problem with using touch at any time.

a.Some cultures may have specific restrictions about non–skill based touch.

b.Touch is a form of nonverbal communication.

d. Touch can successfully influence a patient’s level of comfort.

An example of a nurse caring behavior that families of patients who are acutely ill perceive as important to patients’ well-being is:

A. Making health care decisions for patients.

B. Having family members provide a patient’s total personal hygiene.

C. Injecting the nurse’s perceptions about the level of care provided.

D. Asking permission before performing a procedure on a patient

Asking permission before performing a procedure on a patient

Describe health

“State of complete physical, mental, and social well-being, not merely the absence of disease”

“The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being”

Describe wellness

• An active pursuit of a lifestyle that promotes holistic health

• Actions taken by individuals to achieve health

• Multidimensional

  • Mental

  • Emotional

  • Spiritual

  • Social

  • Environmental

  • Vocational

  • Intellectual

Describe Well-Being

• A general state of contentment

• Balance in body, mind, and spirit

• Connection to purpose, people, and community

Social determinants of health

1. Economic stability

2. Education

3. Healthcare access and quality

4. Neighborhood and built environment

5. Social and community context

6. Racism

Identify variables influencing health, health beliefs, and health practices.

• Internal and External Variables

• Health Beliefs

• Social Determinants of Health

• Culture and Community

Explore the concept of self-concept

• Self-concept: individuals perception of self and influences the relationships we form

• Nurses must understand how mental and physical health alterations influence client’s self-concept to help with coping and achieving optimal health outcomes

• A healthy sense of self is necessary for overall mental, emotional, physical and spiritual wellness.

Factors that affect self-concept

• Identity

• body image

• role performance

• self-esteem

self-esteem

• Overall feelings of self-worth

• May be incongruent with reality

role performance

• Perception of ability to carry out significant roles(parent, friend, etc.)

body image

• Attitudes related to the body

• Mental image may differ from actual physical appearance

identity

• Internal sense of individuality

• Being oneself

• Sexuality and culture are apart of identity

Explore stressors that affect self-concept

• identity

• body image

• role performance

Understand how self-concept impacts patients' health and wellness and the nurse's role related to self-concept

• Acceptance of the patient

  • Be aware of your own feelings, values, judgments, etc.

    • Nonverbal communication

• Patient’s with changes in body appearance

  • Maintain a positive, matter-of-fact approach

What are some ways you can phrase assessment questions related to sexual health?

● Can you tell me how you express your sexuality?

● What concerns or questions do you have about your sexual health?

● What interventions or information can I provide to help support your sexual health?

What acronym can we apply to assess sexual health history

PLISST

What does “P” in PLISSIT stand for?

Permission

What does “LI” in PLISSIT stand for?

Limited information

What does “SS” in PLISSIT stand for?

Specific Suggestion

What does “IT” in PLISSIT stand for?

Intensive Therapy

Factors Influencing Sexual Health in Older Adults

• stroke

• depression

• dementia

• alcohol intake

• obesity

• heart disease

• arthritis

• diabetes

• incontinence

• STI

Sexual Response Cycle

1. desire/libido: neurotransmitter-dopamine and serotonin; hormones

2. arousal/excite: parasympathetic nervous system mediates engorgement

3. plateau/orgasm:

   1. increased blood flow, arterial dilation, enlargement

   2. Increased HR, BP, RR

4. recovery: return to baseline

blood pressure meds and diuretics

• thiazides

  • hydrochlorothiazide

• beta blockers

  • atenolol

  • metoprolol

  • propranolol

antidepressants

● Selective Serotonin Reuptake Inhibitors (SSRI)

○ Fluoxetine (Prozac)

○ Sertraline (Zoloft)

● Benzodiazepines

○ Lorazepam (Ativan)

○ Diazepam (Valium)

Culture

communication, language, actions, beliefs, values, customs, norms, and institutions of racial, religious, social, and ethnic groups

Cultural diversity:

within and among groups

Diversity:

age, ethnicity, gender identity, geographic location, language, religious beliefs, and socioeconomic status

Cultural awareness:

investigating and understanding differences between perceptions, beliefs, traditions, and values within the nurse’s own culture and those in other cultures

What are health disparities?

● Preventable differences in diseases, violence, and/or opportunities to achieve optimal health experienced by socially disadvantaged populations (CDC, 2023)

● Risk factors: Poverty, education inequalities, access to health care, sensory deficits, LGBTQ+, race, ethnicity, location, disabilities, etc

What are some causes of health disparities?

Location, education and income gaps, racism, stigma

What is the impact of these health disparities?

Poorer health outcomes, quality of life, life expectancy, generational continuation

• Chronic stress - can lead to more diseases (obesity, heart disease,

etc.)

What can be done to address these health disparities to achieve health equity?

• system level change

• individual level

When should cultural assessments be completed and why?

• At the beginning of the first encounter to provide culturally competent care

• Improves the caring relationship, improves patient outcomes, and reduce disparities

When do we use interpreters?

Individuals who are more comfortable, fluent, in another language besides english including ASL

Who can we use as interpreters?

certified medical interpreter

what is the importance of an interpreter

Patient’s right and improves patient care and outcomes

sex assigned at birth

• Female

• Male

• Intersex

gender identity

Inner sense of being a boy/man, girl/woman, another gender, or no gender

sexual orientation

Emotional attraction Physical attraction (sometimes behaviors)

Transgender

gender identity doesn’t align with sex assigned at birth

Cisgender

gender identity aligns with sex assigned at birth

Non-binary

umbrella term that encompasses several gender identities

Barriers to Accessing Care

● medical mistrust

● lack of trained providers

● lack of insurance coverage for affirming care

compared to the general population, transgender people experience higher rates of these health concerns

• HIV infection

• substance use disorders

• mental health problems

• violence and victimization

How can we make a difference to improve gender identity and health disparities?

1. Eliminate cisnormativity

2. Take an individual and holistic approach to care

3. Reduce accessibility barriers

4. Improve each interaction with patients

5. Provide training for healthcare professionals

A nurse is reviewing information to enhance their own cultural awareness. The nurse should identify the need to examine which of the following?

● the nursing process

● self-bias

● health disparities

● cultural diversity

Self Bias

A nurse is caring for a newly admitted client. Which of the following actions should the nurse take first?

a. implement nursing interventions

b. plan nursing interventions

c. perform a cultural health assessment

d. evaluate the care plan

perform a cultural health assessment

A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

a. use a certified medical interpreter

b. use a family member as an interpreter

c. repeat important words so the client recognizes their importance

d. Talk slowly so that each word is heard clearly

use a certified medical interpreter

You are working as a nurse when you notice a discrepancy in the pronouns and gender listed in the Electronic Health Record. Which action would be most appropriate for the nurse to take?

a. Ask the client about their pronouns and gender at the next visit

b. Use the most recent documentation in the chart to identify gender and pronouns

c. Refer to sex assigned at birth to determine gender and pronouns

d. Conclude that this must be an error as pronouns and gender cannot change

Ask the client about their pronouns and gender at the next visit

True or false, persons with non-binary or transgender gender identities are at a higher risk for experiencing anxiety and depression

a. True

b. False

True

Which of the following is a common barrier to healthcare experienced by persons identifying as LGBTQ+

a. Access to healthcare clinics with holistic and/or gender affirming care policies

b. Mistrust of healthcare professionals

c. Lack of representation on intake forms and questionnaires

d. Experience with micro and macroaggressions in care environments

e. All of the above

All of the above

The nurse is preparing to perform a sexual health assessment on an older adult. Which statement by the nurse demonstrates the best approach?

a. “Older adults aren’t usually sexually active, are you?”

b. “Many clients who experience a cancer diagnosis have concerns about sexual health. Are there concerns that you’d like to discuss?”

c. “Sexual health should only be discussed with your physician”

d. “We can’t talk about sexual health unless your partner is here too”

“Many clients who experience a cancer diagnosis have concerns about sexual health. Are there concerns that you’d like to discuss?

What types of stressors can one experience?

1. Physiological (physical)

a. Injury or illness (trauma)

2. Psychological (emotional)

a. Event, situation, condition (work, academic pressures, financial difficulties)

Acute vs. Chronic Stress

1. Acute: short term

• MVA, loss of a love one

2. Chronic: unrelenting serious life problem

• Poverty, racism, illness, etc.

Alarm stage of GAS

Fight or flight: release of hormones(epi, norepi, and cortisone).

• ↑ BP, HR, blood glucose levels, oxygen intake, mental alertness, and blood flow to muscles. Pupil dilation. Reduction of pain receptors.

  Immune Response: Prolonged stress changes the immune system because of cortisol resulting in impaired immune

When does an individual move from the alarm stage to the resistance stage?

When the stressor is a severe threat or prolonged duration

PNS tries to return body back to homeostasis. What do we see in the body?

Normalization of hormones, heart rate, blood pressure and cardiac output. Body repairs damage.

When does the exhaustion stage occur?

Continuous stress leads to body unable to maintain response to the stressor and cannot adapt

Chronic stress and elevated endocrine response leads to..

Excessive wear and tear on body organs and long term complications

■ HTN, depression, anxiety, anger, addiction, sleep deprivation, etc.

Immune Response:

Prolonged stress changes the immune system because of cortisol resulting in impaired immune function

Post-Traumatic Stress Disorder

• Prolonged & heightened stress following a traumatic event

  • Months to years

• Causes

  • Accident, sexual abuse, natural disaster, war, etc.

Symptoms of PTSD

● Recurring and intrusive memories or flashbacks of the trauma

● Nightmares

● Increased heart rate

● Startled by experiences that remind them of the traumatic event

● Anger, Avoidance

PTSD interventions

● Therapeutic relationship

● Active listening

● Safe environment

● Positive coping strategies

● Connect with mental health NP, psychiatrist, social worker

What is a Crisis?

● Threatening situation resulting in strong behavioral, emotional, or psychiatric response.

● Traumatic injury, natural disaster, loss of financial security, death of family or friend, etc.

● Severity can vary - severe = sucide risk or harm of others

How do I know a crisis is happening?

Perform assessment: suicide or homicidal risk, drug and alcohol use, need for medical attention, ineffective coping strategies, protective factors, support systems

What to do during a crisis as a nurse

• Maintain therapeutic nurse-client relationship

  • How?

• Explore past coping strategies

• top priority: patient safety

Nursing Interventions for Crisis or Suicide Risk

● Patient safety is our top priority

● Constant supervision (even in bathroom, shower, etc.)

● Room safety - no cords, sharp objects, no personal items, etc.

● Call provider for psychiatric consult

● Follow your facility policy

Nursing Role: Clients Experiencing Stress

● Establish trust and safe environment

● Use therapeutic communication

● Active listening, open-ended questions, etc.

● Comprehensive assessment related to stress and symptoms

Stress and Coping: Variations Among older adult clients

● Life experiences make problems seem insignificant

● Often use prayer and religious practices for coping

● Higher incidence of depression

● Long term care - risk for social isolation and loneliness

What should the nurse consider with stress and coping with different cultures

● It varies

● Identify individual cultural practices related to stress management

● Identify resources in their culture to help with coping

What kind of stress and stressors might the nurse experience?

• Secondary traumatic stress

  • Symptoms - intrusive nightmares and anxiety

• Situational factors - high-acuity loads, job environment, and intensity of care

• Burnout: perceived demands outweigh perceived resources

  • Symptoms - irritable, restless, and unable to engage with patients

  • Can lead to depersonalization of client care

Describe spirituality

- Unique to each person

- Sense of, and awareness of one’s inner self and connection to a higher power or purpose

- Spirituality is expressed through beliefs, values, traditions, and practices

- It is broader than religion and culture, but is influenced by both

What is Spiritual Health?

- A purposeful life, transcendence, and actualization of different dimensions of the human experience

- Balance between a person’s values, goals, beliefs, and relationships within themselves and others

- Connection

• Self, others, God, nature

- Influences how a person responds to times of stress, illness, or loss

Why is Spiritual Health important?

- Help you cope with medical diagnosis and treatment

- Decrease anxiety, stress, anger, and depression

- Increase the quality of your life

- Enhance feelings of inner peace and hope

Factors Influencing Spirituality

• spiritual distress

• acute illness

• chronic illness

• terminal illness

• near-death experience

What can nurses do to support Spiritual Health for patients and families?

1. Nurses need to be aware of their own spirituality to provide appropriate and relevant spiritual care to others

2. Conduct spirituality or spiritual health assessments to identify strengths

   • FICA (Faith, Importance, Community, Address)

   • Spiritual well-being scale (SWB)

3. Take a patient-centered approach to spiritual health

definition of FICA

F: Faith and belief

I: Importance

C: Community

A: Address in Care

Which of the following is the most appropriate intervention to support a patient’s spiritual well-being?

a. Spend time with the patient to obtain a spiritual assessment

b. Ask the patient’s family about their spiritual practices

c. Write a referral to a professional spiritual care advisor

d. Share your spiritual and religious preferences with the

patient

Spend time with the patient to obtain a spiritual assessment

Explain the effect of rest and sleep in maintaining physical and mental health.

Physical:

● Slowed reflexes

● Blurred vision

● Fine-motor clumsiness

● Trouble thinking or concentrating

● Decreased reasoning and judgment

● Decreased auditory and visual alertness

● Cardiac arrhythmias

Mental:

● Mood effects

• Irritability

• Depression

• Anxiety

● Confusion and disorientation

● Increased sensitivity to pain

● Agitation or hyperactivity

● Decreased motivation

What happens if we don’t get enough sleep?

• Disruption in glucose metabolism

• Disruption in cortisol regulation

• Circadian rhythm disruption

• Decreased cellular immunity

• Increased risk for long term sleep difficulties

• Increased risk for chronic conditions and mood disorders

Explore nursing interventions that promote rest and sleep

• Stick to a sleep schedule

• Engage in something relaxing if you cannot fall asleep easily

  • Reading

  • Listen to soothing music

  • Deep breathing

• Pay attention to eating and drinking

  • Not too hungry

  • Not too full

  • Avoid large meals

  • Avoid nicotine, caffeine, alcohol at least 4-6 hours before bed

• Modify the environment

  • Cool, dark, and quiet at bedtime

  • increase amount of light during the day to sync Circadian Rhythm

  • Avoid screen time before bed

  • Consider earplugs

• Calm your mind before bed

• Exercise during the day (5-6 hrs before bed) and spend time outside - avoid exercising before bed

• Eliminate the underlying cause of sleep disruption whenever possible

• Talk to a healthcare provide

How does the lack of sleep affect adults?

↑ risk of falls

↑ risk of dementia

↑ risk for depression

↓ ability to manage chronic conditions

What is Nacrolepsy?

Chronic disorder characterized by sudden sleepiness and sudden periods of sleep.

• Two types:

  • Narcolepsy with cataplexy (NT1)

  • Narcolepsy without cataplexy (NT2)

Signs/symptoms of narcolepsy

• Difficulty staying awake, daytime sleepiness even with adequate sleep Nocturnal hallucinations

• Vivid dreams

• Paralysis while asleep - REM sleep occurs within 15 minutes

• Cataplexy

Narcolepsy diagnosis and treatment:

• Dx: Overnight sleep study (polysomnography) and clinical history

• Treatment: behavioral + pharmacologic

  • Psychological counseling

  • Short naps and adequate sleep at night

  • Wakefulness-promoting medications → Use the Epworth Sleepiness Scale to monitor progress/response

Epworth Sleepiness Scale

Measures the patient’s perception of their chances of “dozing off” or falling asleep during various activities

○ Scored from 0-24

■ 0-5 = Lower normal daytime sleepiness

■ 6-10 = Higher normal

■ 11-12 = Mild Excessive

■ 13-15 Moderate Excessive

■ 16-24 Severe Excessive

Polysomnography

● Used to diagnose sleep disorders

● Monitors sleep stages and cycles to detect disruptions and causes of disruption

● Includes measurement and monitoring of:

○ Brain waves

○ SpO2

○ Heart rate

○ Breathing patterns

○ Eye and leg movements

Nursing Interventions for Narcolepsy

• Nursing diagnoses

  • Anxiety r/t fear of lack of control over falling asleep

  • Disturbed Sleep Pattern r/t uncontrollable desire to sleep

  • Risk for Physical Trauma r/t potential for falling asleep during dangerous activity

• Lifestyle modifications and interventions

  • Planned daytime naps less than 20 minutes

  • Regular exercise program

  • Good sleep habits

  • Light meals high in protein

  • Practicing deep breathing

• Multidisciplinary/Medical interventions

  • Wakefulness-promoting agents or stimulant medications

  • Antidepressant medications to help suppress cataplexy

What is Insomnia?

Inability to get restorative sleep due to difficulty falling asleep or difficulty staying asleep

May be acute (a few days or weeks, but not longer than 3 months) or chronic (at least 3 days per week for more than 3 months)

Signs/symptoms of insomnia

• Trouble falling asleep or staying asleep

• Early waking

• Fatigue, impaired memory, irritability

• Higher levels of cortisol, or more sensitive to cortisol

• Reduced levels of estrogen and progesterone

Insomnia treatment

• Reducing alcohol, caffeine, nicotine

• Creating a calm environment and using the bed only for sleep

• Eye covers or ear plugs

• Don’t force sleep! If not asleep after 20 minutes, leave the bed and engage in a calming activity

• Cognitive Behavioral Therapy

• Medication (melatonin agonists, non-benzo sedatives such as Trazodone, antidepressants, benzos)