NR226 Units 4, 5, and 6 Comprehensive Refresher

NR226 Comprehensive Refresher Notes

Units 4, 5, and 6 Overview

This refresher covers key concepts from NR226 Units 4, 5, and 6, including pain, sleep, aging, coping, perioperative nursing, and bowel elimination.

Functions of Sleep and Rest

Sleep and rest are essential for:

• Restoration of biological processes, including tissue renewal (cell division and protein synthesis).
• Recovery from illness.
• Memory consolidation.
• Mental relaxation.
• Preparation for wakefulness.
• Dreaming, which is important for learning, memory, and stress adaptation.
• Rapid eye movement (REM) sleep, crucial for early brain development, cognition, and memory.

Consequences of Sleep Deprivation

Lack of proper sleep and rest can lead to:

• Decreased ability to concentrate.
• Increased irritability.
• Decreased ability to make judgments.
• Increased confusion.
• Decreased ability to participate in daily activities.
• Increased risk for chronic diseases (hypertension, diabetes mellitus, obesity).
• Decreased body functionality (mood, motor performance, memory).
• Increased health care costs and hospitalization.
• Decreased immunity.
• Increased risk for motor vehicle and industrial accidents.
• Decreased metabolism.

Developmental Sleep Requirements

Neonates & Infants

• Sleep 15-16 hours per day.
• Approximately 50% is REM sleep, stimulating higher brain centers for development.
• Wake time is essential for significant external stimulation.

Toddlers

• Sleep 12 hours per day.
• Nighttime waking and decreasing REM sleep are common.
• Often resist bedtime due to their need for autonomy and separation anxiety.

Preschoolers and School-Age Children

• Require 9-12 hours a day, decreasing with age.
• Preschoolers may have difficulty relaxing for bedtime after a long day of activity.
• Bedtime fears, nightmares, crying, sleepwalking, or bed-wetting are not uncommon.
• Sleep requirements vary in school-age children and decrease with age.

Adolescents

• Often sleep less than 7 hours a night, but 8-10 hours are recommended.
• Reduced sleep is attributed to school demands, activities, and part-time jobs.
• Electronic devices in bedrooms can lead to poor sleep hygiene, excessive daytime sleepiness (EDS), and behavioral/mood issues.

Young and Middle Adults

• Require 6-9 hours a night.
• Stage N3 sleep declines with age, and insomnia becomes common due to adult stresses.
• Anxiety, depression, and physical illnesses contribute to poor sleep quality.

Older Adults

• Experience increased sleep difficulties with age.
• Spend less time in deep, REM sleep.
• More frequent periods of non-rapid eye movement (NREM) sleep occur.
• Takes longer to fall asleep.

Factors Affecting Sleep

• Physical illnesses, such as respiratory and/or heart disease, hypertension, nocturia, restless leg syndrome (RLS), and GI disorders.
• Age and/or developmental cycle.
• Medications and substance use disorder.
• Emotional stress.
• Environmental factors (home, hospital, long-term care facility).
• Lifestyle.
• Usual sleep patterns and pre-existing sleep disturbances.
• Exercise.
• Fatigue.
• Food and caloric intake.

Common Sleep Disorders

Insomnia

• The most common sleep disorder, involving chronic difficulty in getting to sleep, waking up frequently, and/or inadequate sleep quality.
• Commonly associated with depression and situational stress, but may signal an underlying disorder.
• Treatment includes assessing and improving sleep hygiene, relaxation, behavioral, and cognitive therapies.

Obstructive Sleep Apnea (OSA) and Central Sleep Apnea (CSA)

• Characterized by difficulty or inability to breathe during sleep due to a lack of airflow.
• Hypoxia and lack of deep sleep lead to insomnia and excessive daytime sleepiness (EDS), along with headaches, irritability, and depression.
• Untreated sleep apnea increases the risk for hypertension, diabetes, heart disease, and heart failure.
• Management includes treating the underlying cause and using devices to change airway pressure during sleep.

Narcolepsy

• Causes excessive daytime sleepiness (EDS) due to dysfunctional sleep and wake cycles.
• Characterized by sudden and overwhelming waves of sleepiness, causing the person to uncontrollably fall asleep.
• Patients reach REM sleep quickly and may experience cataplexy (sudden muscle weakness) triggered by intense emotions.
• Severe cataplexy may cause falls.
• Treatment includes medications and improving sleep hygiene.

Acute or Chronic Sleep Deprivation

• Results from sleep disorders, illness, emotional stress, medications, and/or environmental disturbances.
• Interrupted sleep impacts normal sleep cycles and leads to the accumulation of sleep deprivation.
• Manifested by physiological (decreased reflexes, blurred vision, cardiac arrhythmias) and psychological (confusion, agitation, apathy) symptoms.

Parasomnia

• Sleep issues seen more often in children, potentially caused by autonomic nervous system abnormalities.
• Includes somnambulism (sleepwalking), night terrors, sleep paralysis, nocturnal enuresis (bed-wetting), and nocturia.
• Treatment varies based on the issue; safety is a priority.

Interventions for Impaired Sleep

• Establish a routine.
• Avoid food/drink/vigorous activity/screens before bed.
• Create a soothing environment.
• Use low light and white noise.
• In the hospital, cluster care activities.
• Exercise during the day.

Pain

• Pain is subjective and often misunderstood and inadequately treated.
• Only the person experiencing the pain knows whether it is present and how intense it feels.
• A 0-10 or Faces self-report scale is the most accurate measurement of someone’s pain.

Factors Influencing Pain

• Social, cultural, spiritual factors, and previous experience with pain.
• Anxiety, stress, and fear can heighten pain.
• Poor coping skills.
• Sleep deprivation.

Acute Pain

• Acute pain is a transient, protective response that warns of injury or illness.
• Physiological responses include changes in vital signs, facial expressions, and vocal expressions.
• It is usually short but can threaten a client’s recovery. It can lead to prolonged hospitalization, exhaustion, immobility, pulmonary complications, and sleep deprivation.
• The person has difficulty concentrating on anything else but the pain until it is reduced to a manageable level.
• If not resolved, acute pain can lead to chronic pain.
• The primary nursing goal with acute pain is relief to a level that allows the client to participate in their recovery, prevent complications, and improve their functional status.

Physiological Responses to Acute Pain

The body's response to pain involves several physiological changes:

These responses are designed to prepare the body for action and reduce sensitivity to pain.

Chronic Pain

Psychological responses include social isolation, insomnia, and depression.

• Chronic (persistent) non-cancer pain is not protective and serves no purpose; it significantly impacts the person’s quality of life.
• It can be constant or recurrent, lasting beyond any acute illness or injury healing (longer than 3-6 months).
• It is a disease with its own pathology as the cause is not always known, but it is commonly associated with arthritis, low back pain, headaches, fibromyalgia, and peripheral neuropathy.
• The often unknown cause and lengthy duration mean that it can be difficult to treat, which can lead to job loss, self-care deficits, social isolation, depression, and even suicide.
• Symptoms associated with chronic pain can include mental and physical fatigue, insomnia, anorexia, weight loss, and anger.
• The primary nursing goal with chronic non-cancer pain is improved functional status with the encouragement of both non-pharmacological and pharmacological management in collaboration with a primary healthcare provider.

Factors Impacted by Pain

• Quality of Life and Daily Activities
  • Pain affects the ability to work, attend school, and interact socially.
  • It causes economic and social burdens.
  • The person may have depression, a change in eating habits, and sleep loss.
• Self-Care and Physical Limitations
  • Pain affects a person's activities of daily living (ADLs), such as shopping and house cleaning.
  • It causes limitations in physical activity, walking, participation in social activities, and independent living.
• Work
  • Performance at work and/or school decreases.
  • Absenteeism, job loss, or expulsion occur more often.
• Social Support
  • Family members and caregivers can be impacted by a person's pain due to isolation and lack of engagement.
  • Relationships decline.

Pharmacological Pain Management

• Pharmacological interventions can include the use of analgesics, anesthetics, opioids, and non-opioids (such as nonsteroidal anti-inflammatory drugs [NSAIDs]).
• If pain score is high, the patient may require medication first, then non-pharm measures.
• If pain is chronic, they may need a long-acting med in addition to a PRN for breakthrough pain.
• Patient-controlled analgesia (PCA) devices allow clients to control and self-administer a prescribed amount of medication on demand and maintain a steady plasma level of pain medication while avoiding delays in receiving the med when it’s needed. For severe and ongoing pain concerns.
• Will need to wean off IV and transition to oral; taper off to avoid withdrawal effects.
• Topical and transdermal analgesics: Topicals include creams, gels, sprays, and patch medications, such as non-steroidal anti-inflammatory drugs (NSAIDs) and lidocaine.
• Transdermal analgesic drugs are absorbed (typically from a patch applied away from the pain area) into the bloodstream over time and, therefore, have systemic effects. Nurses should always wear gloves when using these medications and avoid contact with sensitive areas such as the eyes. They should not be applied over wounds or on the face.

Non-Pharmacological Pain Management

• Self-management strategies: regular exercise, sleep hygiene and improvement techniques (pain typically impacts sleep and rest), herbals (under the prescriber's direction to avoid drug-herbal interactions), and nutrition practices.
• Adjunct therapies: acupuncture, massage, and chiropractic care.

Relaxation Techniques

• Guided imagery
• Yoga
• Music
• Distraction

Heat/Cold

• Use of heat and cold on an area of pain, depending on the type and location of the pain.
• The client should test the temperature of the heat or cold application before use.
• Cold can reduce pain caused by inflamed joints.
• Heat is typically effective for chronic pain.
• Do not use warm compresses or heat packs that have been warmed in a microwave unless directed by the manufacturer, as hot spots may cause burns.

Common Signs of Aging based on body systems:

Supportive Interventions for Older Adults

• Encouraging family visits and joining groups to address social isolation.
• Providing memory cues (clocks, calendars, and name tags) for addressing acute and chronic confusion.
• Compensating for sensory deficits (hearing and vision) by speaking slowly and clearly and allowing time to respond.
• The risk for dehydration and malnutrition (fluid volume deficit and nutrition, less than body requirements) increases when mobility is impaired and they can't reach beverages or feed themselves while in bed or connected to medical equipment.
• Older adults are at greater risk for dehydration and malnutrition during hospitalization because of standard procedures such as limiting food and fluids in preparation for diagnostic tests and medications that decrease appetite.

Cognitive Changes

Delirium

• Acute confusional state.
• Potentially reversible cognitive impairment.
• Occurs suddenly or worsens at night.
• Often has a physiological cause.
• Common: occurs in 20-70% of hospitalized patients.

Dementia

• An umbrella term (Alzheimer's disease, Lewy body disease, Frontal-temporal dementia, Vascular dementia).
• Generalized impairment of intellectual functioning.
• Interferes with social & occupational functioning.
• Gradual, progressive, irreversible decline in cerebral function.

Therapeutic Communication Techniques

• Validation therapy (for confused clients): accepts the description of time and place as stated by the older adult.
• Reality orientation: insists that the confused older adult agrees with statements of time, place, and person.

Therapeutic Communication Continued

• REFLECTION: Ask the client to reflect back to a time when they were successful in handling stressful situations in the past.
• RESTATING: “What I hear is that you feel…” to restate using the same words as the patient to help them feel understood.
• ACKNOWLEDGEMENT: “It sounds like this is a very difficult time for you…”
• ACTIVE LISTENING: “Tell me more about how you’re feeling…”

Kübler-Ross Grief Cycle

Coping stages for grief related to readiness or ineffective denial:

• Denial: avoidance, confusion, excitement, shock/fear.
• Anger: frustration, irritability, anxiety.
• Bargaining: struggle to find meaning, to help others, to tell your own story.
• Depression: helplessness, hostility, avoidance.
• Acceptance: Exploring opportunities, introducing new plans, moving forward.

Grief

• Normal: Consists of normal behaviors, reactions to loss, and symptoms.
• Anticipatory: Process of