NSG 1050 - Module 4 flashcards

Personal hygiene influences patients’ comfort, safety, and well-being. Hygiene includes cleaning and grooming activities that maintain personal body cleanliness and appearance. 

However physical or cognitive impairments and emotional challenges often cause individuals to need some degree of assistance with hygiene care.

Critical thinking applied with clinical judgement… implement patient-centered care

When implementing hygiene, it is important to use your time with your patents as an additional opportunity to completely assess for and identify skin and musculoskeletal abnormalities and any self-care deficits related to hygiene. 

The Skin

The skin serves several functions, including protection, secretion, excretion, body temperature regulation, and cutaneous sensation

The epidermis (outer layer) shields underlying tissues against water loss and injury, prevents entry of disease-producing microorganisms, and generates new cells to replace the dead cells that are continuously shed from the outer surface of the skin.

Hygiene practices frequently influence skin status and can have beneficial and negative effects on the skin.

The oral cavity

Medications, exposure to radiation, dehydration, and mouth breathing may impair salivary secretion in the mouth, which increases the patient’s risk for xerostomia, or dry mouth.

Regular oral hygiene helps to prevent gingivitis (i.e., inflammation of the gums) and dental caries (i.e., tooth decay produced by interaction of food with bacteria).

When providing hygiene, the eyes, ears, and nose require careful attention because of sensitive anatomical structures.

Nursing knowledge base

Since no two individuals perform hygiene care in the same manner, you must individualize care based on assessing your patient’s unique hygiene practices and preferences. 

Be aware that developmental changes also influence the need and preferences for types of hygiene care. 

Social practices

Social practices influence a person’s hygiene preferences and practices, including the type of hygiene products used and the nature and frequency of personal care practices.

Personal preferences

Patient’s have individual preferences about how and when to perform hygiene and grooming care. 

Knowing patient’s personal preferences and cultural practices promotes individualized care.

Body image

Body image is a person’s subjective concept of their body, including physical appearance, structure, or function.

Cultural aspects of care 

Hygiene practices

Provide your patient with a culturally congruent plan

• Maintain privacy, especially for women… provide gender-congruent caregivers as requested

• Collaborate with community leaders

• Allow family members to participate

• Cultural practices that may affect the timing of hygiene activities

• Different cultural backgrounds have differing preferences regarding touch and personal space

• Do not cut or shave hair without prior discussion with the patient or family

• Toiling practices vary by culture

• Preferences about hot and cold water.

Socioeconomic status

A person’s economic resources influence the type and extent of hygiene practices used.

Health beliefs and motivation

Knowledge about the importance of hygiene and its implications for well-being influences hygiene practices.

Patient perceptions of the benefits of hygiene care and the susceptibility to and seriousness of developing a problem affect the motivation to change behavior.

Cultural variables

Cultural beliefs, religious practices, and personal values influence hygiene care

Avoid expressing disapproval or forcing changes in hygiene practices unless the practices affect a patient’s health. In these situations, use tact, provide information, and allow choices.

Developmental stage

The normal process of aging affects the condition of body tissues and structures

Skin

The neonate’s skin is relatively immature at birth… Handle a neonate very carefully during bathing.

The condition of the adult’s skin depends on bathing practices and exposure to environmental irritants.

Too-frequent bathing and bathing with hot water or harsh soap cause the skin to become excessively dry

Feet and nails

Foot health is a key component to a person’s mobility, health, and overall well-being.

Foot problems may be overlooked and impact a patient’s comfort, mobility, and quality of life.

The mouth

Healthy eating patterns and dental care. Avoiding fermentable carbohydrates and sticky sweet helps to keep the teeth free of dental caries. In addition, regular brushing (twice a day) and flossing reduce caries and periodontal disease.

Eyes, ears, and nose.

Hygiene of sensory structure must be provided in a way to prevent injury to sensitive tissues such as the cornea of the eye and the internal ear canal.

Physical condition

Sensory deficits alter a patient’s ability to perform care. However decreased sensation also places a patient at risk for pressure or thermal injuries.

However, be aware that sedation and drowsiness associated with analgesics used for pain management may also limit a patient’s ability to safely participate in care.

When people with cognitive impairments are unaware of their hygiene and grooming needs, they may become fearful and agitated during hygiene care, resulting in aggressive behavior.

Critical thinking

The care of any patient who requires complete hygiene care is complex.

Sound clinical judgements require you to consider a patient’s condition, anticipate any risks or problems, gather thorough assessment data, and then analyze data to form nursing diagnoses.

Comfort, rest, and sleep ATI

RNs and PNs. PNs be able to contribute to the plan of care depending on the state’s laws. PNs almost always act under the authority of RNs.

Sleep is essential for all body systems to function properly because of the rejuvenation that sleep provides.

May need to provide interventions so that patients get proper sleep to become properly healed.

Brain has 4 main regions including the cerebrum, cerebellum, diencephalon, and brainstem. 

Cerebral cortex covers the cerebrum, which controls sensory and facilitates memories to long term memory. 

Brainstem contains midbrain, pons, and medulla oblongata. Midbrain controls many motor functions.

Diencephalon controls temperature and ANS. Above the brainstem, between cerebral hemispheres. Contains: thalamus, hypothalamus, and pineal gland. 

Thalamus = sensory info, regulate sleep

Hypothalamus = control center for autonomic motor system. (suprachiasmatic nucleus is located inside. Assists in circadian rhythm regulation)

Hypocretin is a hormone produced in the hypothalamus and is responsible for maintaining alertness.  Narcolepsy (NT1) with cataplexy is caused by a lack of hypocretin.

Pineal gland = melatonin production

Physiology of sleep

Two internal biological mechanisms

Circadian rhythm = Natural internal process that regulates the sleep-wake cycle within a 24 hour period.

Sleep-wake homeostasis = Assists the body to remember to sleep after a given time.

Things that affect sleep-wake rhythm: Bright lights (can affect circadian rhythm), medications, caffeine, foods, sleep, environment, and stress.

Brain structures that are involved in sleep regulation: hypothalamus, suprachiasmatic nucleus (SCN), brainstem, thalamus, and pineal gland.

Hypothalamus = affect sleep and arousal

SCN (inside hypothalamus) = behavioral rhythm directly from eyes. (Can be disturbed to disrupt sleep.)

Brainstem(BS) sends signals to the hypothalamus. 

BS contains pons and medulla = Influence REM sleep

Sleep-promoting cells produce gamma-aminobutyric acid (GABA) reduces the activity of arousal centers.

Short term memory (STM) = Ability to recall information for a short time

Long term memory (LTM) = Ability to recall information for an indefinite time.

Thalamus transfers info to the cerebral cortex to process from STM to LTM. (Also influences the content of dreams).

Pineal glands produce melatonin. 

Melatonin = Hormone that regulates the sleep-wake cycle.

Sleep has many benefits!!! SO SLEEP!!!

Stages of sleep

REM or NREM. Approximately 4-6 times per night.

REM has dreams, low muscle tone.

Electroencephalogram (EEG) is used to read brain waves

Rapid eye movement (REM) = Rapid movement of the eyes accompanied by low muscle tone associated with the dream stage of sleep.

Electroencephalogram (EEG) = Measurement of the brain’s electrical activity.

Wake stage (NREM) is the first stage of sleep. Alpha and beta waves.

Alpha waves = Electrical brain waves in the frequency range of 8-12 hertz.

Beta waves = Electrical brain waves in the frequency range of 12-30 hertz.

Stage 1 (NREM) of the sleep cycle is the lightest stage of sleep. It begins when greater than 50% of the alpha waves are exchanged for low-amplitude, mixed-frequency activity. Stage 1 can last from 1 to 5 minutes and accounts for approximately 5% of the total sleep cycle.

Stage 2 (NREM) is a deeper sleep. It is characterized by sleep spindles (sluggish spindles that are different in length) or K-complex (brief delta waves).... The first sleep cycle of stage 2 lasts for approximately 25 minutes, but become progressively longer with each successive sleep cycle. Stage 2 consumes approximately 50% of a total sleep cycle.

Stage 3 (NREM) is the deepest sleep. It is characterized by delta waves, electrical brain waves that have a slow wave frequency and high-amplitude signal…. As clients age, they have fewer stage 3 cycles and more stage 2 cycles. Stage 3 is very deep sleep and lasts up to 40 minutes.

REM is the dreaming stage. This stage appears like an awake cycle on an EEG, as it also consists of beta waves…. The initial cycle lasts 10 minutes, then becomes longer as the night progresses. This stage can last up to 1 hour. As clients age, they have fewer REM cycles.

Summary:

Stage 1

Non-rapid eye movement (REM) sleep

Breathing remains regular and muscle tone is present

Body temperature starts to decrease

5% of a person’s total sleeping time

Stage 2

Non-REM sleep

50% of a person’s total sleeping time

No eye movements detected, heart rate and breathing decreases, and muscles relax

Stage 3

Non-REM sleep

The brain activity, through an EEG, shows the delta wave

Body’s short-term hibernation period

Immune system strengthens

Muscles and tissues relax

15% of a person’s total sleeping time

Stage 4

REM sleep

The heart rate and blood pressure increase

Muscle mobility and body temperature decrease further

Brain activity, as noted in an EEG, increases

20% to 25% of a person’s total sleeping time

The wake stage is the first stage of sleep and is characterized by alpha and beta electrical waves. Stage 1 is the lightest stage of sleep. In stage 2, heart rate and body temperature decrease. Stage 3 is characterized by delta waves. In stage 4 (REM), breathing is irregular, and the heart rate can become elevated.

According to the CDC, recommended hours of sleep for each age are as follows:

Newborns (birth to 3 months): 14 to 17 hours

Infants (4 months to 1 year): 12 to 16 hours

Toddlers (1 to 2 years): 11 to 14 hours

Preschool (3 to 5 years): 10 to 13 hours

School-age children (6 to 12 years): 9 to 12 hours

Adolescents (12 to 18 years): 8 to 10 hours

Adults (18 to 60 years): 7 or more hours

Adults (61 to 64 years): 7 to 9 hours

Adults (65 years or older): 7 to 8 hours

Individuals who perform shift work are at an increased risk for developing health conditions, including diabetes mellitus, obesity, and cardiovascular disease.

During sleep, the body repairs muscles, tissue, and bones and strengthens the immune system. Sleep helps prevent weight gain by decreasing production of ghrelin (the hunger hormone) and leptin (the decreasing-hunger hormone). Sleep also helps reduce the risk of type 2 diabetes by lessening the release of cortisol (the stress hormone): Increased levels of cortisol make it difficult for insulin to move sugar into cells.

sleep deprivation

When the body does not meet its biological sleep requirement, either chronically or acutely.

Nurses can assist clients by teaching and reinforcing the use of the following nonpharmacologic interventions to improve sleep:

1. Avoid stimulants, such as caffeine, alcohol, and nicotine, at least 4 to 6 hours before bedtime.

2. Remove any unnecessary light and noise; substitute calming white noise if necessary.

3. Establish a bedtime routine, such as taking a warm shower or bath before bedtime.

4. Keep the room dark, quiet, and at a comfortable, cold temperature.

5. Only go to bed when tired. If the client feels restless while attempting to sleep, they should go to another room and do a simple activity like reading or listening to preferred music.

6. Keep a consistent sleep–wake cycle by going to bed and waking at the same time, which allows the body to fall into a biologic rhythm.

7. Keep naps short, less than 30 minutes.

8. Engage in a regular exercise routine, along with healthy eating; complete exercising at least 3 hours before going to bed.

9. Remove all work items and televisions from the bedroom when possible. The bedroom should be associated with sleep and sexual activity only.

sensory overload

Receiving stimuli at a rate and intensity beyond the brain's ability to process the stimuli in a meaningful way.

Menopause is a common cause of sleep disturbances. Approximately 46% to 48% of menopausal women report sleeping difficulties, and at least 38% of perimenopausal women experience this challenge.

The nurse should identify that the client is exhibiting manifestations of narcolepsy (NT1). Narcolepsy (NT1) is a chronic sleep condition that is characterized by sudden sleepiness and sudden periods of sleep accompanied by cataplexy, or episodes of involuntary loss of muscle tone brought on by strong emotions, such as laughter. Clients who have narcolepsy (NT1) with cataplexy lack hypocretin in their central nervous system. Clients who have both NT1 and NT2 narcolepsy might experience nocturnal hallucinations, paralysis while asleep, and vivid dreams.

Narcolepsy is a chronic sleep condition that is characterized by sudden sleepiness and sudden periods of sleep. Clients who have narcolepsy (NT2) have difficulty staying awake. However, these clients do not experience involuntary episodes of lost muscle tone.

insomnia

Ongoing inability to sleep despite having the opportunity to sleep.

Central sleep apnea (CSA) is the result of reduction of the brain's transmission of signals to the respiratory muscles. This results in the cessation of breathing and is commonly caused by opioid overdose and heart failure.

central sleep apnea (CSA)

The reduction of the brain's transmission to the respiratory muscles resulting in the cessation of breathing.

obstructive sleep apnea (OSA)

Recurrent episodes of upper airway collapse and obstruction while sleeping combined with waking from sleep.

polysomnography

A test that documents heart rate, blood pressure, breathing, oxyhemoglobin saturation, brain wave patterns, body movements, and snoring patterns.

narcolepsy

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

The nurse should recommend including that hypersomnia is characterized by excessive daytime fatigue that does not improve if the client receives additional sleep.

hypersomnia

A disorder of excessive daytime fatigue without improvement after more sleep.

Restless legs syndrome (RLS), also called Willis-Ekbom disease, is an uncontrollable urge to move the legs, which is often accompanied by an uncomfortable sensation…. Avoiding caffeine, nicotine, and alcohol may help control RLS symptoms.

Pain can be caused by a client’s emotional state or actual or potential damage to tissues, whereas comfort is defined as obtaining relief from pain, negativity, and emotional and physical distress.