What changes are seen developmentally in infants, toddlers, and preschoolers with decreased mobility?
Slower progression in gross motor skill, intellectual and musculoskeletal development
Body aligned with line of gravity, resulting in unbalanced posture
What changes are seen developmentally in adolescents in relation to decreased mobility?
Growth spurt that is imbalanced and possibly altered with immobility
Delayed development of independence
Social isolation
What changes are seen developmentally in adults in relation to decreased mobility?
Alterations in every physical system
Alterations in family and social systems
Alterations in job identity
What changes are seen developmentally in older adults with decreased mobility?
Alteration in balance resulting in major risk for falls and injuries
Steady loss of bone mass resulting in weakened bones
Decreased coordination
Walking more slowly
Taking tiny steps
Alteration in functional status
Increased dependence on staff, family and significant others
What are some nursing diagnoses related to mobility/immobility?
Activity intolerance
risk for constipation
ineffective airway clearance
risk for disuse syndrome
bathing/hygiene self-care deficit
disturbed sleep pattern
social isolation
impaired tissue integrity
What is the primary goal for the integumentary system for clients with decreased mobility?
Maintaining intact skin
What are the primary goals for the respiratory system for clients with decreased mobility?
Maintaining a patent airway, achieving optimal lung expansion and gas exchange and mobilizing airway secretions
What are the primary goals for the cardiovascular system for clients with decreased mobility?
Maintaining cardiovascular function, increasing activity tolerance and preventing thrombus formation
What are the primary goals for the metabolic system for clients with decreased mobility?
Decreasing injuries to the skin and maintaining metabolism within normal functioning
What are the primary goals for the elimination system for clients with decreased mobility?
Maintaining or achieving normal urinary and bowel elimination patterns
What are the primary goals for the musculoskeletal system for clients with decreased mobility?
Maintaining or regaining body alignment and stability, decreasing skin and musculoskeletal system changes, achieving full or optimal ROM and preventing contractures
What instructions are given to a client using a cane?
- Maintain two points of support on the ground at all times
- Keep the cane on the stronger side of the body
- Support body weight on both leg, move cane forward 6 to 10 inches, then move the weaker leg forward toward the cane
- Next, advance the stronger leg
- Repeat
What instructions are given to the client using crutches?
- Do not alter crutches after proper fit has been determined
- Follow crutch gait prescribed by physical therapy
- Support body weight at hand grips with elbows flexed 30 degrees
- Position crutches on unaffected side when sitting or rising from chair
What are the primary goals for psychosocial health in clients with decreased mobility?
Maintaining normal sleep/wake patterns, achieving socialization, and independent completion of self-care
What are the primary goals developmentally for clients with decreased mobility?
Continuing normal development and achieving physical and mental stimulation
A client has been sitting in a chair for 2 hr. What is the client most at risk for developing?
B. pressure ulcer
Which of the following nursing interventions should be implemented to maintain a patent airway in a client on bedrest?
A. teach to use an incentive spirometer while awake
Which of the following findings should be reported to the PCP for a client on bedrest?
C. orthostatic hypotension
Which of the following nursing interventions will reduce the risk of thrombus development? (select all that apply)
- teach the client not to use the Valsalva maneuver
- apply elastic stockings
- review lab values for total protein level
- place pillows under the client's knees and lower extremities
- assist the client to change position often
- apply elastic stockings
- assist the client to change position often
What does a sleep cycle consist of?
Nonrapid eye movement (NREM)
Rapid eye movement (REM)
During the course of the night, how many sleep cycles does a person normally experience?
After a person experiences stage 1 of NREM, he cycles 4 to 6 times through the other stages of sleep
Very light sleep
Only a few minutes long
Vital signs and metabolism beginning to diminish
Can be awakened easily
Feels relaxed and drowsy
These are the characteristics of what stage of sleep?
Stage 1 NREM
Deeper sleep
10 to 20 minutes in length
Vital signs and metabolism continuing to diminish
Can still be awakened easily
Increased relaxation
These are the characteristics of what stage of sleep?
Stage 2 NREM
Deep sleep
15 to 30 minutes in length
Vital signs continuing to decrease
Difficult to awaken
Relaxation such that the person seldom moves
These are the characteristics of what stage of sleep?
Stage 3 NREM
Deepest sleep
15 to 30 minutes in length
Vital signs very low as compared to when awake
Very difficult to awaken
Stage at which the body achieves physical rest and restoration
Stage at which enuresis and talking and walking in one's sleep occur
These are the characteristics of what stage of sleep?
Stage 4 NREM
Occurrence of dreams
20 minutes long and starts about 50 to 90 minutes after falling asleep
Varying vital signs
Very difficult to awaken
Stage at which mental rest and restoration occur
These are the characteristics of what stage of sleep?
REM
Match the sleep averages with the ages (one option may be used twice)
1. 16 hr a day
2. 12 hr a day with some of the sleep coming during a daytime nap
3. 12 hr a night with less napping during the day
4. 8 to 10 hr a night with two to three naps during the day
5. 7.5 hr a night
6. 11 to 12 hr a night for younger children with 9 to 10 hr a night for older ones
7. 6 to 8.5 hr per a night with daytime naps possibly accounting for some of the hours
8. 6 to 8.5 hr a night
A. Birth to 3 months
B. Infants (3 months to 1 year)
C. Toddlers
D. Preschoolers
E. School-age
F. Adolescents
G. Young adults
H. Middle adults
I. Older adults
1 - A
2 - C
3 - D
4 - B
5 - F
6 - E
7 - I
8 - G and H
What are three common sleep disorders?
Insomnia
Sleep apnea
Narcolepsy
Which sleep disorder consists of difficulty falling asleep or the inability to receive restorative sleep, is more common in women and causes may include stress, illness, and work-related issues?
Insomnia
Which sleep disorder is a disorder caused by the lack of airflow to the nose and mouth for > 10 sec or longer during sleep?
Sleep apnea
Which sleep disorder may be caused by a single disorder or a mixture of a CNS dysfunction and obstructive problem?
Sleep apnea
which sleep disorder is a disorder of the sleep and wake mechanism, which may cause the person to lose the ability to stay awake?
Narcolepsy
When assessing a client's sleep patterns, history and changes that have occurred what questions would you ask about sleep problems?
Type of problem
Symptoms
Timing
Seriousness
Related factors
How the lack of sleep has impacted the client
What type of scale or visual is used to rate sleep?
Linear scale with "best night sleep" on one end and "worst night sleep" on the other
or
Rate the sleep on a scale of 0 to 10
What are common factors that interfere with sleep?
Illness
Current life events
Emotional stress or mental illness
Diet
Exercise
Sleep environment
Medications
What are some nursing diagnoses related to rest and sleep?
Sleep deprivation
Fatigue
Disturbed sleep pattern
What are some nursing interventions to implement for a client with a sleep disorder?
Assist the client in establishing and following a bedtime routine
Attempt to minimize the number of times the client is awakened during the night while hospitalized
Offer to assist the client with personal hygiene needs and/or a back rub prior to sleep to increase comfort
What are some lifestyle changes a client can implement to help with sleep?
Exercise regularly at least 2 hr before bedtime
Arrange the sleep environment to what is comfortable
Limit alcohol, caffeine and nicotine in the late afternoon/evening
Limit fluids 2 to 4 hr before bedtime
Engage in muscle relaxation if anxious or stressed
What are special instructions that can be given to a patient with narcolepsy in regard to sleep?
Participate in regular exercise
Eat small meals that high in protein
Avoid activities that increase sleepiness
Avoid activities that would cause injury should the client fall asleep
Take naps when narcoleptic events are likely to occur
Take stimulants as prescribed by PCP
What device may be prescribed for a client with sleep apnea?
Continuous positive airway pressure (CPAP)
A client presents to the clinic reporting fatigue and an inability to sleep at night. Which of the following assessment findings supports the client's statement?
D. the client's eyes are puffy and red and he is irritable
Which of the following recommendations should be given to a client to promote sleep and rest? (select all that apply)
- Avoid all caffeinated beverages
- Participate in regular exercise each morning
- Take an afternoon nap
- Practice relaxation exercises before bedtime
- Limit fluid intake after dinner
- Participate in regular exercise each morning
- Practice relaxation exercises before bedtime
- Limit fluid intake after dinner
A client is diagnosed with obstructive sleep apnea. Which of the following nursing diagnoses should be the highest priority?
C. ineffective breathing pattern
Since admission to the hospital, a client has bathed in the morning following facility/agency routine; however, at home, she always takes a warm bath just before bed. Now she is having difficulty sleeping. Which of the following interventions is most beneficial to the client at this time?
B. allow her to take a bath in the evening
Is undertreatment of pain a serious healthcare problem in the US?
Yes
What are the physiological and psychological consequences of undertreaatment of pain?
Acute/chronic pain can cause anxiety/fear and depression
Poorly managed acute pain may lead to chronic pain syndrome
When assessing for pain, in what clients may challenges occur?
Cognitively impaired
Ventilator dependent
What does proper pain management include?
Pharmacological and nonpharmacological methods
In the physiology of pain what is the conversion of painful stimuli to an electrical impulse?
Transduction
In the physiology of pain what occurs as the electrical impulse travels along the nerve fibers and is regulated by neurotransmitters?
Transmission
In the physiology of pain where does perception or awareness of pain occur?
In the brain and is influenced by thought and emotional processes
Where does modulation of pain occur and what does it cause?
In the spinal cord
Causes muscles to reflexively contract, moving the body away from painful stimuli
These factors increase or decrease pain transmission?
Substance P
Prostaglandins
Bradykinin
Histamine
Increase
These factors increase or decrease pain transmission?
Serotonin
Endorphins
Decrease
This type of pain is protective, temporary, usually self-limiting and resolves with tissue healing
Acute pain
With this type of pain the physiological responses (SNS) are fight-or-flight
Acute pain
What are the fight-or-flight responses to acute pain?
Tachycardia
Hypertension
Anxiety
Diaphoresis
Muscle tension
What behavioral responses may be seen with acute pain?
Grimacing
Moaning
Flinching
Guarding
What are interventions for acute pain?
Treating the underlying problem
Which type of pain is not protective, is ongoing or reoccurs frequently, lasting > 6 months and persisting beyond tissue healing?
Chronic pain
What are the physiological responses to chronic pain?
Usually no alterations in vital signs
Client may experience depression, fatigue, and decreased level of functioning
What can psychosocial implications of chronic pain lead to?
Disability
Which type of pain may or may not have a known cause?
Chronic pain
What type of pain management is aimed at symptomatic relief?
Chronic pain
For which type of pain is pain rating not useful?
Chronic pain
Which type of pain can be malignant or nonmalignant?
Chronic pain
What is nociceptive pain?
Typical processing of stimuli that has damaged normal tissues - it arises from injured body tissues
This pain is usually throbbing, aching and localized
Nociceptive pain
What are the three types of nociceptive pain?
Somatic
Visceral
Cutaneous
Which type of pain typically responds to opioids and nonopioid medications - nociceptive or neuropathic?
Nociceptive
Where does nociceptive somatic pain come from?
Bone, muscle, skin or connective tissue
Where does nociceptive visceral pain that may cause referred pain in other body locations come from?
Internal organs
Usually poorly localized
Where does nociceptive cutaneous pain come from?
Originates in the skin or subcutaneous tissue
What is neuropathic pain?
Atypical processing of stimuli by the peripheral or central nervous system
What is neuropathic pain associated with?
Damaged nerve fibers
Which type of pain (nociceptive or neuropathic) includes phantom limb pain, pain below the level of a spinal cord injury, and diabetic ______?
Neuropathic
What are the typical characteristics of neuropathic pain?
Intense, shooting, burning or "pins and needles"
What does neuropathic pain respond to for treatment?
What is a patient controlled anaglesia (PCA) pump?
Medication delivery system that allows the client to self-administer safe doses of opioid narcotics
What are the advantages of PCAs?
Constant plasma levels are maintained by small, frequent doses
The client experiences less lag time between identified need and delivery of medication
What does the client need to understand about the use of PCAs?
He is the only person who should push the PCA button to prevent inadvertent overdosing
What are two commonly used opioids in PCAs?
Morphine sulfate and hydromorphone
What are some other strategies for effective pain management?
Proactively giving analgesics before pain becomes to severe
Instructing client to not wait until pain is severe to request medication
Educating the client
Assisting the client to reduce fear and anxiety
Creating a treatment plan that includes both nonpharmacological and pharmacological pain relief measures
Who are the high risk clients for sedation, respiratory depression and coma?
Older adults
Opioid-naive client
When should the opioid be stopped and Narcan given?
When respirations are less than 8/min, shallow and the client is difficult to arouse
What other scale should be used along with a pain rating scale when a client is receiving opioids?
Sedation scale
A nurse is performing a pain assessment on a client who has come to the emergency department with a report of severe abdominal pain. The nurse asks the client if he has experienced nausea and vomiting. The nurse is assessing
C. presence of associated symptoms
Frequent pain assessment includes assessing the intensity of the pain. The nurse can best assess the intensity of a client's pain by
A. offering the client a pain scale to measure his pain
Which of the following statements are true regarding pain? (select all that apply)
- all cultures have the same attitudes regarding pain
- feelings of anger and guilt may be caused by pain
- it may be difficult to adequately assess pain in a client with cognitive impairment
- a client who is sleeping could not be experiencing pain
- it is best to wait until pain is severe before administering analgesics
- feelings of anger and guilt may be caused by pain
- it may be difficult to adequately assess pain in a client with cognitive impairment
A nurse is taking a history on a client with pain knows that
A. pain is whatever the client says that is is
Match the following types of pain with their descriptors: V = visceral, S = somatic, and N = neuropathic
- Phantom limb pain
- Poorly localized pain
- Referred pain
- Fracture pain
- Burning "pins and needles" pain
- Sharp, aching pain
V = Poorly localized, referred pain
S = Fracture pain, sharp, aching pain
N = Phantom limb pain, burning "pins and needles" pain
