IM1-Exam 7 Flashcards
1
Q
Sleep is _____ process
A
Physiological
2
Q
What is sleep associated with
A
Recumbency and & Immobility
3
Q
What is Recumbency?
A
“to be laying down”
4
Q
When sleeping you __1__ conscious awareness but are __2__ awakened?
A
1.Lack
2. Easily
5
Q
True or false: Sleep is not essential for healthy functioning and survival?
A
False- It is essential for healthy functioning and survival
6
Q
What is sleep?
A
Sleep is the state in which an individual lacks conscious awareness of environmental surroundings but can be easily aroused
7
Q
What is insufficent sleep?
A
Obtaining the less than recommended amount of sleep. (most adults require 7-8 hours in a 24 hour period)
8
Q
What is the recommended amount of sleep for an adult?
A
Most adults require 7-8 hours in a 24 hour period
9
Q
What is fragmented sleep?
A
Frequent arousal or actual awakenings that interrupt sleep
10
Q
What is nonrestorative sleep?
A
Sleep that is of adequate duration but does not result in the individual feeling refreshed and alert the next day
11
Q
Sleep disturbances are the result of ______?
A
Conditions of poor sleep quality
12
Q
Sleep disorders are the result of _____?
A
Abnormalities unique to sleep.
13
Q
What are some examples of sleep disorders?
A
- Insomnia
- Narcolepsy
14
Q
True or false: Daytime sleepiness can interfere with daily living?
A
True
15
Q
What controls a person’s sleep-wake cycle? (general anwser)
A
The brain.
16
Q
More specifically what part of a persons brain plays a role in a person’s sleep wake cycle?
A
- The RAS (Reticular Activating system)
- Orexin (Hypocretin)- Neuropeptide that comes out of the hypothalamus.
17
Q
What is orexin (hypocretin)?
A
Neuropeptide that comes out of the hypothalamus that helps regulate sleep/wake cycle.
18
Q
What are some things we should know about the RAS (Reticular activating system).
A
- Sensory stimuli within cerebral cortex
- Regulates sleep-wake cycle
- 4 functions
-Motor- Sensory
- Visceral
- Consciousness
19
Q
What part of our body manages our Circadian Rhythm?
A
- Suprachiasmatic nucleus (SCN) in hypothalamus
20
Q
Our Circadian Rhythm is synchronized through ______ in retina
A
Light detectors
21
Q
What is the strongest cue for our circadian rhthym.
A
Light
22
Q
What are somethings we should know about our circadian rhythm?
A
- Managed by the suprachiasmatic nucleus (SCN) in hypothalamus
- Synchronized through light detectors in retina
- Light is the strongest time que
23
Q
True or false: Patients in ICU can suffer from ICU psychosis
A
True
24
Q
How many phases of sleep are there
A
3
25
What does NREM stand for?
Non rapid eye movement
26
What phase is the majority of our sleep spent in?
NREM
27
What are the phases of sleep?
1. Sleep Latency
2. NREM (3 stages)
3. REM (rapid eye movemet
28
What is sleep latency?
This is the time it takes for a person to fall asleep.
29
When does sleep latency start?
1. Starts when eyes are closed for sleep
30
When does sleep latency end?
Ends when non-rem sleep is entered
31
True or false: The time spent in "sleep latency" is usually 10-40 minutes sometimes longer?
True
32
What percentage of sleep is spent in the NREM stage?
75%-80% of sleep time
33
What are the stages of NREM?
Stage 1: Slow eye movement
Stage 2: HR and temperature decrease
Stage 3: Deep or slow wave sleep (SWS) delta, waves, parasomnias
34
True or false: The older we get the more deep sleep we get?
False- The older we get the less deep sleep we get.
35
What is happening in stage 1 in NREM sleep?
1. Slow eye movements
36
What is happening in stage 2 NREM sleep?
HR and temp decrease
37
What is happening in stage 3 NREM sleep?
Deep or slow wave sleep (SWS); delta waves, parasomnias
38
What is parasomnias?
Unusual and often undesirable behaviors while falling asleep, transitioning between sleep stages, or during arousal from sleep
39
What causes parasomnias?
CNS activation
40
What are some actions that can happen as a result of parasomnias?
1. sleepwalking
2. Sleep terrors
3. Nightmares
4. Sleep paralysis
5. sleep hallucinations
41
What percentage of sleep is spent in the REM stage?
20 to 25%
42
How often does REM sleep occur?
3 to 4 times a night
43
In what stage of sleep is skeletal muscle tone greatly reduced?
REM sleep
44
In what stage of sleep do we experience most of our vivid dreams?
REM
45
During what stage of sleep is the brain very active but mentally restful?
REM sleep
46
Middle-aged people experience what changes to their sleep?
1. More stage shifts- decreased NREM3 and REM
2. Resistant to sleep deprivation
3. Increased awaking's
4. Changes in sleep efficiency
47
Older adults experience what changes to their sleep?
1. Phase changes- go to bed earlier and arise earlier
48
What effects can sleep deprivation have on the neuro system
1. Cognitive impairment
2. Behavioral changes (e.g., irritability, moodiness)
49
What effects can sleep deprivation have on your immune system?
1. Impaired function
50
What effects can sleep deprivation have on your respiratory system?
1. Asthma exacerbated during sleep
51
What effects can sleep deprivation have on your cardiovascular system?
1. Heart disease (hypertension, dysrhythmias)
2. Increased BP in people with hypertension
3. Stroke
52
What effects can sleep deprivation have on your gastrointestinal system?
1. Risk for obesity
2. Gastroesophageal reflux disease (GERD)
53
What effects can sleep deprivation have on your endocrine system?
1. Increased risk for type 2 diabetes
2. Increased insulin resistance
3. Decreased growth hormone
54
Hospitalization are associated with decreased sleep time due to what factors?
1. Enviromental sleep-disruptive factors (light & noises)
2. Psychoactive medications (drugs)
3. Acute and critical illness
55
What are symptoms of insomnia?
1. Difficulty falling asleep
2. Difficulty staying asleep
3. Waking up too early
4. Complaints of waking up feeling unrefreshed.
56
What is acute insomnia?
Difficulty falling asleep or remaining asleep for at least 3 nights/week for less than a month
57
What is chronic insomnia?
1. Difficulty falling asleep or remaining asleep for at least 3 nights/week for less than a month
2. Daytime symptoms that persist for 1 month or longer
58
Insomnia is aggravated by what?
inadequate sleep hygiene
59
What are some inadequate sleep hygiene factors?
1. Stimulants
2. Medications
3. Using alcohol to induce sleep
4. Irregular sleep schedules
5. Nightmare
6. Exercising near bedtime
7. Jet lag
60
True or false: Alcohol reduces REM sleep?
True-- causes interrupted sleep?
61
Why should you not exercise near bedtime?
Should not exercise two hours prior to bedtime because it will raise your metabolism and make it harder for you to fall asleep.
62
True or false: The cause of chronic insomnia is often unknown?
True
63
What could be some likely causes of chronic insomnia?
1. Stressful life event
2. Psychiatric illness or medical condition
3. Medications or substance abuse
64
What are the clinical manifestations of insomnia?
1. Difficulty falling asleep (long sleep latency)
2. Frequent awakening (fragmented sleep)
3. Prolonged nighttime awakenings
4. Feeling unrefreshed on awakening (nonrestorative sleep)
5. Fatigue, trouble with concentration
6. Forgetfulness, confusion
7. Anxiety
65
How is insomnia typically diagnosed?
1. Self report
2. Actigraphy
3. Polysomnography (PSG)
66
What is the 1st thing we will ask a patient do when they think they have insomnia?
Keep a sleep journal for two weeks of when they went to bed, what time they woke up, if they woke up during the night, if they woke up feeling refreshed.
67
What is an actigraphy?
Watch like device, worn on the wrist, that can determine sleep and wake over a 14 day period.
68
What is a polysommongraphy?
Sleep study-- records breathing patterns, thoracic movements, pulse ox, heart rate, sleep waves
69
What are things we can do for our patients with insomnia?
1. Education
2. Track sleep
3. Sleep hygiene
4. Cognitive-behavioral therapy for insomnia (CBT-I)
5. Complementary and alternative therapies
6. Drug therapy
70
What are some sleep hygiene techniques we can teach our patients?
1. Do not go to bed unless you are sleepy
2. If you are not asleep after 20 minutes, get out of bed and do non-stimulating activities. Return to bed only when you are sleepy.
3. Adopt a regular pattern in terms of bedtime and awakening.
4. Begin rituals that help you relax each night before bed.
Refer to slide 32 for more examples
71
What are some causes on insomnia?
1. Psychiatric
2. Medical illness, medications
3. Stress: finances, employment, school, life
4. Substances: Caffeine, alcohol, nicotine
5. Exercise
6. Age, gender
8. Other factors: travel
72
True or false: Tx for insomnia should begin with the most invasive method?
False
73
Cognitive behavior therapy and counseling can be treatments for insomnia?
Yes
74
What are some drugs used to treat insomnia?
1. Benzodiazepines
2. Benzodiazepine-receptor-like agents
3. Melatonin-receptor agonists
4. Antidepressants
5. Antihistamines
6. Alternative therapies
75
What should we know about sedative-hypnotic drugs
1.Depress the CNS function
2. primarily used to tx anxiety and insomnia
3. Antianxiety agents or anxiolytics
4. distinction between antianxiety effects and hypnotic effects depends on dosage
76
What are some things we should know about benzodiazepines?
1. used to tx anxiety and insomnia
2. Used to induce general anesthesia
3. Used to manage seizure disorders, muscle spasms, panic disorder, and alcohol withdrawal
4. potential for abuse
5. Can produce physical dependence
77
What benzodiazepines are used specifically for sleep?
1. Temazepam (Restoril)
2. Triazolam (halcion)
78
What are two common types of benzodiazepines not usually used in sleep? DOUBLE CHECK I THINK THIS IS WRONG
1. Diazepam (valium)
2. Lorazepam (Ativan)
3. Alprazolam (Xanax)
79
What are the pharmacologic effects of benzodiazpines?
1. CNS: reduce anxiety and promote sleep
2. Cardiovascular system: oral vs. intravenous
3. Respiratory system: weak respiratory depressants
80
What are the therapeutic uses of benzodiazepine?
1. Anxiety
2. Insomnia
3. Seizure disorders, muscle spasm
4. ETOH withdrawal, perioperative application
81
What are some adverse effects of benzodiazepines
1. CNS depression
2. Amnesia
3. Sleep driving
4. Paradoxical effects
5. Respiratory depression
6. Abuse
82
What types of toxicity can benzodiazepine have?
1. Acute toxicity
2. Oral overdose
-drowsiness, lethargy, and confusion
3. Intravenous toxicity
-Life-threatening reactions, profound, hypotension, respiratory arrest, and cardiac arrest
83
What are some general tx measurements in benzodiazepine toxicity?
Oral
1. Gastric lavage, activated charcoal, and dialysis
84
What is the antidot for Benzodiazepine?
Flumazenil (romazicon)
1. Competitive benzodiazepine receptor agonist
2. Reverses sedative effects if benzodiazepine but may not reverse respiratory depression
3. Monitor for seizure when benzodiazepine stopped
4. Effects fade an hour after administration: monitor for sedation.
85
What should we know about zolpidem (ambien)
1. It is a benzodiazepine-receptor like agent
2. Sedative-hypnotic
3. Short-term management of insomnia
4. Side effects: daytime drowsiness and dizziness
MAJOR SIDE AFFECT-- CRAZY DECSION MAKING
86
What should we know about zaleplon (sonata)
1. Benzodiazepine-receptor-like agent
2. Approved for short-term management of insomnia
3. Most common side effects: headache, nasea, drowsiness, dizziness, myalgia and abdominal pain
87
What should we know about Eszopiclone (Lunesta)?
1.Benzodiazepine-receptor-like agent
2. Approved from treating insomnia
3. No limitation on how long it can be used
4. Generally well tolerated
5. Adverse effect: bitter aftertaste, headache, somnolence, dizziness, and dry mouth
6. Low potential for abuse
88
What should we know about the antidepressant trazodone (oleptro)?
1. Atypical antidepressant with strong sedative actions
2. Can decrease sleep latency and prolong sleep duration
3. Does not cause tolerance or physical dependence
89
What should we know about the antidepressant doxepin and amitriptyline?
1. Old tricyclic antidepressant with strong sedative actions
2. Used to tx patients who have trouble staying alseep
90
What should we know about diphenhydramine (Benadryl)- antihistamine?
1. May be added to night time cold/pain preparations
91
What should we know about Doxylamine (unisom)- antihistamine
1. Can be purchased without a prescription
2. Less effective
3. Tolerance develops quickly (1 to 2 weeks)
4. Adverse effects: daytime drowsiness and anticholinergic effects
5. Not intended for long term use.
92
What are some complementary and alternative therapies used to treat insomnia?
1. Melatonin: effective related to jetlag and shift work
2. Valerian root, chamomile, passionflower, lemon blam, lavender, have very mild sedative effects, proof of benefits in insomnia is lacking.
3. White noise and relaxation strategies.
93
What should our nursing assessment include when assessing patients sleep?
1. Sleep history
2. Assess diet, caffeine, and alcohol intake
3. ask about sleep aids
4. Sleep diary for 2 weeks
5. Medical history: factors that affect sleep
94
What would the nursing diagnosis include with sleep related issues?
1. Sleep deprivation
2. Disturbed sleep pattern
3. Readiness for enhanced sleep
95
What should the nursing implementation for sleep include?
1.Assume primary role in teaching sleep hygiene
2. Teach patient about sleep medications
96
What are some key points to teach about regarding sleep hygiene?
1. Decrease caffeine intake
2. Bedtime routine
3. Decreased blue light before bedtime
4. Reduce light and noise
97
Sleep apnea occurs when the _____ gets closed
1. Airway
98
What are some symptoms of sleep apnea?
1. Loud snoring
2. Excessive day time sleepiness
3. Frequent episodes of obstructed breathing during sleep
4. Morning headaches
5. Unrefreshing sleep
6. Increased irritability
99
What are some non-surgical treatments for sleep apnea?
1. Change sleep position
2. Decrease weight
3. CPAP
4. Drug therapy for underlying cause
100
What are some surgical treatments for sleep apnea?
1. Adenoidectomy
2. Uvulectomy
3. Remodeling posterior oropharynx
4. Bariatric surgery to decrease weight
101
Complications of respiratory and sleep problems can result in
1. Hypertension
2. Cardiac changes
3. Poor concentration/memory
4. Impotence
5. Depression
102
What are some respiratory and sleep problems?
1. sleep apnea
2. Snoring and hypoventilation
3. Obesity hypoventilation syndrome
4. Reduced CW compliance
5. Increased work of breathing
6. Decrease in total lung capacity and functional residual capacity
7. Also called obstructive sleep apnea hypopnea syndrome (OSAHS)
8. partial or complete upper airway obstruction during sleep
9. Apneic period may include hypoxemia and hypercapnia
103
What is sleep apena?
1. Apnea is cessation of spontaneous respirations for longer than 10 seconds.
2. Each obstruction may last from 10-90 seconds.
3. Apnea and arousal cycles occur repeatedly, as many as 200 to 400 times during 6 to 8 hours of sleep.
104
What are some more symptoms of sleep apnea?
1. Frequent arousal during sleep
2. Insomnia
3. Excessive daytime sleepiness
4. Witness apneic episodes
5. loud snoring
6. Morning headache
7. Irritability
105
What are some risk factors of sleep apnea?
1. Obesity (BMI > 28 kg/m2)
2. Age > 65 years
3. Neck circumference > 17 inches
4. Craniofacial abnormalities that affect the upper airway, and acromegaly
5. Smokers are more likely to have osa
6. OSA is more common in men than women after menopause, when the prevalence of the disorder is the same in both genders. Women with OSA have high mortality rates.
106
What lab/diagnostic testing can be done to determine if a patient has sleep apnea?
Polysomnography AKA sleep study
107
What are treatments for mild sleep apnea?
1. Sleeping on one's side
2. Elevating head of bed
3. Avoiding sedatives and alcohol 3 to 4 hours before sleep
4. weight loss
5. Oral appliance
108
What are some treatments for severe sleep apnea?
severe (>15 apnea/hypopnea events/hr)
1. CPAP- possible compliance issues
2. BiPAP
3. Surgery
-uvulopalatopharyngoplasty (UPPP or UP3)
- genioglossal advancement and hyoid myotomy (GAHM)
109
What should we include in our patient teaching for a patient with sleep apnea?
1. if a patient on CPAP or BIPAP remind them to always take with them if overnight trips are planned
2. Explain the benefit of loosing weight
3. Explain the benefits of sleeping on side
4. Explain the need to avoid sedatives or alcohol 3-4 hours prior to bedtime
5. Stress reduction
6. stress importance of exerise
7. avoid smoking
8. Self imagine distrubance
110
What should we include in our patient teaching for a patient with sleep apnea??
1. if a patient on CPAP or BIPAP remind them to always take with them if overnight trips are planned
2. Explain the benefit of loosing weight
3. Explain the benefits of sleeping on side
4. Explain the need to avoid sedatives or alcohol 3-4 hours prior to bedtime
5. Stress reduction
6. stress importance of exercise
7. avoid smoking
8. Self imagine disturbance
111
Discharge planning for patients with sleep apnea should include?
1. Case manager- need for equipment
2. Nutritional consult
3. Spiritual consult
112
Nursing diagnosis for a patient with possible sleep apnea includes?
1. anxiety
2. insomnia
3. imbalanced nutrition more than body requires
4. knowledge deficit
113
What is narcolepsy?
Brain unable to regulate sleep-wake cycles normally, causes uncontrollable urges to sleep, often go directly into REM sleeo
114
What is the cause of narcolepsy?
Unknown cause
1. associated w/destruction of neurons that produce orexin
115
What is Orexin?
1. Neuropeptide that regulates sleep/wake cycles
116
True or false: Low levels of Orexin lead to difficulty staying awake?
True
117
When in a person's life is narcolepsy usually diagnosed?
Adolescents to early in the 3rd decade
118
What are the two types of narcolepsy?
1. Type 1: With cataplexy
2. Type 2: without cataplexy
119
What is cataplexy?
Is a brief and sudden loss of skeletal muscle tone that can manifest as muscle weakness or complete postural collapse and falling
120
Nursing and interprofessional management include what in regards to narcolpsy?
1. Teach about sleep and sleep hygiene
2. Take naps ( advise 3 or more short (15min nap) throughout the day
3. Avoid heavy meals and alcohol
4. Ensure patient safety
5. Lifestyle changes (discourage driving, swimming)
121
What are two wake-promotion drugs used to treat narcolepsy?
1. Modafinil (Provigil)
2. Armodafinil (Nuvigil)
122
In terms of sleep what are some gerontologic considerations?
Older age is associated with
1. Overall shorter total sleep time
2. Decreased sleep efficiency
3. More awakenings
4. Insomnia symptoms
5. Awakenings during the night increase risk for falls
6. medications used by older adults can contribute to sleep problems
7. Avoid long-acting benzodiazepiens
123
In terms of sleep what are some gerontologic considerations?
Older age is associated with
1. Overall shorter total sleep time
2. Decreased sleep efficiency
3. More awakenings
4. Insomnia symptoms
5. Awakenings during the night increase risk for falls
6. medications used by older adults can contribute to sleep problems
7. Avoid long-acting benzodiazepines
124
What are some nurse fatigue: facts?
1. Inadequate sleep
2. Extended work hours
3. Increased risk for errors
125
Mobility can be....
1. Nonverbal gestures
2. Self-defense
3. ADL's
4. Recreational
5. Satisfaction of basic needs
6. Expression of emotion
126
What are some factors affecting mobility and activity?
1. Developmental
2. Nutrition
3. Lifestyle
4. Stress
5. Environment
6. Diseases and abnormalities
127
What are some diseases and abnormalities that can affect mobility?
1. Bones, Muscles and nervous system
2. Pain
3. Trama
4. Respiratory system
5. Circulatory
6. Psychological/social
128
What is immobility?
1. A person's inability to move about freely?
129
What is paraplegia?
Refers to paralysis to the lower part of the body
130
What is hemiplegia?
Paralysis or restrictive movement to one part of the body (stroke)
131
What is quadriplegia?
AKA Tetraplegia paralyzed from the neck down.
132
What is bedrest?
Restricts patients to bed for therapeutic reasons?
133
What are some benefits of a patient being on bedrest?
1. Sometimes prescribed for selected patients
2. Reduces physical activity and o2 demand of the body
3. Reduces pain
4. Allow ill or debilitated patients to rest
5. Allows exhausted patients to rest
6. Duration depends on illness or injury and prior state of health.
134
What are some physical causes of immobility?
1. Bone fracture
2. Surgical procedure
3. Major sprain or strain
4. Illness/disease
5. Cancer
6. Aging process
135
What are some psychosocial causes of immobility?
1. Stress/depression
2. Decreased motivation
3. Hospitalization
4. Long term care facility residents
5. Voluntary sedentary lifestyle
136
Prolonged immobility leads to...
1. Reduced functional capacity
2. Altered metabolism
3. Numerous physiological changes
137
Immobility can affect what parts of body/system?
1. Musculoskeletal
2. Lungs
3. Heart and vessels
4. Metabolism
5. Integument
6. Gastrointestinal
7. Genitourinary
8. Psychological
138
What effects can immobility have on the musculoskeletal system?
1. Brittle bones
2. Contractures
3. Muscle weakness and atrophy
4. Foot drop
139
What effects can immobility have on the nervous system?
1. Lack of stimulation
2. Feelings of anxiety and isolation
3. Confusion
4. Depression
140
What effects can immobility have on the digestive system?
1. Decreased appetite and low fluid intake
2. constipation and/or bowel obstruction
3. Incontinence
4. Electrolyte imbalances
141
What effects can immobility have on the integumentary system?
1. Decreased blow flow
2. Pressure ulcers
3. Infections
4. Skin breakdown and pressure ulcers
142
What effects can immobility have on the cardiovascular system?
1. Blood clots
2. Reduced blood flow
143
What effects can immobility have of the respiratory system?
1. Pneumonia
2. Decreased respiratory effort
3. Decreased oxygenation of bl0od
144
What effects can immobility have on the urinary system?
1. Reduced kidney function
2. Incontinence
3. Urinary tract infections
4. Urinary retention
145
What are some musculoskeletal assessments we can do for immobile patients?
1. Activity intolerance
2. anthropometric measurements
3. Nutrition
-Muscle loss, bone loss and joint stiffness can occur
- the longer you remain still the worse the activity intolerance will be
- For every week on bedrest a person will lose 10% of there muscle mass
- Protein is going to be a crucial part of a immobile patient
146
What two types of cells are part of bone resorption?
1. Osteoclasts
2. Osteoblasts
147
What is an osteoclasts?
1. Dissolve bone and calcium get released into the bloodstream (clast means to break)
148
What is an osteoblast?
Trys to reabsorb and deposit calcium back into bone (blast means to grow)
149
True or false: Immobile patients have decreased bone mass because the osteoclast come in, tear down and dissolve the bone?
True
150
What are characteristics of osteoporosis?
Pores in bone or a bone with lots of dead speace
151
What are characteristics of osteoporosis?
Pores in bone or a bone with lots of dead space
152
What are some risk factors of osteoporosis?
1. gender (females more affected than males especially after menopause)
2. Insufficient exercise or too much exercise
3. Poor diet (low in Ca and protien)
4. Smoking
153
True or false: Bone density is strongly linked to estrogen?
True
154
Changes in bone density with age is more pronounced in women or men?
Women
155
True or false: the further away from menopause the more likely a fracture can occur?
True
156
What is range of motion:
1. Maximum amount of movement available to a joint
157
Joints not moved are at risk for what?
contractures- which can begin forming within 8 hours
158
True or false: ROM exercises do not help improve joint mobility
False-- it helps
159
What is one of the easiest interventions to maintain or improve joint mobility?
1. ROM excercise
160
True or false: ROM exercises can be coordinated with other activities?
True
161
What is active ROM or AROM
Done by the patient
162
What is active assist ROM?
Done by patient but with help
163
What is passive ROM
Done by nurse or other caregiver or CPM (continuous passive motion)
164
How often should you try to do ROM exercises?
3 times a day
1. After bath
2. Mid day
3. Bedtime
165
What are some good techniques for ROM exercises?
1. Start gradually and move slowly using smooth motions
2. Support the extremity
3. Stretch the muscle only to the point of resistance/pain
4. Encourage active ROM if possible
166
What is contractures?
Shortening of the muscle
167
What should your respiratory assessment on an immobile patient include?
1. Lung sounds (general patient every 8 hours, cirtical every 4 hours.)
2. O2 sats
3. Respiratory rate
4. Activity tolerance (SOB)
5. Chest x-ray
6. ABG
168
True or false: If a patient is laying in bed with a high resp rate this is an indicator of a MAJOR problem
True
169
What should our cardiac assessment include on an immobile patient?
1. Blood pressure
2. Pulse rate
3. Heart sounds
4. Activity tolerance (BP,HR, Chest pain)
5. Calf pain
170
Deep vein thrombosis is caused by?
1. Decreased muscle activity leading too
2. Pooling of blood leading too
3. Clot formation
171
What are some treatments o f DVT'S
1. Ambulation
2. TED hose
3. SCD's
172
TED hoses are used on patients that....
1. Are post surgical
2. Non-walking
173
True or false it is important that the ted hose do not bunch up at the top?
True
174
What should we know about SCD's?
1. Sleeves around the legs
2. Alternately inflate and deflate
3. For patients post surgery/circulatory disorders
175
What should be included in our metabolism assessment on immobile patients?
Assess for
1. Decreased appetite
2. Weight loss
3. Muscle loss
4. Weakness
5. Labs
176
What should be included in our integument assessment of a immobile patient?
1. Skin assessment ( color changes & integrity)
2.Nutrition
3. Incontinence
177
What should be included in our gastrointestinal assessment?
1. Bowel sounds
2. Abdominal palpation
3. Bowel habits (last BM)
4. I & O
Gi tract will slow down so making sure that they have good active bowel sounds. If you dont hear bowel sounds in all four quadrants this could be an indicator of something more
178
What should be included in our genitourinary assessment in immobile patients?
1. I & O
2. Palpate abdomen
3. Incontinence
4. Urine (color, smell, clarity?)
179
What is the number one culprit of kidney stones?
Calcium- so if you have a patient who is laying still in bed there bones are being broken down and calcium is being entered into the blood stream which travels to the kidneys further increasing risk of kidney stones.
Keep in mind a person laying flat will have urine that settles in the renal pelvis/bladder. Urine then becomes concentrated and does not move the way it should. Adding the calcium will increase risk of kidney stones plus infection
180
True or false: Standing urine travels down but laying down urine settles?
True
181
What is urinary stasis?
1. When the renal pelvis fills before urine enters the ureters because peristaltic contractions of ureters are insufficient to overcome gravity.
182
Immobility--> decreased fluid intake--> dehydration--> concentrated urine--> leads too what?
1. Increased risk for UTI and kidney stones
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What should our psychosocial assessment include in an immobile patient?
Assess
1. Mood
2. Orientation
3. Speech
4. Affect
5. Sleep
184
What are some psychosocial effects of immobility?
1. social isolation
2. Loneliness
3. Decreased coping
4. Depression
5. Anxiety
6. Withdrawal
7. Delerium
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What are some benefits of of mobility?
1. Strengthen muscles
-especially those of the abdomen and legs
2. Joint flexibility
- especially that of the hips, knees and ankles
3. Stimulates circulation
- which helps prevent phlebitis and development of clots
4. Prevents constipation
- the movement of the abdominal muscle stimulates the intestinal tract
5. Prevents osteoporosis
- due to mineral loss from the bones when they do not bear weight
6. Stimulates the appetite
7. Prevents urinary incontinence and infections
- when patient s are able to the bathroom on thier own, incontinence is reduced
8. Relieves pressure
- on the body and skin, helping to prevent pressure injuries
9. Improves self-esteem
- and the patients feelings of independence
10. Decreases anxiety and depression
- induced by hospitalization
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What is the best intervention to prevent immobility complications?
Ambulaton
187
What are restraints?
Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move arms, legs, body or head freely.
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What would be some reasons we place non-violent restraints on a patient?
1. Actions impede medical care
2. Lack of awareness of potential harm to self/others
3. Unable to follow commands and comply with safety instructions
4. Attempts to pull out tubes, drains or other lines/devices medically necessary for tx
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What are some requirements that must happen in order to place a patient in restraints?
1. Requires every 2 hours monitoring and documentation
2. New order required every calendar day
3. Wehn discontinuing, date & time must be documented
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What are some type of restraints?
1. Extremity
2. Mitten
3. Posey
4. Belt
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Covenant restraint policy states that prior to restraining alternatives such as________________ be attempted
1. Reorientation (explain what's going on, who they are, where they are)
2. Limit setting (remind them of what they cant do)
3. Increased observation and monitoring (using sitters)
4. Change the patients physical environment (open window, move them out to the rn station)
5. Review and modification of medication regimens
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What are some alternative measures for restraints?
1. Orient family and patient to environment
2. Offer diversionary activities
3. Use calm simple statements
4. promote relaxation techniques
5. Attend to needs
6. use of glasses/hearing aids
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True or false: You must have an order prior to applying a restraint unless it is an emergent situation?
True-- asap let provider know
194
True or false: You want to try and discontinue restraints ASAP?
True
195
Restraint assessment should include?
1. Vitals, hydration and circulation, skin integrity and patients level of distress
2. Regularly assess the need for continued use of restrains
3. Assess patients behavior
4. Assess circulation, motion, sensation
5. Make sure restraint fits properly
6. Mental status- ask to move limbs/or if they feel tingling
196
What are some risks of using restraints? (More emotional)
1. Increase in injury or death
2. Loss of self-esteem
3. Humiliation
4. Fear
5. Anger
6. Increased confusion and agitation
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What are some complications of restraints?
1. Impaired skin integrity
2. Lower extremity edema
3. Altered nutrition
4. Physical exhaustion
5. Social isolation
6. Immobility complications
7. Death
198
Intervention of application with restraints includes
1. Restrict movement as little as necessary
2. Make sure restraint fits properly
3. Always tie (slip knot or bow tie) to bed from/mattress spring- NEVER TO A MOVING PART
4. Always explain the need for restraint
5. Never leave patient unattended without the restraint
6. Pad bony prominences
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What are some interventions we can do prevent complications from restraints?
1. ROM
2. Reposition
3. Nutrition/hydration/Toileting
4. Release at the earliest possible time
200
What should you document in regards to restraints?
1. Any medical eval for restraint
2. Description of the patient's behavior and the intervention used
3. Any alternative or less restrictive interventions attempted
4. Patient's conditions or symptom that warranted the use of the restraint
5. Patients response to the intervention used and rationale for continued use of the intervention.
6. the intervals for monitoring
7. revisions to the plan of care
8. Pts behavior and staff concerns regarding safety risks to the patient, staff and others that necessitated the use of the restraint
8. injuries to the patient
9. death associated with the use of restraint
10. The identity of the provider who ordered the restraint
11. Orders for restraint
12. Notification of the use of restraint to the attending physician
13. Consultations
14. Pt/family teaching
15. response to removing restraint
