Fundamentals of Nursing Chapters 27, 33, and 45

• Promotion of Health
• prevention of Illness/Injury
• Resotration of Health
• Adapting to Altered Health & Function

The art and science of teaching adults.

The discipline concerned with helping children learn.

The term used to describe the the process involved in helping older adults learn.

• Cognitive domain
• Affective domain
• Psychomotor domain

• The "thinking" domain: Involves six (6) intellectual abilities and thinking processes.
• Beginning with:
• 1. Knowing
• 2. Comprehending
• 3. Applying to analysis
• 4. Synthesis
• 5. Evaluation.

• The "feeling" domain: Devided into categories that specify the degree of a "person's depth of emotional responses to tasks".
• It includes emotional and social goals such as:
• 1. Feelings
• 2. Interests
• 3. Attitudes
• 4. Appreciations

• The "skill" domain: Includes fine and gross motor abilities
• Such as:
• 1. Giving an injection

• Behaviorism
• Congnitivism
• Humanism

• 1. Age and developmental stage
• 2. Motivation
• 3. Readiness 
• 4. Active involvement
• 5. Relevance
• 6. Feedback
• 7. Nonjudgmental support
• 8. Simple to complex learning
• 9. Repetition
• 10. Timing
• 11. Environment
• 12. Emotions
• 13. Physiological events
• 14. Cultural aspects
• 15. Psychomotorability

• Muscle strength
• Motor coordination
• Energy
• Sensory acuity

A disorder of excessive daytime sleepiness caused by a lack of the chemical hypocretin in the area of the CNS that regulates sleep.

The period of Rapid-Eye Movement

Non-Rapid-Eye Movement

• Refers to interventions used to promote sleep. Largely involves nonpharmacologic measures.
• These involve teaching about: Sleep habits, support of bedtime rituals, the provision of a restful environment, specific measures to promote comfort and relaxation, and appropriate use of hyponotic medications

It is sort of a 24 hour internal biological clock. It is from the latin "Circa Dies", which means "about a day".  Although sleep and waking cycles re the best known of the circadian rhythms, body temperature, blood pressure, and many other physiological functions follow a circadian pattern

Very light sleep that only lasts a few minutes. The person feels drowsy and relaxed, eyes roll back and forth (side to side), heart rate and respirations drop, and  the person is easily awakened and may deny sleeping.

Light sleep where body processes continue to slow down. Eyes usually still, heart rate and respirations continue to slow down, body temperature falls. This stage lasts about 10-15 minutes, but makes up 44-55% of total sleep. To awaken the individual in this stage of sleep requires more effort, than Stage I.

This is the deepest sleep and stages III and IV only differ in the percentage of delta waves recorded during a 30 second period. During delta/deep sleep the heart rate and respirations drop to 20-30% below what they are during waking hours. It is very hard to awaken the individual. They are extremely relaxed and snoring may occur. 

• 1. Arterial b/p falls
• 2. Pulse rate decreases
• 3. Peripheral blood vessels dilate
• 4. Cardiac output decreases
• 5. Skeletal muscles relax
• 6. Basal metabolic rate decreases by 10-30%
• 7. Growth hormone levels peak
• 8. Intracranial pressure decreases

16-18 hours of sleep (usually awake 1-3 hours at a time)

At first they awaken every 3-4 hours and they eventually even out to approximately 14-15 hours of sleep

12-14 hours of sleep

11-13 hours of sleep, which can fluctuate depending on the physical activity and growth spirts

10-11 hours of sleep

Most healthy adults need 7-9 hours of sleep (give or take a few)

7-9 hours of sleep (although they usually go to bed one hour earlier and get up an hour and half earlier than young adults)

• Illness
• Environment
• Lifestyle
• Emotional stress
• Stimulants/Alcohol
• Diet
• Smoking
• Motivation
• Medications

Learning should be based ont he learners behavior and what is directly observable. "An act is called a RESPONSE when it can be traced to the effect of a stimulus."

Learning is largely a mental, intellectual, or thinking process. The learner structures and processes information, perceptions are selectively chosen by the individual, and personal characteristics have an impact on how a cue is perceived. Importance is put on social, emotional, and physical contexts in which learning occurs, such as the teacher-learner relationship and the environment. 

Learning is believed to be self motivated, self initiated, and self evaluated. Each individual is viewed as a unique composite of biological, phychological, social, cultureal, and spiritual factors. Learning focuses on self development and achieving full potential; it is best when it is relevant to the learner. Autonomy and self determination are important; the learner identifies the learning needs and takes the initiative to meet these needs. Teh learner is an active participnt and takes responsibility for meeting individual learning needs.

It causes pain or physical distress and requires more sleep than normal.

The absence of usual stimuli or the presence of unfamiliear stimuli can prevent sleep.

Exercise or desk work, late in the day, can delay sleep. This type of activity should be done earlier in the day.

The number one cause of sleep difficulties due to inability to relax

• Stimulants such as caffeine should be used early in the day, otherwise it can be difficult to fall asleep. 
• Alcohol, while it can induce sleep, disrupts REM sleep

• Weight gain can cause broken sleep and early awakening
• Weight loss can increase sleep and it is less broken up

• It has a stimulating effect on the body
• It causes poor sleep (many claim they are light sleepers)

• It can increase alertness in some situations
• EXAMPLE: An individual is tired, but they want to see a concert
• It can also have no effect on other situations
• EXAMPLE: An individual is tired and wants to drive longer, but may not be able to stay awake

• Hypnotics: Interfere with deep sleep and suppress REM sleep
• Beta-blockers: Can cause insomnia and nightmares
• Narcotics: Like morphine, are known to suppress REM sleep and to cause frequent awakening and drowsiness
• Traquilizers: Interfere with REM sleep
• Antidepressants: Suppress REM sleep, which is considered to be therapeutic (in some cases, depriving a depressed client of REM sleep will result in an immediate but transient imporvement in mood)
• NOTE: Clients accustomed to taking hypnotic medications and antidepressants may experience a REM rebound (increased REM sleep) when these medications are discontinued.

It is a major aspect of the practice

• Independent
• You do not need a doctor's orders

• Leagal and professional responsibility
• The Joint Commission expanded its standards - Provider must consider client literacy level, educational background, language skills, and culture

• System of activities intended to produce learning
• Process designed to produce specific learning
• Teaching-learning process dynamic
• Involves variety of learners and settings
• 1. Clients and families
• 2. Community
• 3. Health Personnel

• Reducing health risks
• Increasing wellness
• Taking protective health measures

Dynamic

Not to know

• Change in juman disposition or capability that persists and is not simply due to growth
• Represented by change in behavior

• Experience that occurs inside the learner
• Discovery of the personal meaning and relevance of ideas = Aha moments
• Consequence of experience
• Collaborative and cooperative process
• Evolutionary process
• Process that is both intellectual and emotional

• Learning need
• Compliance
• Adherance

The desire to know

The desire to act on learning

The commitment to regimen - If we do not commit to the entire regimen of this class, we will not succeed.

• Move from dependence to independence
• Previous experiences can be used as a resource
• Related to an immediate need, problem, or deficit
• More oriented when material is useful immediately
• Reinforced by application and prompt feedback
• EXAMPLE: Lecture and reading alone, does not work, we need our labs!

• Smile when you put on your thinking CAP!
• Cognitive: Thinking level
• Affective: Feeling level
• Psychomotor: Physical skill level
• ****All domains must be included in teaching plans****

• Pavlov
• Skinner
• Thorndike
• Bandura

• Learning is based on the learner's behavior
• Act is a response when it is traced to the effects of a stimulus
• Conditioning used to change behaviors
• Positive reinforcement (Skinner and Pavlov)
• Observational learning and instruction, learn through imitation and modeling (Bandura)
• EXAMPLE: The door closes at 9AM, people learn to be early!

1. Provide sufficient practice time 2. Provide immediate and repeat testing and return demonstration 3. Provide opportunity to solve problems by trial and error 4. Select teaching strategies that avoid distracting information and evoke desired response 5. Praise correct behavior and give positive feedback 6. Provide role models of desired behavior

• Piaget
• Bloom
• Lewin

• Learning is a complex cognitive activity
• Learner structures and processes information
• Perception chosen by individual
• Personal characteristics affect perceptions
• Social, emotional, and physical contexts are important

1. Provide social, emotional, physical environments conducive to learning 2. Encourage positive teacher-learner relationships 3. Select multisensory teaching strategies 4. Recognize personal characteristics have an impact on how cues are perceived 5. Develop appropriate approaches for different learning styles 6. Assess developmental and individual readiness to learn 7. Adapt teaching to developmental level 8. Select behavioral objectives and teaching strategies that encompass cognitive, affective and psychomotor domains

• Maslow
• Rogers

• Learning is self-motivated, self-initiated, and self-evaluated
• An individual is a unique composite of biological, psychological, social, cultural, and spiritual factors
• Learning focuses on self-development and achieving full potential
• Learning best when relevant to the learner
• Autonomy and self-determination are important
• Learner is an active participant and takes responsibility for meetinglearning needs

1. Convey empathy 2. Encourage learner to establish goals 3. Promote self-learning 4. Serve as facilitator, mentor, or resource for learners 5. Use active learning strategies 6. Expose the learner to new, relevant information 7. Ask appropriate questions 8. Encourage the learner to seek answers

• Age and developmental stage
• Motivation
• Readiness
• Active involvement
• Relevance
• Feedback
• Nonjudgmental support
• Simple to complex learning
• Repetition
• Timing
• Environment
• Emotions
• Physiological events
• Culture aspects
• Psychomotor ability

• Age and development influence the client’s ability to learn.
• Three major developmental stage factors must be considered at each developmental period throughout the life cycle, they are: physical, cognitive, and psychosocial maturation.

The desire to learn. It greatly influences how quickly and how much a person learns. Motivation is generally greatest when a person recognizes a need and believes the need will be met through learning. Often the nurse’s task is to help the client personally work through the problem and identify the need. EXAMPLE: Person with heart disease may need to know the effects of smoking before they recognize the need to stop smoking.

The demonstration of behaviors or cues that reflect the learner’s motivation to learn at a specific time. Readiness reflects not only the desire or willingness to learn, but also the ability to learn at a specific time.

• When the learner is actively involved in the process of learning, learning becomes more meaningful.
• If the learner actively participates in planning and discussion, learning is faster and retention is better.
• Clients who are actively involved in learning about their health care may be more able to apply the learning to their own situation.

• The knowledge or skill to be learned must be personally relevant to the learner. Clients learn more easily if they can connect the new knowledge to that which they already know or have experienced.
• EXAMPLE: If a client is diagnosed with hypertension, is overweight, and has symptoms of headaches and fatigue, he is more likely to understand the need to lose weight if he remembers having more energy when he weighed less.

• Support of desired behavior through praise, positively worded corrections, and suggestions of alternative methods are ways of providing positive feedback.
• Negative feedback such as ridicule, anger, or sarcasm can lead people to withdraw from learning, since it is viewed as a type of punishment and it may cause the client to avoid the teacher and their punishment.

• People learn best when they believe they are accepted and will not be judged. The person who expects to be judged as a “poor” or “good” client will not learn as well as the person who feels no such a threat.
• Once learners have succeeded, it builds their confidence and reduces their anxiety, which in turn motivates greater learning.

This concept allows the nurse to determine the learner’s level of knowledge and to facilitate learning from that point, building with more complex ideas.

• Repetition of key concepts and facts facilitates retention of newly learned material.
• Practice of psychomotor skills, particularly with feedback from the nurse, improves performance of those skills and facilitates their transfer to another setting.

• People retain information and psychomotor skills when the time between learning and active use is short.
• EXAMPLE: Teaching a client how to use their insulin and then having them do it, solidifies the teaching.

• An optimal learning environment facilitates learning by reducing distractions and providing physical and psychological comfort.
• Adequate lighting, comfortable temperature, good ventilation, choose a time when there are no visitors and interruptions are unlikely.
• Privacy is imperative and a support person may give them the confidence they need.

• Fear, anger, anxiety, agitation, and depression can impede learning. Families who are experiencing extreme emotional states may not hear spoken words or may retain only part of the communication.
• Medications may be prescribed for extremely distraught clients or families to reduce their anxiety and put them in a state where learning can occur.

• Critical illness, pain, or sensory deficits inhibit learning. The client cannot concentrate and thus learning is impaired. 
• The nurse needs to try to reduce the physiological barriers to learning, as much as possible before teaching.

• Barriers include language and values.
• Western medicine may conflict with a client’s cultural healing beliefs and practices. 
• To be effective the nurse must be culturally sensitive and competent.

• The nurse must be aware of the client’s psychomotor (physical) skills, as they can be affected by the client’s health.
• The following physical abilities are important for learning psychomotor skills: 1. Muscle strength 2. Motor coordination 3. Energy 4. Sensory acuity

Health information, services, and products provided on the internet

61%

e-patient

Those who are 55 and older

False

• Listen to the information they have found
• Ask questions 
• Kindly validate or dispute (with information) what they have learned
• NOTE: Integrate the internet into your teaching plan (apply other strategies for those who do not have access)

• Age
• Client's understanding of the health problem
• health beliefs and practices
• Cultural factors
• Economic factors
• Learning style
• Client's support system

• General survey provides useful clues, such as:
• 1. Mental status
• 2. Energy level
• 3. Nutritionaal status
• Other parts of physical exam reveal additional information, such as:
• 1. Visual ability
• 2. Hearing ability
• 3. Muscle coordination

• Nursing History
• Physical Assessment
• Readiness to Learn
• Motivation
• Newest Vital Sign: Health Literacy Test 
• Joint Commission Suggestions

Six questions for the client to answer, while referring to a food label.

• Associated with poor health oucomes and higher health care costs
• Clients hide low literacy and so lack critical information
• Have less information about health promotion or management of a disease process
• Nurses must look for this silent epidemic

• To determine the capacity to obtain, process, and understand the basic health information and services needed to make appropriate health decisions.
• NOTE: Clear communication and plain language is imperative when communicating with all.

• Use plain language
• Use "teach back" and "show back"
• Limit information to two or three important points
• Use drawings or models

• 1. Deficient Knowledge (specify)
• 2. Readiness for Enhanced Knowledge (specify)
• 3. Noncompliance (use with caution because other factors may be the cause - can come off as judgemental)

• 1. Risk for Impaired Parenting r/t deficient knowledge
• 2. Risk for Injury r/t ineffective Health Maintenance

• Teaching plan
• Involve the client
• Determining priorities
• Learning outcomes

The plan should stimulate the client's motivation

• Client's learning needs must be ranked
• Maslow's hierarchy of needs used to establish priorities

• State the client behavior
• Reflect an observable or measurable activity
• May add conditions or modifiers
• Use criteria that specify the time that learning occurs

It should be: 1. Accurate 2. Current 3. Based on learning outcomes 4. Adjusted for the learner's age, culture, and ability 5. Consistent with information the nurse is teaching 6. Reflects time and resources available

They should be suited to the individual: 1. Explanation or description 2. One-to-one discussion 3. Answering questions 4. Demonstration 5. Discovery 6. Group discussion 7. Practice 8. Printed and audiovisual materials 9. Role-playing 10. Modeling 11. Computer learning resources

• 1. Start with something the learner is concerned about
• 2. Discover what the learner knows
• 3. Address areas that cause anxiety early
• 4. Teach simple to complex
• 5. Schedule time for review of content

• Be flexible
• Use techniques that enhance learning
• Reduce or eliminate barriers to learning
• EXAMPLE: When the client is watching "Days of our Lives" or busy some other way, it may not be the best time to try and teach. Pick a time when you will have their full attention.

1. Maintain a respectful relationship (do not be condescending) 2. Use the client's previous learning in the present situation 3. Determine optimal time for each session depending on the learner 4. Communicate clearly and concisely 5. Use a layperson's vocabulary 6. Be sensitive to teaching pace (too fast or too slow) 7. Choose the best environment for learning 8. Use teaching aids to foster learning and focus attention 9. Involve the senses 10. Allow learners to discover content for themselves 11. Repetition reinforces learning 12. Employ "organizers" to introduce material 13. Make sure anticipated behavioral changes that show learning has taken place are possible within the context of client's lifestyle and resources

• Client contracting
• Group teaching
• Computer learning resources
• Discovery/problem solving
• Behavior modification
• Transcultural teaching

1. Obtain teaching materials, pamphlets, and instructions in languages used by client 2. Use visual aids, such as pictures, charts, or diagrams to communicate meaning 3. Use concrete rather than abstract words 4. Allow time for questions 5. Avoid medical terminology or health care language 6. If understanding another's pronunciation is a problem, validate information in writing 7. Use humor cautiously 8. Do not use slang or colloquialisms (word or phrase that is not formal or lierary, typically used in familiar conversations) 9. Do not assume that a client who nods, uses eye contact, or smiles is understanding what is being taught 10. Invite and encourage questions during teaching 11. When explaining procedures or functioning related to personal areas of the body, consider having a nurse of the same gender do the teaching 12. Include family in planning and teaching 13. Consider the client's time orientation 14. Identify cultural health practices and beliefs

• Ongoing and final process
• Nurse, client, and support people determine what has been learned
• Cognitive learning
• Psychomotor learning
• Affective learning

• 1. Direct observation 
• 2. Written measurements 
• 3. Oral questioning 
• 4. Self-reports or self-monitoring

Observing how well the client carries out the skill

• More difficult to evaluate
• Inferred by the following: 1. Listening to client's responses to questions 2. Noting how the client speaks about relevant subjects 3. Observing client's behavior that expresses feelings and values

• Provides a legal record that the teaching took place
• Communicates teaching to other health professionals
• Documents responses of the client and support people to teaching activities

• Diagnosed learning needs
• Learning outcomes
• Topics taught
• Client outcomes
• Need for additional teaching
• Resources provided

• Self-evaluation is important and the nurse must consider all factors: 1. Timing 2. Strategies 3. Content 4. Apparent helpfulness of teaching, etc.
• Include client evaluations about teaching

Hair loss: May be caused by Chemo and Radiation

The growth of excessive body hair.

• Infestation of head lice - Three kinds infect humans:
• 1. Pediculus Capitis
• 2. Pediculus Corporus
• 3. Pediculus Pubis

A contagious skin infestation by the itchmite

• 1. Flat
• 2. Fowler's position
• 3. Semi-Fowlers position
• 4. Trendellenburg's position
• 5. Reverse Trendellenburg's position

•   0 = Completely independent
• +1 = Requires use of equipment or device
• +2 = Semi-dependent - Requires help from another person for assistance, supervision, or teaching
• +3 = Moderately dependent - Requires help from another and equipment or a device
• +4 = Totally dependent - Does not participate in activity.

The science of health and its maintenance

• Skin
• Feet
• Nails
• Oral and nasal cavities
• Teeth
• Hair
• Eyes
• Ears
• Perineal-genital area

• Urinal or bedpan
• Washing face and hands
• Oral care

Leave them on too long!!

• Elimination
• Bath or shower
• perineal care
• Back massage
• Oral, nail, and hair care

• Elimination
• Washing face and hands
• Oral care
• Back massage
• As needed (prn) care includes: more frequent bathing and changes of clothing

• Culture
• Religion
• Environment
• Developmental level 
• Health and energy
• Personal preferences

The left hand is used for cleaning, thus they will always eat and take pills with the "clean" right hand. When feeding this individual, you must also feed them with your "clean" right hand.

• Protects underlying tissue
• Reulates body temperature
• Secretes sebum
• Transmits sensation
• Maintains moisture
• Bactericidal action
• Produces and absorbs vitamin D

• Sudoriferous (sweat) glands
• Apocrine glands
• Eccrine glands

• Any of the glands in the skin that secrete perspiration
• Sweat glands

• A type of sweat gland
• Apocrine glands develop in areas abundant in hair follicles, such as on your scalp, armpits and groin and open into the hair follicle just before it opens onto the skin surface.

• A type of sweat gland
• Eccrine glands occur over most of your body and open directly onto the surface of the skin

• Client's skin care practices
• Self-care abilities
• past or current skin problems

• Taking a Nursing History
• Physical assessment of the skin

• Abrasion - superficial damage to the epidermis
• Excessive dryness
• Ammonia dermatitis - diaper or undergarment rash
• Acne
• Erythema - Redness
• Hirsutism - Excessive hair growth

• Bathing Self-Care Deficit
• Dressing Self-Care Deficit
• Toileting Self-Care Deficit

• Nurse and, if appropriate, client and/or family set outcomes for each nursing diagnosis
• Nurse performs nursing interventions and activites to achieve the client outcomes

• Assisting dependent clients with bathing, skin care, and perineal care
• Providing back massages to promote circulation
• Instructing clients/families about appropriate hygienic practices and alternative methods to dressing
• Demonstrating use of assistive equipment and adaptive activities

• An intact, healthy skin is the body's first line of defense
• The degree to which the skin protects the underlying tissues from injury depends on the general health of the cells, the amount of subutaneous tissue, and the dryness of the skin
• Moisture in contact with the skin for more than a short time can result in increased bacterial growth and irritation
• Body odors are caused by resident skin bacteria acting on body secretions
• Skin sensitivity to irritation and injury varies among individuals and in acccordance with their health
• Agents for skin care have selective actions and purposes

• Removes accumulated oil, perspiration, dead skin cells, and some bacteria
• Stimulates circulation
• Produces a sense of well-being
• Offers opportunity for assessment

• Complete bed bath
• Self-help bed bath
• partial bath
• Bag bath (microwave washcloth)
• Towel bath
• Tub bath
• Shower
• Therapeutic baths

• Give for physical effecs
• Soothe irritated skin
• Treat a certain area (perineum - when a woman gives birth)
• Medication may be placed in the water

Using a corner of the washcloth, move from the inner canthus to the outer canthus.

• With long firm strokes from the wrist (ankle) to the shoulder (hips).
• This will help with circulation
• You always go from cleanest to dirtiest, thus hands and feet, armpits and groin are last, when cleaning limbs.

• Soaking the hands can loosen soil (feces) from under the nails and in the nail beds
• Soaking the feet, can help moisturize and soften 

• Yes, but they can only report their findings
• Assessment is an RN task

• Less about tasks than about people and relationships between people
• Bathing needs to focus on the experience for the client rather than the oucomes (i.e. getting a bath or shower)

necessary and routine

Doing things that make the experience soothing: Playing music, singing, and talking can be nice distractions

From the top, down, outer to inner

• Gently pull the skin back on the penis, especially if uncircumcised. 
• NOTE: Remember to slide it back in place!!

• Genital care, peri care
• Many clients can clean own perineum with assistance
• To avoid embarrassment, provide care in matter-of-fact way
• Wear gloves

• These exist in plants, animals, and humans. 
• In humans: these are controlled from within the body and synchronized with environmental factors, such as light and darkness. The most familiar biological rhythm is the circadian rhythm (24-hour internal biological clock).

A way of measuring sleep objectively, in a sleep disorder laboratory. Electrodes are placed on the scalp to record brain waves. The electrodestransmit electric energy frm the cerebral cortex and muscels of the face to pens that record teh brain waves and muscle activity on graph paper. 

A way of measuring sleep objectively, in a sleep disorder laboratory. Electrodes are placed on the chin muscles. The electrodestransmit electric energy frm the cerebral cortex and muscels of the face to pens that record teh brain waves and muscle activity on graph paper. 

A way of measuring sleep objectively, in a sleep disorder laboratory. Electrodes are placed on the outer canthus of each eye to record eye movement. The electrodestransmit electric energy frm the cerebral cortex and muscels of the face to pens that record teh brain waves and muscle activity on graph paper. 

• Conditions wehre the affected individual obtains sufficient sleep at night but still cannot stay awake during the day. Can be caused by medical conditions. 
• EXAMPLE: CNS damage and certain kidney, liver, or metabolic disorders, such as diabetic acidosis and hypothyroidism. Rarely does it have a psychological orgin.

• Wet dreams - experienced by boys, during adolescence
• orgasm and emission of semen during sleep, several times each month

Sleep that occurs when activity in the RAS is inhibited. About 75% to 80% of sleep during a night is spent in the four stages of this sleep cycle.

• Behaviors that may interfere with sleep and may even occur during sleep. 
• The International Classification of Sleep Disorders has put these into different categories: 1) Arousal Disorders - Sleepwalking, sleep terrors 2) Sleep/Wake Transition Disorders - Sleep talking 3) Parasomnias Associated with REM Sleep - Nightmares and 4) Others - Bruxisms

• Sleep is measured objectively in a sleep disorder laboratory
• The following tests are recorded: 1) Electroencephalogram (EEG) 2) Electromyogram (EMG) and 3) Electro-oculogram (EOG)

Rapid-eye-movement sleep

• An altered state of consciousness in which the individual's perception of and reaction to the environment are decreased. 
• Characterized by minimal physical activity, variable levels of consciousness, changes in the body's physiological processes, and decreased responsiveness to external stimuli. 
• It appears that individauls respond to meaningful stimuli (smoke detector), while selectively disregarding nonmeaningful stimuli (coo-coo-clock)

• Characterized by frequent short breathing pauses during sleep. 
• More than five episodes or five breathing pauses longer than 10 seconds/hour

Refers to the basic organization of normal sleep

• Refers to interventions used to promote sleep.
• Nursing interventions to enhance the quantity and quality of clients' sleep involve largely nonpharmacologic measures. 
• These involve health teaching about sleep habits, support of bedtime rituals, the provision of a restful environment, specific measures to promote comfort and relaxation, and appropriate use of hypnotic medications.

Bacteria killing

• A thickened portion of epidermis, a mass of keratotoc material.
• Most are painless and flat and are found on the bottom or side of the foot over a bony prominence.

Earwax

• Given chiefly for hygiene purposes (rather than therapeutic).
• Involves all of the following: 1) Complete bed bath 2) Self-help bed bath 3) Partial bath 4) Bag bath (microwave bag) 5) Towel bath 6) Tub bath 7) Shower

• A keratosis caused by friction and pressure from a shoe.
• Commonly occurs on the fourth or fifth toe, usually on a bony prominence such as a joint.
• Ususally conical (circular and raised)

The movement of microorganisms from one client to another

Appears as a diffuse scaling of the scalp. In severe cases it involves the auditory canals and the eyebrows. 

Cavities

• Deep grooves, frequently occur between the toes as a result of dryness and cracking of the skin.
• The treatment of choice is good foot hygiene and application of an antiseptic to prevent infection.
• Often a small piece of guaze is inserted between the toes in applying the antiseptic and left in place to assist healing by allowing air to reach the area

The gums

Red, swollen gingiva (gums)

The growth of excessive body hair

The self-care by which people attend to such functions as bathing, toileting, general body hygiene, and grooming.

Teh growing inward of the nail into the soft tissues around it, most often results from imporper nail trimming.

The fine hair on the body of the fetus, also referred to as down or woolly hair.

• An infestation with lice 
• Three common types are: 1) Pediculus capitis - Head louse 2) Pediculus corporis - Body louse and 3) Peduculus pubis - the crab louse

Gum disease

• Warts that appear on the sole of the foot. 
• Caused by the virus papovavirus hominis and they are moderately contagious.
• Frequently painful and make walking difficult

An invisible solt film that adheres to the enamel surface of teeth. It consists of bacteria, molecules of saliva, and remnants of epithelieal cells and leukocytes.

• Advanced pariodontal disease.
• The teeth are loose and pus is evident when the gums are pressed

• An oily substance that 1) softens and lubricates the hair and skin 2) prevents the hair from becoming brittle 3) decreases water loss from the skin when the external humidity is low.
• Because fat is a poor conductor of heat, sebum 1) Lessens the amount of heat lost from teh skin and 2) has a bactericidal (bacteria-killing) action

• A contagious skin infestation by the itch mite.
• Characteristic lesion is the burrow produced by the female mite as it penetrates into the upper layers of the skin. Burrows are short, wavy, brown or black, threadlike lesions most commonly observed between the fingers, creases of the wrists and elbows, beneath breast tissue and in the groin area. 
• More intense in the evening because teh increased warmth of hte skin has a stimulating effect on the parasites.

• On all body surfaces except the lips and parts of the genitals
• The body has from 2 - 5 million, which are all present at birth
• Most numerous on the palms of the hands and the soles of the feet

A visible, hard deposit of plaque and dead bacteria that forms at the gum lines

• Given for physical effects, such as to sooth irritated skin or to treat an area. 
• Medications may be placed in the water

Small gray-brown parasites that bite into tissue and suck blood

Ringworm of the foot, caused by a fungus

• Dry mouth that occurs when the supply of saliva is reduced.
• This condition can be caused by side effects of certain medications (antihistamines, antidepressants, and antihypertensives)

Commitment or attachment to a regimen

• The feeling domain
• Divided into categories that specify the degree of the "person's depth of emotional responses to tasks"

An individual's desire to learn and to act on the learning

• The capacity to obtain, process, and understand the basic health information and services needed to make appropriate health decisions.
• This would include such tasks as comprehending prescription labels, interpretingappointment slips, completing health insurance forms, and following instructions for diagnostic tests. 

The nurse focuses on the feelings and attitudes of learners, on the importance, on the importance of the individual in identifying learning needs and in taking responsibilty for them, and on the self-motication of the learners to work toward self-reliance and independence.

The process by which individuals copy or reproduce what they have observed

• A change in human disposition or capability that persists and that cannot be soley accounted for by growth. 
• Represented by a change in behavior

A desire or a requirement to know somethingthat is presently unknown to the learner

The process by which a person learns by observing the behavior of others

The desire to learn

A pleasant experience such as praise and encouragement, in fostering repetition of an action

• To learn is the demonstation of behaviors or cues that reflect the learner's motivation to learn at a specific time
• Readiness reflects not only the desire or willingness to learn but also the ability to learn at a specific time.

• A system of activities intended to produce learning.
• The teaching process is intentionally designed to produce precific learning

• 1. Convey empathy in the nurse-client relationship
• 2. Encourage the learner to establish goals and promote self-directed learning
• 3. Encourage active learning by serving as a facilitator, mentor, or resource for the learner
• 4. use active learning strategies to assist the client's adoption of new behavior
• 5. Expose the learner to new relevant information and ask appropriate questions to encourage the learner to seek answers

• Funtional ability for self care
• Efficacy of instructions and assistive devices
• Client status
• Need for analgesics
• Tissue integrity
• Nutrition adequate to support skin integrity

• Essential for ambulation - 2 to 3 times body weight on the foot with each step
• Feet develop and are affected by restrictive or supportive shoes
• Feet fully grown by about 20 years
• Changes with aging; aging may affect self-care

• Nursing history 
• Physical assessment

• Normal nail and foot care practices
• Type of footwar worn
• Self-care abilites
• Presence of risk factors for foot problems
• Any foot discomfort
• Any perceived foot problems with foot mobility

• Calluses
• Corns
• Unpleasant odors
• Plantar warts
• Fissures between the toes
• Fungal infections (tinea pedis)
• Ingrown toenails

• 1. Bathing Self-Care Deficit (foot care)
• 2. Risk for Impaired Skin Integrity
• 3. Risk for Infection
• 4. Deficient nowledge (diabetic foot care)

• Identify nursing interventions that will help the client maintain or restore healthy foot care proactices
• Establishing desire outcomes for each client

• Teach the client about correct nail and footcare
• Proper footwear
• Wearing the correct size
• Ways to prevent potential foot problems
• Physical assessment of the feet

• Self-care ability and participation
• Hygiene
• Skin integrity and correct practices

• Normally present at birth
• continue to grow throughout life
• Tend to be tougher, more brittle, and in some cases thicker with age
• Older person's nails may grow more slowly and be ridged and grooved

• Nursing history 
• Physical assessment

• Normal care practices
• Self-care abilities
• Any problems associated with them

• Bathing Self-Care Deficit
• Risk for Infection

• Identify measures that will assist the client to develop or maintain health nail care practices
• Establish a shecdule of nail care

• Check agency's policy regarding nail care
• One hand or foot is soaked, if needed, and dried
• Nail is cut or filed straight across beyond the end of the finger or toe
• Avoid trimming or digging at the lateral corners

• Nails should be filed rather than cut
• Infections around the cuticle or inflammation of the tissues must be recorded and reported

• Demonstrate healthy nail care practices
• Describe causes of nail problems
• Blanch test (capillary refill)

• Each tooth: crown, root, pulp cavity
• Gingiva (gum)
• Periodontal disease
• Dental caries (cavities)

• Nursing history
• Physical assessment of the mouth

• Oral hygiene practices
• Dental visits
• Self-care abilities
• Past or current mouth problems

• Halitosis (bad breath)
• Glossitis
• Gingivitis
• Periodontal disease
• Pyorrhea
• Reddened or excoriated mucosa
• Excessive dryness of the bucal mucosa
• Cheilosis
• Plaque
• Tartar
• Dental caries (cavities)
• Sordes
• Stomatitis
• Parotitis

• Serious illness
• Confusion
• Coma
• Depression
• Dehydration
• Deficient knowledge, inadequate nutrition, lack of money or insurance, radiation treatment

• Impaired Oral Mucous Membrane
• Deficient Knowledge

• The nurse and, if appropriate, the client and/or family set outcomes for each nursing diagnosis
• The nurse performs nursing interventions and activities to achieve the client outcomes

• Promote oral health throughout the life span
• Infants and toddlers: after tooth eruption start dental hygiene, dental visit starting 2 or 3 times a year
• Preschool and school-aged children: Care essential in deciduous-to-permanent tooth transistion, brush teeth after eathing, regular checkups
• Adolescents and adults: Maintenance
• Older adults: Number of eduntulous (denture wearing) adults declining, so cavities a factor

• Mechanical brushing and flossing of the teeth: Stimulation of the gums and flushing of the mouth
• Caring for dentures: Brushing or soaking and flushing of the mouth
• Assisting clients with oral care: Special needs: xerostomia (dried/cracked lips)

• Use data collected
• Judge whether desired outcomes have been achieved: if not, explore why
• Modify care plan if needed

It reflects a person's feeling or self-concept, well-being, state of health

• Nursing history
• Physical assessment

• Usual hair care
• Self-care abilites
• History of hair or scalp problems
• Conditions known to affect the hair (e.g. Alopecia)

• Dandruff
• Hair loss
• Ticks
• Pediculosis
• Scabies
• Hirsutism

• Dressing Self-Care Deficit
• Impaired Skin Integrity
• Risk for Infection
• Disturbed Body Image

• The nurse and, if appropriate, the client and/or family set outcomes for each nursing diagnosis
• The nurse performs nursing interventions and activities to achieve the client outcomes

• Brush or comb daily
• Washed as needed to keep it clean
• Beard or moustache care daily

• Use data collected
• Judge whether desired outcomes have been achieved: if not, explore whyModify care plan if needed

• Require no special hygiene
• Lacrimal fluid washes the eye
• Eyelids and eyelashes prevent entrace of foreign particles

• Nursing history
• Physical assessment

• Client's eyeglasses or contact lenses
• Recent examinations by ophthalmologist
• Any history of eye problems and related treatments

• Risk for Infection
• Risk for Injury

• The nurse identifies nursing activities that will assist the client to maintain the integrity of the eye structures
• Prevent eye injury and infection

Open eye wide and gently press from the top, down and the bottom, up, with both thumbs.

Gently pull down on conjunctival sac, have the client look up and with the other hand, pinch the contact lens at the bottom of the sac and pull straight out

• Eye care
• Eyeglass care
• Contact lens care: Teach clients how to clean, insert, and remove contact lenses
• Ways to protect the eyes from injury and strain

• Use data collected
• Judge whether desired outcomes have been achieved: if not, explore why
• Modify care plan if needed

• Minimal hygiene
• Clean auricles and excessive cerumen during bed bath
• Hearing aids may require nursing assistance
• Hearing aids are usually removed before surgery

They are VERY expensive, be careful that they do not get lost!!

• Behind-the-ear open fit
• Behind-the-ear with earmold
• In-the-ear aid
• In-the-canal aid
• Completely-in-the-canal aid
• Eyeglasses aid
• Body hearing aid

• Usually cared for by client blowing into tissue
• Clean with cotton-tipped applicator (not inserted farther than cotton tip) or saline

• Temperature
• Ventilation
• Noise

• Mattresses
• Side rails
• Footboard or footboot
• Bed cradles

• Wash hands thoroughly after handling a client's bed linen
• Hold soiled linen away from uniform
• Never place linen for one client on another client's bed = cross contamination
• Place soiled linen directly in a portable hamper or tucked into a pillow case at the end of the bed for disposal
• Do not shake soiled linen into the air
• Conserve time and energy; make one side of the bed first
• Gather all linen before starting to strip a bed

• 1. Maintain the client in good body alignment
• 2. Move the client gently and smoothly
• 3. Explain what you plan to do throughout the procedure before you do it?
• 4. Use the bed-making time, like the bed bath time, to assess and meet the client's needs

Bed making is usually delegated to the UAP - Both occupied and unoccupied

• Instruct the UAP to report immediately any tubes or dressings that become dislodged
• Stress the importance of having the call light available for the client out of bed.

• Determine the extent to which the client can assest or the need for a second person to assist
• Instruct in how to handle tubes or equipment as well as in need for special equipment (e.g. a footboard)

It regulates the sleep/wake cycle through the release of certain neurotransmitters.

• serotonin
• GABA
• melatonin

• acetylcholine
• dopamine
• noradrenaline
• cortisol

Sleep is an altered state of consciousness where perception of and reaction to environment decrease.

• Helps us cope with stresses
• Prevents fatigue
• Conserves energy
• Restores normal levels of activity
• Restores normal balance among parts of the nervous system
• Necessary for protein synthesis
• Psychological well-being
• Restores mind and body so we can enjoy life more fully and enhances our daytime functioning

• preparing for sleep
• darkness
• reduced activity
• laying down

24 hour internal biological clock

Biological clock coincides with sleep-wake cycle.-person is awake when body temp is the highest and asleep when body temp is lowest.

• One third (1/3)
• This is a universal biological need

• The lower part of the brain: Neurons in reticular formation integrate sensory information from the PNS and relay it to the cerebral cortex.
• Reticular activating system (RAS): is involved in the sleep/wake cycle

Thought to lessen response to sensory stimulation

Thought to shut off activity in neurons of the RAS

They are associated with cerebral cortical arousal

• A. Cortisol
• B. Growth Hormone (GH)

Reticular Activating System (RAS)

Melatonin: It makes a person feel less alert

Refers to basic organization of sleep

• NREM - Non-rapid eye movement
• REM - Rapid-eye movement

• Occurs when activity in RAS is inhibited
• Constitutes 75% to 80% of sleep
• Consists of four stages

• Very light sleep and lasts only a few minutes
• Feels drowsy and relaxed
• Eyes roll from side to side
• HR and RR drop slightly
• Can be readily awakened and may deny sleeping

• Light sleep lasts only about 10 to 15 minutes
• Body processes continue to slow down
• Eyes are generally still
• HR and RR decrease slightly more
• Body temperature falls
• 44 to 55% of total sleep
• Requires more intense stimuli to awaken

• Deepest stages of sleep (delta sleep or deep sleep)
• HR and RR drop 20-30% below waking hours
• Difficult to arouse
• Not distribued by sensory stimuli
• Skeletal muscles very relaxed
• Reflexes are diminished
• Snoring is likely to occur
• Swallowing and saliva production reduced
• Essentiaal for restoring energy and releasing important growth hormones

• BP and HR decrease
• Peripheral blood vessels dilate
• CO decreases
• Skeletal muscles relax
• BMR decreases 10-30%
• GH levels peak
• Intracranial pressure decreases

• Occurs every 90 minutes
• Lasts 5-30 minutes
• AcH and dopamine increase
• Most dreams take place in REM
• Brain is highly active
• Brain metabolism increases as much as 20%
• Distinctive eye movements occur

• Voluntary muscle tone dramatically decreased
• Deep tendon reflexes absent
• May be difficult to arouse or may wake up spontaneously
• Gastric secretions increase (REST & DIGEST)
• HR and RR often are irregular
• Regions of brain associated with learning, thinking, organizing information stimulated

• Usually last 90-110 minutes in adults
• Usually four to six cycles during 7-8 hours of sleep
• If awakened from any stage, must restart at stage I
• As sleep progresses, less time in stages III and IV of NREM and more in REM, dreams become longer

• Sleep 16-18 hours a day
• Periods of 1 to 3 hours spent awake
• Enter REM sleep immediately
• 50% NREM and 50% REM
• Sleep cycle ~ 50 minutes

• Awaken every 3 to 4 hours, eat, and then go back to sleep
• Periods of wakefulness gradually increase
• By 6 months, most infants sleep through the night and establish a pattern
• Establish a pattern of daytime naps

• 12 to 14 hours are recommended
• Most still need an afternoon nap
• Nighttime fears and nightmares are also common

• Preschool child (3-5 years) requires 11 to 13 hours of sleep: The sleep needs fluctuate in relation to activity and drowth spurts
• School age child (aged 5-12) needs 10-11 hours of sleep: Most receive less than needed

• Require 9-10 hours of sleep each night
• Nocturnal emmissions (wet dreams) occur in boys
• Circadian rhythms tend to shift: Tendency to stay up later and wake later

• Most healthy adults need 7-9 hours of sleep
• Individual variations

• Tendency toward earlier bedtime and wake times
• May show an increase in disturbed sleep
• With dementia: Sundowning syndrome may last through the night
• The need for sleep does not decrease with age

• Illness
• Environment
• Lifestyle
• Emotional stress
• Stimulants and alcohol
• Diet
• Smoking
• Motivation
• Medication

• Insomnia
• Excessive daytime sleepiness
• Parasomnia

• Difficulty falling alseep
• Waking up frequently
• Difficulty staying asleep
• Daytime sleepiness
• Difficulty concentrating 
• Irritability
• Risk factors: Older age and Female (menapause)

• Irritability
• Behavioral treatment: 1) Stimulus control 2) Cognitive therapy 3) Sleep restriction

• Hypersomnia
• Narcolepsy
• Sleep apnea
• Insufficient sleep

• Sufficient sleep at night but cannot stay awake during the day
• Caused by medical or psychological disorders

• Caused by lack of hypocretin in CNS that regulates sleep
• Clients have sleep attacks
• Sleep at night usually begins with sleep onset REM period
• NOTE: Should not be driving!!!

• Frequent short breathing pauses during the night
• More than 5 apneic episodes > 10 sec/hr considered abnormal
• Symptoms include snoring, frequent awakenings, difficulty falling asleep, morning headaches, memory and cognitive problems, irritability
• May exhibit loud snoring
• May experience major headaches

• Obstructive
• Central 
• Mixed

• Leads to sleepiness and fatigue during the day and may lead to attention and concentration deficits
• 19 hours of wakefulness produces: the equivalent of 0.05 blood alcohol level
• 24 hours of wakefulness produces: the equivalent of 0.1 blood alcohol level

• Behavior that may interfere with or occur during sleep: Arousal disorders (sleepwalking, sleep terrors, etc.)
• Sleep-wake transition disorders (sleep talking)
• Associated with REM sleep (Nightmares)
• Others (Bruxism - grinding of the teeth, enuresis - bedwetting, periodic limb movement disorders, etc.)

• Experience sleepiness and fatigue during the day
• Attention and concentration deficits
• Reduced vigilance
• Distractibility
• Reduced motivation
• Fatique, malaise, diplopia, dry mouth

Double vision

• Sleep history
• Health history
• Physical exam
• NOTE: If warranted, a sleep diary and diagnostic studies

• When the client usually goes to sleep
• Bedtime rituals
• Does the client snore
• Whether or not the client can stay awake during the day
• Whether they are taking any prescribed or OTC medications

• Obtain information about medical or psychiatric problems that may influence sleep
• Medication history

• Enlarged and reddened uvula and soft palat
• Enlarged adenoids and tonsils (children)
• Obesity (adults)
• Neck circumerence > 17.5 inches (men)
• Deviated septum (occasionally)
• NOTE: Rarely yields information unless the client has obstructive sleep apnea

• Time factors associated with sleep
• Acitivites performed 2-3 hours prior to sleep
• Consumption of caffeine or alcohol
• Medications
• Bedtime rituals
• Difficulty remaining awake during the day
• Any worries or fears that may be contributing

Sleep studies

Disturbed Sleep Pattern: With specific descriptions such as "difficulty falling asleep" or "difficulty staying asleep" (various etiologies may be involved and specified)

• Risk for injury
• Ineffective coping
• Fatigue
• Risk for impaired gas exchange
• Deficient knowledge
• Anxiety
• Activity intolerance

• Maintain (or develop) a sleeping patttern that provides sufficient energy for daily activities
• Enhance feeling of well being
• Improve the quality and quantity of the client's sleep

• Sleep hygiene (term used for interventions that promote sleep) include:
• 1) Reducing environmental distractions
• 2) Promoting bedtime rituals
• 3) providing comfort measures
• 4) Scheduling nursing care to promote uninterrupted sleep
• 5) Teaching stress reduction, relaxation techniques or good sleep hygiene
• 6) Sleep medications, if appropriate

• The importance of sleep
• Conditions that promote sleep
• Conditions that interfere with sleep
• Safe use of sleep medications
• Effects of prescribed medications on sleep
• Effects of disease states on sleep
• The importance of long periods of uninterrupted sleep

• Listening to music
• Reading
• Soothing bath
• Praying

• Need to be socialized into presleep routine
• Usually preceded by hygienic ritual (bathing)

• A. Altering
• B. eliminating

• Minimal noise
• Comfortable room temperature
• Appropriate ventilation (fan)
• Appropriate lighting
• White noise (fan)

• Ensure a safe environment
• Display a concerned, caring attitude
• Do some of the following for the client:
• 1. Loose fitting nightwear
• 2. Hygienic routines
• 3. Smooth, clean, dry bed linens
• 4. Encouragement to void
• 5. Relaxation techniques, i.e., backrub, breathing
• 6. Correct positioning
• 7. Schedule medications for maximum effectiveness and least interference with sleep
• 8. Listen to and deal with problems as they arise (Kathy's story of elderly woman who missed her husband - Turned her on her side, gave her a pillow to cuddle and a back massage)

• Sedative - hypnotics (induce sleep)
• Anti-anxiety or tranquilizers
• Start with low dose
• Avoid regular use and abrupt cessation
• NOTE: Must be aware of the actions, effects, risks of specific medications

Mildest form of CNS depression is sedation (diminishes physical and mental responses at lower dosages but does not affect consciousness)

• Benadryl (diphenhydramine)
• It is a short acting hypnotic

• (SEE Kee Book, p. 309, table 20-1)
• Hangover
• REM rebound
• Dependence
• Tolerance
• Excessive depression
• Respiratory depression
• Hypersensitivity

• (SEE Kee book, p. 312)
• Long acting
• Intermediate acting
• Short acting
• Ultrashort acting

1900's

Usually used to control seizures (Phenobarbital)

• Useful as sleep sustainers (longer periods of sleep).
• Should be closely monitored (Alurate, Butisol, etc.)

• Used to induce sleep for insomnia.
• Should be monitored (Seconal, Nembutal, etc.)

Used as general anesthetic (Pentothal)

• (SEE Kee book, p. 314 and Mosby's 2012 Drug Reference)
• Selected medications that are ordered as sedative-hypnotics for inducing sleep.

• Can supress stage 4 of NREM sleep (may result in vivid dreams or nightmares
• Can delay REM sleep
• Special considerations: Patients with renal or hepatic dysfunction

Usually used for short term treatment of insomnia (nonbensodiazepine)

• Using data collected during care and the desired outcomes developed during the planning stage as a guide, the nurse judges whether the client goals and outcomes have been achieved.
• If the desired outcomes are not achieved, the nurse and client should explore the reasons.