copyright 2015, 2011 by pearson education, inc. all rights reserved nursing: a concept-based...

Copyright © 2015, 2011 by Pearson Education, Inc.All Rights Reserved

Nursing:A Concept-Based Approach to Learning

VOLUME ONE | SECOND EDITION

Nursing: A Concept-Based Approach to Learning Volume One, Second Edition

Comfort

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Nursing:Nursing:A Concept-Based Approach to LearningA Concept-Based Approach to Learning

Volume One

MODULE

Nursing: A Concept-Based Approach to Learning, Volume One



Alterations and Manifestations

• Pain Most common reason to seek health care Unpleasant sensory, emotional experience Associated with actual or potential tissue

damage Fifth vital sign



Alterations and Manifestations, continued

• Pain Acute pain: Sudden onset, lasts through

recovery (30 days – 6 months) Chronic pain: Persists > 6 months; varying

severity



Prevention

• Begins with client Personal preference Lifestyle habits Nutrition Smoking, alcohol use Sleep hygiene Occupation Culture



Nursing Assessment

• Client health history• Nursing interview

Client description of symptoms Pain scale Depression assessment

• Client's culture affects how client perceives discomfort and expresses pain



Nursing Assessment, continued

• Physical assessment Vital signs Visual inspection PSG for identification of suspected sleep

disorders Blood and urine analysis

• Diagnostic tests for underlying cause X-ray Blood tests



Lifespan and Cultural Considerations

• Age and developmental stage affect ability to describe pain Special considerations for assessing

discomfort and promoting comfort for ach stage

• Cultural differences in expressions of pain



Interventions and Therapies

• Initial interventions directed at identifying source of discomfort

• Pain relief is priority



Independent

• Relaxation therapy Reduce stress, induce sleep, reduce pain,

calm emotions Four main categories (often combined)

• Breathing exercises• Muscle relaxation• Imagery• Movement techniques

Other forms: massage, acupuncture, meditation, biofeedback



Collaborative

• Pharmacologic Nonopioids NSAIDs Opioids Hypnotics/sedatives

• Nonpharmacologic Acupuncture Herbal supplements



Exemplar 3.3 Fatigue



Pathophysiology and Etiology

• Tiredness, exhaustion, apathy, lack of motivation

• Symptom of underlying cause Illness Sleep deprivation Intense physical or mental exertion Pressure to perform a certain role



Etiology

• Anemia• Depression or grief• Medications such as sedatives,

antidepressants• Persistent pain



Etiology, continued

• Sleep disorders such as insomnia, obstructive sleep apnea, and narcolepsy

• Hyperthyroidism, hypothyroidism• Regular use of alcohol or illicit drugs• Chronic diseases: arthritis, cancer,

diabetes, fibromyalgia, liver or kidney disease



Risk Factors

• Acute or chronic illness or condition• Lifestyle factors• Medications• Medical procedures• Mood disorders• Genetics• Women more at risk than men



Prevention

• Lifestyle choices Balanced diet Daily exercise Good sleep hygiene Stress reduction



Clinical Manifestations

• Drowsiness, exhaustion, lack of motivation• Lethargy• Muscle weakness• Palpitations• Dizziness• Dyspnea on mild exertion• Loss of appetite• Slow movements• Blurry vision



Clinical Manifestations, continued

• Difficulty concentrating• Impaired decision making• Confusion• Impaired coordination• Slow reflexes• Sleep disturbance• Change in muscle tone• Depression



Clinical Manifestations, continued

• Chronic fatigue syndrome Severe tiredness lasting longer than 6

months Not caused by a primary condition Not relieved by stress reduction Not feeling rested after adequate sleep Forgetfulness, confusion, inability to

concentrate Joint, muscle symptoms



Diagnostic Tests

• Tests to find underlying cause• Sleep study



Pharmacologic Therapy

• Depends on cause• Tailored to specific condition



Nonpharmacologic Therapy

• Good sleep hygiene• Mild to moderate exercise• Cognitive-behavioral therapy• Assist client to determine best time of day

to engage in activities



Complementary and Alternative Therapy

• Acupuncture • Massage• Relaxation techniques• Herbal and dietary supplements• Ginseng• NADH• L-carnitine



Nursing Process

• Determine underlying cause• Thorough assessment of client

Measures to promote rest



Assessment

• Health history Duration, quality, timing of fatigue How fatigue affects ADLs How fatigue affects relationships Diet, sleep, exercise habits Medications Medical conditions Cognitive effects



Assessment, continued

• Physical examination Vital signs Client mobility Hydration status Muscle strength, symmetry, endurance Skin turgor Skin tone



Diagnosis

• Insomnia• Sleep Deprivation• Fatigue• Activity Intolerance• Readiness for Enhanced Coping • Stress Overload



Planning

• Client will verbalize an understanding and practice of good sleep hygiene

• Client will verbalize feelings of increased energy

• Client will indicate an increased ability to perform activities of daily living

• Client will participate in a mild exercise program



Implementation

• Consider client's cultural, developmental needs regarding sleep rituals

• Assess client's methods of coping and social support network

• Establish rapport with client's family and significant others



Evaluation

• Evaluate clients periodically to determine if the medical and nursing interventions are effective

• Further diagnostic tests may be needed to determine if additional physiological factors are contributing



Exemplar 3.5 Sleep–Rest Disorders



Overview

• Sleep is essential to normal physiological functioning.

• Adults need 7–9 hours of sleep each night.



Pathophysiology and Etiology

• Sleep loss When individual gets < 7–8 hours sleep

Chronic sleep loss• Inability to concentrate• Fall asleep sitting still• Reduced motivation• Reduced reaction time



Pathophysiology and Etiology, continued

• Sleep apnea Periods of partial or complete airway

obstruction ≥5 apneic events per hour

• Severe: >30 per hour Breathing pauses last 10–20 seconds Decreased oxygenation




• Hypersomnia Sufficent sleep but still suffers daytime

drowsiness Severe form: narcolepsy

• Daytime sleep attacks




• Parasomnias Abnormal actions during sleep Examples

• Sleepwalking (somnambulism)




• Restless leg syndrome Neurological disorder Overwhelming urge to move legs while at

rest Muscle twitches, jerking movements of legs



Risk Factors

• Insomnia Female more than male Over age 60

• Sleep apnea Obesity Large neck circumference Male more than female Smoking



Risk Factors, continued

• Parasomnias Children Drug or alcohol abuse

• Restless leg syndrome Older age Stress Kidney disease Diabetes



Diagnostic Tests

• Polysomnography (PSG)• Electroencephalogram (EEG)• Video/audio equipment• Heart rate, breathing, O2 saturation



Surgery

• Remove obstruction in sleep apnea• Only if CPAP therapy not tolerated



Pharmacologic Therapy

• Sedative-hypnotic medications• Antianxiety medications• Half-life of drug important for effectiveness• Sleep medications vary in onset, duration



Nonpharmacologic Therapy

• Obstructive sleep apnea Weight loss Alcohol abstinence Avoiding supine position for sleep CPAP or BiPAP Surgery



Nonpharmacologic Therapy, continued

• Bright light therapy• Stimulus control therapy (behavioral)• Sleep restriction• Exercise• Relaxation techniques• Herbal supplements

Valerian Chamomile Melatonin



Assessment

• Sleep history Sleep partner or parents may provide

additional information Sleep assessment scales



Diagnosis

• Insomnia • Sleep Deprivation• Readiness for Enhanced Sleep• Disturbed Sleep Pattern• Fatigue• Wandering



Diagnosis, continued

• Ineffective Breathing Pattern• Ineffective Coping• Stress Overload• Risk for Injury• Deficient Knowledge



Planning, continued

• Client will have sufficient energy for normal daily activities.

• Client will report improved quality and quantity of sleep.

• Client's spouse will report decreased snoring.

• Client's spouse will report no apneic episodes.



Implementation

• Educate client about factors associated with impaired sleep–rest patterns

• Instruct client in proper use of assistive devices

• Review client's medications to determine whether any interfering with sleep

• Teach client about principles of good sleep hygiene



Evaluation

• Data collection Observations of duration of client's sleep Questions about how client feels upon

awakening Observations of client's level of alertness

during day

copyright 2015, 2011 by pearson education, inc. all rights reserved nursing: a concept-based...

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