UR 220 Comprehensive Final Exam Study Guide

Nursing Interventions for Sleep and Sleep Hygiene

  • Assessment Requirements: Before implementing interventions, nurses must assess the following particulars of a patient's sleep history:     * Total number of hours slept daily.     * Specific difficulties including falling asleep, staying asleep, or waking up too early.     * The sleep environment.     * Current pain levels.     * Levels of anxiety and stress.     * Caffeine, alcohol, and medication intake.     * Napping habits.

  • Treatment of Underlying Causes: The primary nursing priority is to treat the root cause of sleep disturbance first. Examples include:     * Pain: Manage with analgesics.     * Dyspnea: Improve oxygenation.     * Anxiety: Implement reduction techniques.

  • Bedtime Routines: Encourage a consistent routine to regulate circadian rhythms, including the same bedtime and wake-up time each night. Examples of relaxation exercises for routines include reading, warm baths, soft music, and relaxation exercises.

  • Environment Management: Promote a quiet environment by closing doors, dimming lights, silencing alarms when appropriate, and reducing bright lights.

  • Cluster Nursing Care: Organize and perform all nursing tasks at once to minimize interruptions and prevent waking the patient.

  • Pain Management Prior to Sleep: Because pain is a leading cause of insomnia, nurses should assess pain, administer prescribed analgesics before bedtime, reposition the patient, and apply heat or cold as ordered.

  • Relaxation Techniques:     * Deep Breathing: Slow inhalation through the nose and slow exhalation through the mouth.     * Progressive Muscle Relaxation: Systematically tensing and kemudian relaxing specific muscle groups.     * Guided Imagery: Visualizing a peaceful location.     * Meditation: Utilized to decrease anxiety.

  • Stimulant Restriction: Avoid coffee, energy drinks, chocolate, and tea, particularly after noon. Caffeine can remain in the body for 6−86-8 hours.

  • Dietary Factors: Avoid large meals before bed as they cause GERD and indigestion. A light snack, such as crackers, warm milk, or a banana, is acceptable.

  • Activity and Napping:     * Encourage exercise during the day to improve sleep quality, but avoid vigorous exercise immediately before bedtime.     * Limit daytime naps to 20−3020-30 minutes and avoid long naps late in the day.

  • Hospitalized Patient Interventions: Specific actions include offering earplugs, controlling room temperature, and adjusting comfort measures.

Sleep Requirements Across the Lifespan

  • Newborn (Birth to 3 Months): Requires 14−1714-17 hours per day; sleep is spread throughout the day and night with no established pattern.

  • Infant (4 to 12 Months): Requires 12−1612-16 hours per day, including naps. Nighttime awakening may be caused by separation anxiety.

  • Toddler (1 to 3 Years): Requires 11−1411-14 hours per day. This group often resists bedtime and may begin experiencing nightmares; they usually require one daytime nap.

  • Preschooler (3 to 5 Years): Requires 10−1310-13 hours per day. Common issues include fear of darkness and imaginary creatures; nightmares are more common than night terrors.

  • School-Age Child (6 to 12 Years): Requires 9−129-12 hours per day. Sleep disruption is often related to school stress or electronic device use.

  • Adolescent (13 to 18 Years): Requires 8−108-10 hours per day. Chronic sleep deprivation is common due to electronics and school schedules. Growth hormone is released during deep sleep.

  • Adult (18 to 64 Years): Requires 7−97-9 hours per day. Sleep is affected by stress, work, caffeine, and alcohol.

  • Older Adult (65+ Years): Requires 7−87-8 hours per day. Aging results in falling asleep and waking up earlier, more frequent awakenings, and less deep sleep. Confusion and excessive daytime sleepiness are not normal.

Stages of Sleep and Sleep Disorders

  • Normal Sleep Stages:     * NREM Stage 1 (N1): Light sleep; transition from awake to asleep; easily awakened.     * NREM Stage 2 (N2): Longest stage of sleep; heart rate slows and body temperature drops.     * NREM Stage 3 (N3): Deep sleep; crucial for tissue repair, immune restoration, and growth hormone release. Sleepwalking, bedwetting, and night terrors occur in this stage.     * REM Sleep: Rapid eye movements; dreaming occurs; memory consolidation. Nightmares occur here and are usually remembered.

  • Insomnia: Characterized by difficulty falling or staying asleep and daytime fatigue. Managed through sleep hygiene, relaxation, and Cognitive Behavioral Therapy (CBT).

  • Sleep Apnea: Characterized by loud snoring, witnessed apnea, and morning headaches.     * Risk Factors: Obesity, large neck circumference, smoking, and male sex.     * Treatment: Weight loss is the biggest modifiable factor; CPAP (first-line treatment) or BiPAP.     * Complications of Untreated Apnea: Hypertension, stroke, heart failure, and dysrhythmias.

  • Sleep Deprivation: Caused by stress, pain, or frequent interruptions. Results in irritability, poor concentration, delayed reaction time, and impaired judgment.

Pain Classification and Management

  • Somatic Pain: Originates from skin, muscles, bones, joints, or connective tissues. It is well-localized, sharp, aching, or throbbing. Patients can point directly to the pain.

  • Visceral Pain: Originates from internal organs (viscera). It is poorly localized, deep, dull, cramping, or pressure-like. Examples include appendicitis, gallbladder disease, and kidney stones.

  • Referred Pain: Pain felt in a location different from the source (e.g., myocardial infarction felt in the jaw/neck/left arm; gallbladder disease felt in the right shoulder).

  • Neuropathic Pain: Caused by nerve damage; described as burning, tingling, shooting, or electric shock-like. Often treated with Gabapentin or Pregabalin rather than opioids.

  • Acute vs. Chronic Pain:     * Acute Pain: Lasts less than 3−63-6 months. Protective warning sign with sudden onset. Triggers the sympathetic nervous system: increased Blood Pressure (BP), Heart Rate (HR), and Respiratory Rate (RR); dilated pupils and diaphoresis.     * Chronic Pain: Lasts longer than 3−63-6 months. No protective purpose. Vital signs (BP, HR, RR) are often normal due to adaptation. Symptoms include fatigue, depression, and social withdrawal.

  • Pain Influencing Factors:     * Modifiable: Anxiety, stress, sleep deprivation, fear, depression, and activity level.     * Non-Modifiable: Age, genetics, gender, culture/ethnicity, and previous pain experiences.

  • Pain Assessment Scales:     * FLACC: (Face, Legs, Activity, Cry, Consolability) For infants, toddlers, or nonverbal/mute patients.     * FACES (Wong-Baker): For children aged 3+3+ and those with language barriers.     * Numeric Rating Scale (NRS): 0−100-10 scale for adults and older children.     * Verbal Descriptor Scale: Helpful for older adults who struggle with numbers.

  • Pharmacological Management:     * Nonopioids: Acetaminophen (Liver toxicity risk; maximum dose 4000 mg/day4000\,mg/day) and NSAIDs (GI bleeding and kidney injury risk).     * Opioids: Morphine, Hydromorphone, Fentanyl. Side effects include respiratory depression (RR < 12/min is a counter-indicator), sedation, and constipation.     * Antidote: Naloxone for opioid overdose.     * Patient-Controlled Analgesia (PCA): Allows patient self-administration; only the patient may press the button.

  • Non-Pharmacological Management:     * Cold Therapy: For acute injuries, swelling, and inflammation (first 24−4824-48 hours).     * Heat Therapy: For muscle spasms, arthritis, and joint stiffness.     * Repositioning: Every 2 hours2\,hours to mitigate musculoskeletal or postoperative pain.

Sensory Pathway and Age-Related Changes

  • Sensation Pathway: Receptor Stimulation → Afferent Nerve (Sensory/Arrives) → Spinal Cord (Dorsal Root) → Brain (Thalamus/Cortex) → Efferent Nerve (Motor/Exits).

  • Age-Related Sensation Changes:     * Vision: Decreased acuity, night vision, and adaptation to darkness.     * Hearing: Presbycusis (loss of high-pitched sounds).     * Touch: Decreased sensitivity to temperature (increased burn risk).     * Taste/Smell: Decrease in taste buds and olfactory sense (nutritional risk).

  • Visual Deficits:     * Myopia: Nearsightedness (can see near).     * Hyperopia: Farsightedness (can see far).     * Presbyopia: Age-related loss of lens elasticity; difficulty seeing close objects or small print.     * Astigmatism: Irregular cornea curvature causing blurred vision at all distances.     * Cataracts: Cloudy lens.     * Glaucoma: Loss of peripheral vision. Angle-closure is an emergency (severe pain, halos).     * Macular Degeneration: Loss of central vision.

  • Hearing Screening:     * Whisper Test: Bedside screening.     * Audiometry: Gold standard measuring decibels (dBdB).     * Weber Test: Sound should be heard equally in both ears.     * Rinne Test: Normal is Air Conduction (AC) > Bone Conduction (BC).     * Conductive Hearing Loss: Physical obstruction (wax, infection). Reversible.     * Sensorineural Hearing Loss: Permanent damage to inner ear or CN VIII. Caused by noise or ototoxic drugs (Gentamicin, Furosemide).

Developmental Theories

  • Erikson’s Psychosocial Stages:     * Birth–1 year: Trust vs. Mistrust.     * 1–3 years: Autonomy vs. Shame & Doubt (Toddlers love saying "No!").     * 3–6 years: Initiative vs. Guilt (Preschoolers learn through play).     * 6–12 years: Industry vs. Inferiority (School-age children value success).     * 12–18 years: Identity vs. Role Confusion (Peers are priority).     * 18–40 years: Intimacy vs. Isolation.     * 40–65 years: Generativity vs. Stagnation.     * 65+ years: Integrity vs. Despair (Reminiscence therapy).

  • Piaget’s Cognitive Theory:     * Birth–2 years: Sensorimotor (Object permanence: knowing objects exist when hidden).     * 2–7 years: Preoperational (Magical thinking, egocentrism; may think illness is punishment).     * 7–11 years: Concrete Operational (Logical thinking, understands conservation).     * 12+ years: Formal Operational (Abstract thinking, hypothetical scenarios).

  • Types of Play:     * Infant: Solitary play.     * Toddler: Parallel play (plays beside others).     * Preschooler: Associative play (shares toys, no organized rules).     * School-Age: Cooperative play (games with rules, teamwork).

Family-Centered Care and Psychosocial Concepts

  • Approaches to Family:     * Family as Context: Focus on individual patient; family is a factor in their health.     * Family as Client: Focus on the entire family as the recipient of care.     * Family as System: Focus on interconnectedness; change in one member affects all.     * Family as Component of Society: Focus on family as a unit within the community.

  • Family Structures: Nuclear, Extended, Blended (step-parents), Skip-Generation (grandparents raising kids), Cohabiting (unmarried adults).

  • Role Concepts:     * Role Conflict: Difficulty meeting expectations of two or more roles (e.g., mom misses child's birthday for work).     * Role Strain: Difficulty meeting expectations of one single role.     * Role Ambiguity: Unclear expectations.     * Role Overload: Too many responsibilities at once.

  • Grief and Loss:     * Stages (Kubler-Ross): Denial, Anger, Bargaining, Depression, Acceptance (DABDA).     * Anticipatory Grief: Occurs before the actual loss.     * Complicated/Dysfunctional Grief: Prolonged, intense, interferes with life (3+3+ years).     * Disenfranchised Grief: Not socially recognized (e.g., miscarriage, death of ex-spouse).

  • Defense Mechanisms:     * Sublimation: Healthy conversion of feelings to acceptable activities (e.g., exercise for anger).     * Regression: Returning to earlier behaviors (e.g., hospitalized child bedwetting).     * Displacement: Redirecting anger to a safer target (e.g., yelling at a nurse).     * Repression: Unconscious blocking.     * Suppression: Conscious choosing to ignore.

Health Assessment and IV Therapy

  • Priority Assessment Findings (Report Immediately): Stridor, sudden confusion, unilateral weakness, chest pain, O2O_2 saturation < 90\%, absent pulses, rigid abdomen, calf pain/swelling (DVT).

  • Vial Medication Preparation:     * Perform 33 medication checks.     * Inject air into the vial equal to the medication dose (2 mL2\,mL dose = 2 mL2\,mL air).     * Draw clear insulin (Regular) before cloudy (NPH) if mixing.

  • IV Complications:     * Infiltration: Cool, pale, swollen site. Stop infusion and elevate.     * Phlebitis: Warm, red, painful/tender site. Stop infusion and apply warm compress.     * Extravasation: Vesicant leaks causing blister/necrosis. Emergency.     * Air Embolism: Sudden dyspnea/chest pain. Place on left side in Trendelenburg.     * Fluid Overload: Crackles, dyspnea, JVD, bounding pulse.

  • IV Piggyback (IVPB): Secondary bag must hang HIGHER than the primary bag.

Fluid, Electrolytes, and Acid-Base Balance

  • Daily Weight: The most reliable indicator of fluid status (1 kg/2.2 lb=1 L1\,kg/2.2\,lb = 1\,L of fluid).

  • Dehydration Indicators: Dry mucous membranes, poor skin turgor, tachycardia, orthostatic hypotension, urine output < 30\,mL/hr.

  • Sodium (135−145 mEq/L135-145\,mEq/L): Affects neurological status (confusion, seizures).

  • Potassium (3.5−5.0 mEq/L3.5-5.0\,mEq/L): Affects the heart. Hypokalemia = Flat T waves. Hyperkalemia = Peaked T waves/cardiac arrest.

  • Calcium (8.6−10.2 mg/dL8.6-10.2\,mg/dL): Low calcium causes twitching and tetany (Chvostek's and Trousseau's signs). High calcium causes "stones, bones, groans" (kidney stones, bone pain).

  • Magnesium (1.5−2.5 mEq/L1.5-2.5\,mEq/L): Acts as a sedative. High levels cause respiratory depression and bradycardia.

  • Acid-Base Normal Values:     * pH:7.35−7.45pH: 7.35-7.45     * PaCO2:35−45 mmHgPaCO_2: 35-45\,mmHg     * HCO3−:22−26 mEq/LHCO_3^-: 22-26\,mEq/L

  • Respiratory Acidosis: Caused by hypoventilation (COPD, opioid overdose). CO2 is retained.

  • Metabolic Acidosis: Caused by DKA, renal failure, or severe diarrhea. Characterized by Kussmaul respirations (deep and rapid).

Pressure Injuries and Health Promotion

  • Pressure Injury Stages:     * Stage 1: Intact skin, non-blanchable redness.     * Stage 2: Partial-thickness loss, shallow ulcer or blister.     * Stage 3: Full-thickness loss, adipose (fat) visible.     * Stage 4: Full-thickness tissue loss, bone, tendon, or muscle visible.     * Unstageable: Covered by slough or eschar; depth cannot be determined.     * Prevention: Braden Scale (lower score = higher risk); protein-rich diet; turn every 2 hours2\,hours.

  • Incontinence Types: Stress (leakage with cough/sneeze - Kegels), Urge (sudden urge - bladder training), Overflow (retention/dribbling - BPH), Functional (mobility issues).

  • HPV Vaccine (Gardasil 9):     * Recommended for boys and girls ages 11−1211-12 (can start at 99).     * Protects against cervical, anal, and throat cancers.     * Schedule (<15 yrs): 2 doses at 00 and 6−126-12 months.     * Schedule (≥15 yrs): 3 doses at 00, 1−21-2, and 66 months.     * Nurse should monitor adolescents for 15 minutes15\,minutes after injection for syncope risk.

Questions & Discussion

  • Q: A patient says: "I cannot sleep because my incision hurts." What is the priority?     * A: Assess and treat the pain first rather than giving a sleeping pill.

  • Q: Patient receiving zolpidem at bedtime. Priority action?     * A: Implement fall precautions.

  • Q: Hospitalized patient wakes every hour because staff enters the room. Best intervention?     * A: Cluster nursing activities.

  • Q: Patient says: "Why is God doing this to me?" while grieving.     * A: Use therapeutic communication: "Tell me more about what you're feeling."

  • Q: Nursing student misses class to care for a sick child.     * A: This is an example of Role Conflict.

  • Q: A new mother feels overwhelmed caring for three children.     * A: This is an example of Role Strain.