Nursing Care of Older Adults: Challenges, Assessment, and Therapies, Exams of Nursing

Download Nursing Care of Older Adults: Challenges, Assessment, and Therapies and more Exams Nursing in PDF only on Docsity! 1 Fundamentals exam 2 pp notes Chap 14 Older adult • People who are 65 years old are in the lower boundary for “old age” in demographics and social policy within the United States. However, many older adults consider themselves to be “middle-age” well into their seventh decade. • Chronological age often has little relation to the reality of aging for an older adult. Each person ages in his or her own way. Every older adult is unique, and as a nurse you need to approach each as an individual. • America is aging. The number of older adults in the United States is growing, both absolutely and as a proportion of the total population. • There has been a 21% increase in the older adult population since 2002. Part of this increase is caused by the increase of the average life span. The aging of the baby-boom generation and the growth of the population segment older than 85 years contribute to the projected increase in the number of older adults. • When caring for this group of patients, nurses must consider cultural, ethnic, and racial diversity. • The challenge is to gain new knowledge and skills to provide culturally sensitive and linguistically appropriate care. • [Ask students: Do you believe longer life span, better medicine, better treatments, better diagnostic testing, and aging baby boomers makes it easier to treat older adults? Discuss.] Variability Among Older Adults • Most older adults are active and involved members of their communities. A smaller number have lost the ability to care for themselves, are confused or withdrawn, and/or are unable to make decisions concerning their needs. Most older adults live in noninstitutional settings. However, a smaller number have lost the ability to care for themselves. • Aging does not inevitably lead to disability and dependence. Most older people remain functionally independent despite the increasing prevalence of chronic disease. • Nursing assessment provides valuable clues to the effects of a disease or illness on a patient’s functional status. • When you assess older adults, you will need to identify their strengths, weaknesses, and abilities when developing a plan of care. • The physical and psychosocial aspects of aging are closely related. A reduced ability to respond to stress, the experience of multiple losses, and the physical changes associated 2 with normal aging combine to place people at high risk for illness and functional deterioration. • Do not assume that all older adults have signs, symptoms, or behaviors representing disease and decline or that these are the only factors you need to assess. You also need to identify an older adult’s strengths and abilities during the assessment and encourage independence as an integral part of your plan of care 5 • Older adults need to adjust to the physical changes that accompany aging. • Some older adults, both men and women, find it difficult to accept aging. Acceptance of personal aging does not mean retreat into inactivity, but it does require a realistic review of strengths and limitations. • Need to cope with retirement, residence change, and death of loved ones. All require an extended period of adjustment, during which assistance and support from health care professionals, friends, and family members are necessary. Deaths represent both losses and reminders of personal mortality. Coming to terms with them is often difficult. By helping older adults through the grieving process. • A variety of issues sometimes occur, including control of decision making, dependence, conflict, guilt, and loss. How these issues surface in situations and how they are resolved depend in part on the past relationship between the older adult and their adult children. • As adult children and aging parents negotiate the aspects of changing roles, nurses are in the position to act as counselors for the entire family. Helping older adults maintain their quality of life is often a priority. What defines quality of life is unique for each person. Community-Based and Institutional Health Care Services • Nurses help older adults and their families by providing information and answering questions as they make choices among care options. Your assistance is especially valuable when patients and families need to make decisions about moving to a nursing center. • Some family caregivers consider nursing center placement when in-home care becomes increasingly difficult, or when convalescence (recovery) from hospitalization requires more assistance than the family is able to provide. Although the decision to enter a nursing center is never final, and a nursing center resident is sometimes discharged to home or another less-acute facility, many older adults may view the nursing center as their final residence. • The best way to evaluate the quality of a nursing center in a community is for the patient and family to visit that facility and inspect it personally. • The Medicare website (http://www.Medicare.gov/NHcompare) is an excellent resource for information about the quality rating of a nursing center based on health inspections, staffing, and quality measures of the facility. It offers a checklist. • [Review Box 14-2, Focus on Older Adults: Selection of a Nursing Center or Home, with students.] Assessing the Needs of Older Adults 6 • Obtaining a complete assessment takes time; older adults have longer life and medical history. Allow rest periods; be sure to review prescribed and over-the-counter medications. Take into account vision and hearing constraints. 7 • If an older adult is unable to understand your visual or auditory cues, your assessment data will likely be inaccurate or misleading, leading you to incorrectly conclude that the older adult is confused. • When a person has a hearing impairment, speak directly to the patient in clear, low-pitched tones and move to a quiet area to reduce background noise. • When caring for people with visual impairments, sit or stand at eye level and face them. Always encourage the use of assistive devices such as glasses and hearing aids. • Memory deficits, if present, affect the accuracy and completeness of your assessment; may need to enlist help of family member or caregiver. The additional person supplements information with the consent of the older adult, but the older adult remains the primary source of the interview. • Provide culturally competent care. • Must recognize and process your own biases related to ageism, social norms, and racism, as it affects your ability to provide culturally competent care. • Remember which changes are related to the aging process and which changes are related to a disease process. • It is important to recognize early indicators of acute illness in older adults. Note changes in mental status, occurrence and reason for falls, dehydration, decrease in appetite, loss of function, dizziness, and incontinence because these symptoms are not frequently present in younger adults. • Mental status changes commonly occur as a result of disease and psychological issues. • Falls are complex and often cause injury. You need to investigate every fall carefully to find out if it was the result of environmental causes or the symptom of a new-onset illness. • Problems with the cardiac, respiratory, musculoskeletal, neurological, urological, and sensory body systems sometimes present with a fall as a chief symptom of a new-onset condition. • Dehydration is common in older adults because of decreased oral intake related to a reduced thirst response and less free water as a consequence of a decrease in muscle mass. • Decrease in appetite is a common symptom with the onset of pneumonia, heart failure, and urinary tract infection (UTI). • Thyroid disease, infection, cardiac or pulmonary conditions, metabolic disturbances, and anemia are common causes of functional decline. • Nurses play an essential role in early identification, referral, and treatment of health problems. • Dehydration is common for older adults; they do not drink because they do not want to get up to urinate. 10 • The fear of becoming dependent is overwhelming for an older adult who is experiencing functional decline as a result of aging. Educate older adults to promote understanding of age-related changes, appropriate lifestyle adjustments, and effective coping. Factors that promote the highest level of function include a healthy, well-balanced diet; paced and appropriate activity; regularly scheduled visits with a health care provider; regular participation in meaningful activities; use of stress-management techniques; and avoidance of alcohol, tobacco, or illicit drugs. • It may be difficult for older adults to accept the changes that are occurring in all areas of their lives, which in turn have a profound effect on functional status. • Several standardized functional assessment tools are widely available. An online collection of the tools used most commonly with older adults is available at the geriatric nursing website of the Hartford Institute for Geriatric Nursing, www.ConsultGeriRN.org. • A sudden change in function with ADLs is often a sign of onset of an acute illness or worsening of a chronic illness. • When planning and implementing care for older adults, you will want to develop interventions aimed at maintaining, restoring, or maximizing their functional status, while maintaining independence and preserving dignity. Cognitive Disorders • A common misconception about aging is that cognitive impairments are widespread among older adults. Reduction in the number of brain cells, deposition of lipofuscin and amyloid in cells, and changes in neurotransmitter levels occur in older adults both with and without cognitive impairment. • Symptoms of cognitive impairment, such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment, are not normal aging changes and require you to further assess patients for underlying causes. • Remember that forgetfulness is an expected symptom of aging, but confusion is not. • There are standard assessment forms for determining a patient’s mental status, including the Mini-Mental State Exam-2 (MMSE-2), the Mini-Cog, and the Clock Drawing Test. • Delirium is potentially a reversible cognitive impairment that often has a physiological cause, which can include electrolyte imbalances, untreated pain, infection, cerebral anoxia, hypoglycemia, medication effects, tumors, subdural hematomas, and cerebrovascular infarction or hemorrhage. May accompany systemic infections, pneumonia, or UTI. May also be caused by sensory deprivation or overstimulation, unfamiliar surroundings, or sleep deprivation or psychosocial factors such as emotional distress. It is possible for delirium and dementia to occur at the same time. The presence of delirium is a medical emergency and requires prompt assessment and intervention. 11 • Dementia is characterized by a gradual, progressive, irreversible cerebral dysfunction. It interferes with social and occupational activities and is an umbrella term for many conditions, including Alzheimer’s. Assess carefully to rule out the presence of delirium whenever you suspect dementia. Nurses should consider the safety and physical and 12 psychosocial needs of the older adult and the family. Individualize nursing care to enhance quality of life and maximize functional performance by improving cognition, mood, and behavior. • Depression is the most common, yet most undetected and untreated, impairment in older adulthood. Suicide in older adults accounts for 20% of all suicides. Treatment includes medication, psychotherapy, or a combination of both. Electroconvulsant therapy (ECT) is sometimes used for treatment of resistant depression when medications and psychotherapy do not help. White men, age 85 and older, have the highest suicide rate in the U.S. Learning Needs • As you assess the various physical, cognitive, functional and psychosocial problems of older adults, it is important to also assess their associated learning needs. • If a patient has slow responses or reaction time when performing physical activities, it will be necessary to consider these limitations when teaching new psychomotor skills. • Older adults learn new information at a slower rate than younger adults due to a decline in fluid intelligence, which is defined as the reasoning and processing components of learning. In addition, an older adult has difficulty processing multiple bits of information at one moment. • During your assessment, carefully consider a patient’s learning needs and capability to learn. Addressing the Health Concerns of Older Adults • As the population ages and life expectancy increases, emphasis on health promotion and disease prevention increases. • The challenges of health promotion and disease prevention for older adults are complex and affect health care providers as well. • Previous health care experiences, personal motivation, health beliefs, culture, health literacy, and non–health-related factors such as transportation and finances often create barriers for older adults. Barriers for health care providers include beliefs and attitudes about which services and programs to provide, their effectiveness and the lack of consistent guidelines, and absence of a coordinated approach. 15 • Good handwashing • Regular checkups with health care providers • Immunization for seasonal influenza, tetanus, diphtheria and pertussis, shingles, and pneumococcal disease 16 • Ask about the current status of all immunizations, provide information about the immunizations, and make arrangements for them to receive immunizations as needed. • Most older adults are interested in their health and are capable of taking charge of their lives. • Initial screenings establish baseline data that you use to determine wellness, identify health needs, and design health maintenance programs. Following initial screening sessions, share with older adults information on nutrition, exercise, medications, and safety precautions. • By providing information about health promotion and self-care, you significantly improve the health and well-being of older adults. Health Promotion and Maintenance: Physiological Concerns (Cont.) • Heart disease is the leading cause of death in older adults, followed by cancer, chronic lung disease, and stroke. Common cardiovascular disorders are hypertension and coronary artery disease. Nursing interventions for hypertension and coronary artery disease address weight reduction, exercise, dietary changes, limiting salt and fat intake, stress management, and smoking cessation. Patient teaching also includes information about medication management, blood-pressure monitoring, and the symptoms indicating the need for emergency care. • Malignant neoplasms are the second most common cause of death among older adults. Nurses educate older adults about early detection, treatment, and cancer risk factors. Encourage them to report nonhealing skin lesions, unexpected bleeding, change in bowel habits, nagging cough, lump in breast or another part of body, change in a mole, difficulty swallowing, and unexplained weight loss. Nurses need to carefully distinguish between signs of normal aging and signs of pathological conditions. • Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in those 65 and older. Tobacco smoke is a key factor in the development and progression of COPD. It is important to provide patients with information about quit smoking programs. Teach proper exercise, how to use inhalers, techniques for the removal of mucus from the airways, and exercise training. • Cerebrovascular accidents (CVAs) are the fourth leading cause of death in the United States and occur as brain ischemia or brain hemorrhage. Nursing interventions ranges from teaching older adults about risk-reduction strategies to teaching family caregivers the early warning signs of a stroke and ways to support a patient during recovery and rehabilitation. • Cigarette smoking is a risk factor for the four most common causes of death: heart disease, cancer, lung disease, and stroke. If a patient rejects smoking cessation, suggest 17 at least a reduction in smoking. Set a quit or reduction date and a follow-up visit with the older adult to discuss the quit attempt. • Studies of alcohol abuse in older adults report two patterns: a lifelong pattern of continuous heavy drinking and a pattern of heavy drinking that begins late in life. The 20 Older Adults and the Acute Care Setting 21 • Pay special attention to the basic needs of comfort, safety, nutrition/hydration, and skin integrity. • To promote independence and a sense of dignity, you need to include the patient in his or her care. However, you also need to be firm with these patients to ensure that their basic needs are met, and that no decline in their health status occurs owing to hospitalization. • The risk for delirium increases when hospitalized older adults experience immobilization, sleep deprivation, infection, dehydration, pain, sensory impairment, drug interactions, anesthesia, and hypoxia. • Older adults are at greater risk for dehydration and malnutrition during hospitalization because of standard procedures such as limiting food and fluids in preparation for diagnostic tests and medications that decrease appetite. • Increased risk for health care–associated infections in older adults is associated with age-related reductions in immune system responses. • Causes of incontinence include delirium, untreated urinary tract infection, medications, restricted mobility or need for assistance to get to the bathroom, and constipation or stool impaction. • The increased risk for skin breakdown and the development of pressure ulcers is related to changes in aging skin and to situations that occur in the acute care setting such as immobility, incontinence, and malnutrition • The cause of a fall is typically multifactorial and composed of intrinsic or extrinsic factors. • [Review Box 14-6, Risk Factors for Falls in Older Adults, with students if you did not review it previously.] Fluid, Electrolyte, and Acid-Base Balance • Fluid homeostasis is the dynamic interplay of three processes: fluid intake and absorption, fluid distribution, and fluid output. To maintain fluid balance, fluid intake must equal fluid output. Because some of the normal daily fluid output (e.g., urine, sweat) is a hypotonic salt solution, people must have an equivalent fluid intake of hypotonic sodium-containing fluid (or water plus foods with some salt) to maintain fluid balance (intake equal to output). • Fluid intake occurs orally through drinking but also through eating because most foods contain some water. Food metabolism creates additional water. Average fluid intake from these routes for healthy adults is about 2300 mL, although this amount can vary widely depending on exercise habits, preferences, and the environment. Other routes of fluid intake include intravenous (IV), rectal (e.g., enemas), and irrigation of body cavities that can absorb fluid. 22 • The term fluid distribution means the movement of fluid among its various compartments. Fluid distribution between the extracellular and intracellular compartments occurs by osmosis. Fluid distribution between the vascular and interstitial portions of the extracellular fluid (ECF) occurs by filtration. 25 • If disease processes, medications, or other factors disrupt fluid intake or output, imbalances sometimes occur. For example, with diarrhea, fluid output is increased, and a fluid imbalance (dehydration) occurs if fluid intake does not increase appropriately. • Two major types of fluid imbalances are known: volume imbalances and osmolality imbalances. • Volume imbalances are disturbances of the amount of fluid in the extracellular compartment. • Osmolality imbalances are disturbances of the concentration of body fluids. • Volume and osmolality imbalances may occur separately or in combination. • With an extracellular fluid volume (ECV) imbalance, too little (ECV deficit) or too much (ECV excess) isotonic fluid is present. • ECV deficit and excess are abnormal volumes of isotonic fluid, manifested as sudden changes in body weight and changes in markers of vascular and interstitial volume. • ECV deficit is present when isotonic fluid is insufficient in the extracellular compartment. Remember that a lot of sodium is found in normal ECF. With ECV deficit, output of isotonic fluid exceeds intake of sodium-containing fluid. Because ECF is both vascular and interstitial, signs and symptoms arise from lack of volume in both of these compartments. • [Review Table 42-3, Fluid Imbalances, with students.] • ECV excess occurs when too much isotonic fluid is found in the extracellular compartment. Intake of sodium-containing isotonic fluid has exceeded fluid output. For example, when you eat more salty foods than usual and drink water, you may notice that your ankles swell or rings on your fingers feel tight, and you gain 2 lbs (1 kg) or more overnight. These are manifestations of mild ECV excess. • In an osmolality imbalance, body fluids become hypertonic or hypotonic, and this causes osmotic shifts of water across cell membranes. Osmolality imbalances are called hypernatremia and hyponatremia. • An osmolality imbalance body fluids become hypertonic or hypotonic, which causes osmotic shifts of water across cell membranes. The osmolality imbalances are called hypernatremia and hyponatremia. • Hypernatremia, also called water deficit, is a hypertonic condition. One of two general causes make body fluids too concentrated: loss of relatively more water than salt, or gain of relatively more salt than water. When the interstitial fluid becomes hypertonic, water leaves cells by osmosis, and they shrivel. Signs and symptoms of hypernatremia are those of cerebral dysfunction, which arise when brain cells shrivel. • Hyponatremia, also called water excess or water intoxication, is a hypotonic condition. It arises from gain of relatively more water than salt or loss of relatively more salt than water. The excessively dilute condition of interstitial fluid causes water to enter cells by osmosis, causing the cells to swell. Signs and symptoms of cerebral dysfunction occur when brain cells swell. 26 • ECV deficit and hypernatremia often occur at the same time; this combination is called clinical dehydration. The ECV is too low, and the body fluids are too concentrated. Clinical dehydration is common with gastroenteritis or other causes of severe vomiting 27 and diarrhea when people are not able to replace their fluid output with enough intake of dilute sodium-containing fluids. Signs and symptoms of clinical dehydration are those of both ECV deficit and hypernatremia. • [Shown is Figure 42-7: Fluid volume and osmolality imbalances.] Electrolyte Balance • You can best understand electrolyte balance by considering the three processes involved in electrolyte homeostasis: electrolyte intake and absorption, electrolyte distribution, and electrolyte output. • [Review Table 42-4, Electrolyte Intake and Absorption, Distribution, and Output, with students.] • Plasma concentrations of K+, Ca2+, Mg2+, and phosphate are very low compared with their concentrations in cells and bone. • Intake comes from foods and beverages. Some substances enhance or hinder electrolyte absorption. • Although sodium is an electrolyte, it is not included here because serum sodium imbalances are the osmolality imbalances discussed previously. • Electrolyte output occurs through normal excretion in urine, feces, and sweat. Output also occurs through vomiting, drainage tubes, and fistulas. When electrolyte output increases, electrolyte intake must increase to maintain electrolyte balance. Similarly, if electrolyte output decreases, as with oliguria, electrolyte intake must also decrease to maintain balance. Electrolyte Imbalances ● Potassium (K+) ➢ Hypokalemia ➢ Hyperkalemia ● Calcium (Ca2+) ➢ Hypocalcemia ➢ Hypercalcemia ● Magnesium (Mg2+) ➢ Hypomagnesemia ➢ Hypermagnesemia • [Hypernatremia and hyponatremia were discussed with osmolality imbalances.] • [Ask students: Use your knowledge of word origins to analyze the terms on the slide. Discuss: -emia means blood condition; hyper- means excessive; hypo- means deficient; 30 symptoms are similar to those of hypocalcemia because hypomagnesemia also increases neuromuscular excitability. • Hypermagnesemia is abnormally high magnesium concentration in the blood. End- stage renal disease causes hypermagnesemia unless the person decreases magnesium 31 intake to match the decreased output. Signs and symptoms are caused by decreased neuromuscular excitability, with lethargy and decreased deep tendon reflexes being most common. Acid-Base Balance • Normal acid-base balance is maintained with acid excretion equal to acid production. Acids release hydrogen (H+) ions; bases (alkaline substances) take up H+ ions. The more H+ ions that are present, the more acidic is the solution. • If the pH goes outside the normal range, enzymes within cells do not function properly; hemoglobin does not manage oxygen properly; and serious physiological problems occur, including death. Laboratory tests of a sample of arterial blood called arterial blood gases (ABGs) are used to monitor a patient’s acid-base balance. • [Review Table 42-6, Arterial Blood Gas Measures, with students.] • Production: Cellular metabolism constantly creates two types of acids: carbonic acid and metabolic acids. Cells produce carbon dioxide (CO2), which acts as an acid in the body by converting to carbonic acid. • Metabolic acids are any acids that are not carbonic acid. They include citric acid, lactic acid, and many others. • [Shown is Figure 42-8: Acid production and excretion.] • Buffering: If too many free H+ ions are present, a buffer takes them up, so they no longer are free. If too few are present, a buffer can release H+ ions to prevent an acid-base imbalance. Buffers work rapidly—within seconds. • All body fluids contain buffers. The major buffer in ECF is the bicarbonate (HCO3 −) buffer system, which buffers metabolic acids. It consists of a lot of bicarbonate and a small amount of carbonic acid (normally a 20:1 ratio). Addition of H+ released by a metabolic acid to a bicarbonate ion makes more carbonic acid. Now the H+ is no longer free and will not decrease the blood pH. • If too few H+ ions are present, the carbonic acid portion of the buffer pair will release some, increasing the bicarbonate, again returning pH to normal. • Other buffers include hemoglobin, protein buffers, and phosphate buffers. Cellular and bone buffers also contribute. Buffers normally keep the blood from becoming too acid when acids that are produced by cells circulate to the lungs and kidneys for excretion. • The body has two acid excretion systems: lungs and kidneys. The lungs excrete carbonic acid; the kidneys excrete metabolic acids. 32 • When you exhale, you excrete carbonic acid in the form of CO2 and water. If the PaCO2 (i.e., level of CO2 in the blood) rises, the chemoreceptors trigger faster and deeper respirations to excrete the excess. If the PaCO2 falls, the chemoreceptors trigger slower and shallower respirations, so more of the CO2 produced by cells remains in the blood and makes up the deficit. These alterations in respiratory rate and depth maintain the carbonic acid portion of acid-base balance. Sometimes people who have lung disease 35 3 3 3 3 Decreased cerebrospinal fluid (CSF) pH and intracellular pH of brain cells cause decreased levels of consciousness. • [Review Table 42-7, Acid-Base Imbalances, with students.] • Respiratory alkalosis arises from alveolar hyperventilation; the lungs excrete too much carbonic acid (CO2 and water). The PaCO2 falls, creating a deficit of carbonic acid in the blood, which increases pH. Respiratory alkalosis usually is short lived; thus the kidneys do not have time to compensate. When the pH of blood, CSF, and intracellular fluid increases acutely, cell membrane excitability also increases, giving rise to neurological symptoms such as excitement, confusion, and paresthesias. If the pH rises enough, central nervous system (CNS) depression can occur. • Metabolic acidosis occurs from an increase in metabolic acid or a decrease in base (bicarbonate). The kidneys are unable to excrete enough metabolic acids, which accumulate in the blood, or bicarbonate is removed from the body directly, as with diarrhea. In either case, the blood HCO − decreases, and the pH falls. With an increase in metabolic acids, blood HCO − decreases because it is used to buffer metabolic acids. Similarly, when patients have conditions that cause the removal of HCO −, the amount of HCO3 − in the blood decreases. To help identify the specific cause, health care providers and the laboratory calculate the anion gap, a reflection of unmeasured anions in plasma. You calculate anion gap by subtracting the sum of plasma concentrations of the anions Cl− and HCO3 − from the plasma concentration of the cation Na+. When reviewing laboratory reports, check the reference values from the laboratory that measured the electrolyte concentrations. • [Review Table 42-8, Anion Gap in Metabolic Acidosis, with students.] • The abnormally low pH in metabolic acidosis stimulates the chemoreceptors, so the respiratory system compensates for the acidosis by hyperventilation. Compensatory hyperventilation begins in a few minutes and removes carbonic acid from the body. This process does not correct the problem, but it helps limit the pH decrease. Metabolic acidosis decreases one’s level of consciousness. • Metabolic alkalosis occurs from a direct increase in base (HCO3 −) or a decrease in metabolic acid, which increases blood HCO − by releasing it from its buffering function. Common causes include vomiting and gastric suction. The respiratory compensation for metabolic alkalosis is hypoventilation. The decreased rate and depth of respiration allow carbonic acid to increase in the blood, as can be seen by an increased PaCO2. The need for oxygen may limit the degree of respiratory compensation for metabolic alkalosis. Because HCO3 − crosses the blood-brain barrier with difficulty, neurological signs and symptoms are less severe or even absent with metabolic alkalosis. 36 Nursing Process: Assessment • Using a systematic approach in assessment enables you to help patients safely maintain or restore fluid, electrolyte, and acid-base balances. 37 • A patient’s fluid, electrolyte, or acid-base imbalance is sometimes so severe that it prevents initial discussion of his or her expressed needs, values, and preferences. However, when a patient is alert enough to discuss care, you need to elicit this information. Focus on the patient’s experience with fluid, electrolyte, or acid-base alterations and his or her perceptions of the illness. Ask about the patient’s greatest concerns regarding fluid status to build the basis for active partnership in planning, implementing, and evaluating patient-centered care. • Clinical assessment begins with a patient history designed to reveal risk factors that cause or contribute to fluid, electrolyte, and acid-base imbalances. Ask specific, focused questions to identify factors that contribute to a patient’s potential imbalances. • [Review Table 42-9, Risk Factors for Fluid, Electrolyte, and Acid-Base Imbalances, and Box 42-1, Nursing Assessment Questions, with students.] • First, assess a patient’s age. An infant’s proportion of total body water (70% to 80% total body weight) is greater than that of children or adults. Infants and young children have greater water needs and immature kidneys (Hockenberry and Wilson, 2015). They are at greater risk for ECV deficit and hypernatremia because body water loss is proportionately greater per kilogram of weight. • Children who are between the ages of 2 and 12 years frequently respond to illnesses with fevers of higher temperatures and longer duration than those of adults (Hockenberry and Wilson, 2015). At any age fever increases the rate of insensible water loss. Adolescents have increased metabolism and increased water production because of their rapid growth changes. Fluctuations in fluid balance are greater in adolescent girls because of hormonal changes associated with the menstrual cycle. • Older adults experience a number of age-related changes that potentially affect fluid, electrolyte, and acid-base balances. • [Review Box 42-2, Focus on Older Adults: Factors Affecting Fluid, Electrolyte, and Acid- Base Balance, with students.] • Environment. Hot environments increase fluid output through sweating. Sweat is a hypotonic sodium-containing fluid. Excessive sweating without adequate replacement of salt and water can lead to ECV deficit, hypernatremia, or clinical dehydration. Ask patients about their normal level of physical work and whether they engage in vigorous exercise in hot environments. Do the patients have fluid replacements containing salt available during exercise and activity? • Assess dietary intake of fluids; salt; and foods rich in potassium, calcium, and magnesium. Ask patients if they follow weight-loss diets. Starvation diets and those with high fat and no carbohydrate content often lead to metabolic acidosis. In addition, assess the patient’s ability to chew and swallow, which, if altered, interferes with adequate intake of electrolyte-rich foods and fluids. • Take an alcohol intake history. Chronic alcohol abuse commonly causes hypomagnesemia, in part because it increases renal magnesium excretion. 40 • The specific fluid and electrolyte imbalances that occur with cancer depend on the type and progression of the cancer and treatment regimen. Many patients with cancer develop hypercalcemia when their cancer cells secrete chemicals that circulate to bones and cause calcium to enter the blood. Other fluid and electrolyte imbalances occur in cancer because some types of tumors cause metabolic and endocrine abnormalities. In 41 addition, patients with cancer are at risk for fluid and electrolyte imbalances as a result of the side effects (e.g., anorexia, diarrhea) of chemotherapy, biological response modifiers, or radiation • Patients who have chronic heart failure have diminished cardiac output, which reduces kidney perfusion and activates the RAAS. The action of aldosterone on the kidneys causes ECV excess and risk of hypokalemia. Most diuretics used to treat heart failure increase the risk of hypokalemia while reducing the ECV excess. Dietary sodium restriction is important with heart failure because Na+ holds water in the ECF, making the ECV excess worse. In severe heart failure, restriction of both fluid and sodium is prescribed to decrease the workload of the heart by reducing excess circulating fluid volume. • Oliguria occurs when the kidneys have a reduced capacity to make urine. Some conditions, such as acute nephritis, cause a sudden onset of oliguria, whereas other problems, such as chronic kidney disease, lead to chronic oliguria. Oliguric renal disease prevents normal excretion of fluid, electrolytes, and metabolic acids, resulting in ECV excess, hyperkalemia, hypermagnesemia, hyperphosphatemia, and metabolic acidosis. The severity of these imbalances is proportionate to the degree of renal failure. Physical Assessment • Data gathered through a focused physical assessment validate and extend the information collected in the patient history. • [Review Table 42-10, Focused Nursing Assessments for Patients with Fluid, Electrolyte, and Acid-Base Imbalances, with students.] • Daily weights are an important indicator of fluid status. Each kilogram (2.2 lbs) of weight gained or lost overnight is equal to 1 L of fluid retained or lost. These fluid gains or losses indicate changes in the amount of total body fluid, usually ECF, but do not indicate a shift between body compartments. • Weigh daily patients with heart failure and those who are at high risk for or who actually have ECV excess. Daily weights are also useful for patients with clinical dehydration or other causes of or risks for ECV deficit. Weigh the patient at the same time each day with the same scale after a patient voids. Calibrate the scale each day or routinely. • The patient needs to wear the same clothes or clothes that weigh the same; if using a bed scale, use the same number of sheets on the scale with each weighing. Compare the weight of each day with that of the previous day to determine fluid gains or losses. Look at the weights over several days to recognize trends. Interpretation of daily weights guides medical therapy and nursing care. Teach patients with heart failure to take and record their daily weights at home and to contact their health care provider if their weight increases suddenly by a set amount (obtain parameters from their health care 42 providers). Recognizing trends in daily weights taken at home is important. Research shows that patients who are hospitalized for decompensated heart failure often experience steady increases in daily weights during the week before hospitalization. • Measuring and recording all liquid I&O during a 24-hour period is an important aspect of fluid balance assessment. Compare a patient’s 24-hour intake with the patient’s 24-hour 45 • If the patient’s medical condition is not dealt with in a timely manner, fluid, electrolyte, and acid-base balances will worsen. For example, if a patient experiences vomiting and diarrhea, this needs to be addressed immediately, especially if the patient is young, elderly, or chronically ill. • Do not delegate administration of IV fluid and hemodynamic assessment to NAP. When the patient is stable, you can delegate daily weights, I&O, and direct physical care to NAP. • Collaborative care may involve other services, including discharge planning, nutritional support, and pharmacy. • Ongoing communication and consultation are important because the patient’s condition can change quickly. • Begin discharge planning early for patients with acute or chronic fluid and electrolyte disturbances by anticipating the needs of the patient and family as they transition to another setting. In the hospital, collaboration with other members of the health care team ensures that care will continue in the home or long-term care setting with few disruptions. You ensure that therapeutic regimens established in one setting continue through completion at the next setting. • [Review Figure 42-11, Critical thinking model for fluid, electrolyte, and acid-base balances planning, with students.] • [Review Figure 42-12, Concept map for Mrs. Beck, with students.] Implementation • Health promotion activities focus primarily on patient education. Teach patients and caregivers to recognize risk factors for developing imbalances and to implement appropriate preventive measures. Parents must understand that infants and children need to replace fluids when vomiting or diarrhea occurs. Adults, especially the elderly and the infirm, also need to replace fluids when increased perspiration occurs. • Patients with chronic health alterations often are at risk for developing fluid, electrolyte, and acid-base imbalances. They need to understand their own risk factors and the measures to be taken to avoid imbalances. Teach patients with chronic diseases and their family caregivers the early signs and symptoms of the fluid, electrolyte, and acid- base imbalances for which they are at risk, and what to do if these occur. • Acute care nurses administer medications and oral and IV fluids to replace fluid and electrolyte deficits or to maintain normal homeostasis; they also assist with restricting intake as part of therapy for excesses. • Prevention and treatment of ECV deficit, hypernatremia, and electrolyte deficits are accomplished with enteral or parenteral administration of appropriate fluid. 46 • Enteral replacements. Oral replacement of fluids and electrolytes is appropriate as long as the patient is not so physiologically unstable that oral fluids cannot be replaced rapidly. 47 • Oral replacement of fluids is contraindicated when the patient has a mechanical obstruction of the GI tract, is at high risk for aspiration, or has impaired swallowing. • Some patients unable to tolerate solid foods are still able to ingest fluids. Strategies to encourage fluid intake include offering frequent small sips of fluid, popsicles, and ice chips. • Record one-half the volume of the ice chips in I&O measurement. • Pay attention to each patient’s preferred temperature of oral fluids. Cultural beliefs regarding appropriate fluid temperature may interfere with fluid intake unless the fluid with the preferred temperature is available. • [Review Box 42-5, Cultural Aspects of Care: Fluid Therapy, with students.] • When replacing fluids by mouth in a patient with ECV deficit, choose fluids that contain sodium. • Patients who have hyponatremia usually require restricted water intake. Patients who have very severe ECV excess sometimes have both sodium and fluid restrictions. Fluid restriction often is difficult for patients, particularly if they take medications that dry the oral mucous membranes or if they are mouth breathers. • In acute care settings, fluid restrictions usually allot half the total oral fluids between 7 a.m. and 3 p.m., the period when patients are more active, receive two meals, and take most of their oral medications. Offer the remainder of the fluids during the evening and night shifts. Patients on fluid restriction need frequent mouth care to moisten mucous membranes, decrease the chance of mucosal drying and cracking, and maintain comfort. • Fluid and electrolytes may be replaced through infusion of fluids directly into veins (intravenously) rather than via the digestive system. Parenteral replacement includes parenteral nutrition (PN), IV fluid and electrolyte therapy (crystalloids), and blood and blood component (colloids) administration. IV devices are called peripheral IVs when the catheter tip lies in a vein in one of the extremities; they are called central venous IVs when the catheter tip lies in the central circulatory system (e.g., in the vena cava close to the right atrium of the heart). • Practice standard body fluid precautions when administering parenteral fluids. • PN, also called total parenteral nutrition (TPN), is IV administration of a complex, highly concentrated solution containing nutrients and electrolytes that is formulated to meet a patient’s needs. Depending on their osmolality, PN solutions are administered through a central IV catheter (high osmolality) or peripherally (lower osmolality). Chapter 45 reviews principles and guidelines for PN administration, which is used when patients are unable to receive enough nutrition orally or through enteral feeding. • [Shown is Figure 42-13: Central venous lines deliver intravenous fluid into superior vena cava near heart. CVAD, central venous access device.] Intravenous Therapy 50 Intravenous Therapy (Cont.) 51 • Correct selection and preparation of IV equipment assists in safe and rapid placement of an IV line. Because fluids infuse directly into the bloodstream, sterile technique is necessary. • Organize all equipment at the bedside for an efficient insertion. IV equipment includes vascular access devices (VADs), tourniquet, clean gloves, dressings, IV fluid containers, various types of tubing, and electronic infusion devices (EIDs), also called infusion pumps. VADs that are short, peripheral IV catheters are available in a variety of gauges such as the commonly used 20 and 22 gauges. A larger gauge indicates a smaller- diameter catheter. • A peripheral VAD is called an over-the-needle catheter; it consists of a small plastic tube or catheter threaded over a sharp stylet (needle). • Once you insert the stylet and advance the catheter into the vein, you withdraw the stylet, leaving the catheter in place. These devices have a safety mechanism that covers the sharp stylet when withdrawing it to reduce the risk of needlestick injury. Needleless systems allow you to make connections without using needles, which reduces needlestick injuries. • The main IV fluid used in a continuous infusion flows through tubing called the primary line. • The primary line connects to the IV catheter. Injectable medications such as antibiotics are usually added to a small IV solution bag and “piggybacked” as a secondary set into the primary line or as a primary intermittent infusion to be administered over a 30- to 60-minute period. • The type and amount of solution are prescribed by the patient’s health care provider and depend on the medication added and the patient’s physiological status. If an IV infusion is connected to an EID, use the tubing designated for that EID. For gravity-flow IVs (not using an EID), select tubing as described in the equipment list of Skill 42-1. Add IV extension tubing to increase the length of the primary line, which reduces pulling of the tubing and increases a patient’s mobility in changing position. • After you collect the equipment at the patient’s bedside, prepare to insert the IV line by assessing the patient for a venipuncture site. The most common IV sites are on the inner arm. • As you assess a patient for potential venipuncture sites, consider conditions that exclude certain sites. Venipuncture is contraindicated in a site that has signs of infection, infiltration, or thrombosis. • Venipuncture is a technique in which a vein is punctured through the skin by a sharp rigid stylet (e.g., metal needle). The stylet is partially covered either with a plastic catheter or a needle attached to a syringe. • [Review Box 42-7, Focus on Older Adults: Protection of Skin and Veins During Intravenous Therapy, with students.] • After initiating a peripheral IV infusion and checking it for patency, regulate the rate of infusion according to the health care provider’s orders. For patient safety avoid 52 uncontrolled flow of IV fluid into a patient. You are responsible for calculating the flow rate (mL/hr) that delivers the IV fluid in the prescribed time frame. The correct IV 55 • Movement of the VAD in a vein can cause phlebitis and infiltration; VAD dislodgment requires using another VAD at a new IV infusion site. Infusion Nurses Society (INS) standards indicate that use of these devices is preferable over taping when feasible. • [Shown is Figure 42-16: Potential sites for contamination of vascular access device, and Figure 42-17: Catheter stabilization device.] • [Review Skill 42-1, Initiating Intravenous Therapy, with students.] • [Review Skill 42-2, Regulating Intravenous Flow Rate, with students.] • Patients receiving IV therapy over several days require periodic changes of IV fluid containers. It is important to organize tasks so you can change containers rapidly before a thrombus forms in the catheter. Recommended frequency of IV tubing change depends on whether it is used for continuous or intermittent infusion. • [Review Skill 42-3, Maintenance of Intravenous System, with students.] • [Review Skill 42-4, Changing a Peripheral Intravenous Dressing, with students.] • To prevent the accidental disruption of an IV system, a patient often needs assistance with hygiene, comfort measures, meals, and ambulation. • A potentially dangerous complication of IV therapy is circulatory overload with IV solution, which occurs when a patient receives too-rapid administration or an excessive amount of fluids. Assessment findings depend on the type of IV solution that infuses in excess. A potentially dangerous complication of IV therapy is circulatory overload with IV solution, which occurs when a patient receives too-rapid administration or an excessive amount of fluids. Assessment findings depend on the type of IV solution that infuses in excess. • [Review Table 42-12, Complications of Intravenous Therapy with Nursing Interventions, with students.] • Infiltration occurs when an IV catheter becomes dislodged or a vein ruptures and IV fluids inadvertently enter subcutaneous tissue around the venipuncture site. When the IV fluid contains additives that damage tissue, extravasation occurs. • [Review Table 42-13, Infiltration Scale, with students.] • Phlebitis (i.e., inflammation of a vein) results from chemical, mechanical, or bacterial causes. Risk factors for phlebitis include acidic or hypertonic IV solutions; rapid IV rate; IV drugs such as KCl, vancomycin, and penicillin; VAD inserted in area of flexion, poorly secured catheter; poor hand hygiene; and lack of aseptic technique (Wallis et al., 2014). The typical signs of inflammation (i.e., heat, erythema [redness], tenderness) occur along the course of the vein. Phlebitis can be dangerous because blood clots (thrombophlebitis) form along the vein and in some cases cause emboli. This may cause permanent damage to veins. • [Review Table 42-14, Phlebitis Scale, with students.] • Routine changes of peripheral IV catheters to reduce infection are not recommended. • Bleeding can occur around the venipuncture site during the infusion or through the catheter or tubing if these become disconnected inadvertently (see Table 42-12). 56 Bleeding is more common in patients who receive heparin or other anticoagulants or who have a bleeding disorder (e.g., hemophilia or thrombocytopenia) 57 • Discontinue IV access after infusion of the prescribed amount of fluid; when infiltration, phlebitis, or local infection occurs; or if the IV catheter develops a thrombus at its tip. Blood Transfusion • Blood transfusion, or blood component therapy, is the IV administration of whole blood or a blood component such as packed red blood cells (RBCs), platelets, or plasma. Objectives for administering blood transfusions include (1) increasing circulating blood volume after surgery, trauma, or hemorrhage; (2) increasing the number of RBCs and maintaining hemoglobin levels in patients with severe anemia; and (3) providing selected cellular components as replacement therapy (e.g., clotting factors, platelets, albumin). • Caring for patients receiving blood or blood products transfusion is a nursing responsibility. You must be thorough in patient assessment, checking the blood product against prescriber’s orders, checking blood product against patient identifiers, and monitoring for any adverse reactions. Blood transfusions are never regarded as routine; overlooking any minor detail can have dangerous and life threatening events for a patient. • Blood transfusions must be matched to each patient to avoid incompatibility. RBCs have antigens in their membranes; the plasma contains antibodies against specific RBC antigens. If incompatible blood is transfused (i.e., a patient’s RBC antigens differ from those transfused), the patient’s antibodies trigger RBC destruction in a potentially dangerous transfusion reaction. • The most important grouping for transfusion purposes is the ABO system, which identifies A, B, O, and AB blood types. Determination of blood type is based on the presence or absence of A and B red blood cell (RBC) antigens. Individuals with type A blood have A antigens on their RBCs and anti-B antibodies in their plasma. Individuals with type B blood have B antigens on their RBCs and anti-A antibodies in their plasma. A person who has type AB blood has both A and B antigens on the RBCs and no antibodies against either antigen in the plasma. A type O individual has neither A nor B antigens on RBCs but has both anti-A and anti-B antibodies in the plasma. • [Review Table 42-15, ABO Compatibilities for Transfusion Therapy, with students.] • People with type O blood are considered universal blood donors because they can donate packed RBCs and platelets to people with any ABO blood type. People with type AB blood are called universal blood recipients because they can receive packed RBCs and platelets of any ABO type. • Autologous transfusion (autotransfusion) is the collection and reinfusion of a patient’s own blood. Blood for an autologous transfusion most commonly is obtained by preoperative donation up to 6 weeks before a scheduled surgery (e.g., heart, orthopedic, plastic, or gynecological). A patient can donate several units of blood, 60 • Prepare to administer emergency drugs such as antihistamines, vasopressors, fluids, and corticosteroids per health care provider order or protocol. • Prepare to perform cardiopulmonary resuscitation. 61 • Save the blood container, tubing, attached labels, and transfusion record for return to the blood bank. • Obtain blood and urine specimens per health care provider order or protocol. • Another category of adverse transfusion effects is diseases transmitted by blood from infected donors who are asymptomatic. Symptoms of these conditions may arise long after the transfusion. Diseases transmitted through transfusions include hepatitis B and hepatitis C, human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), and cytomegalovirus infection. In the United States all units of blood for blood banks undergo screening for HIV, hepatitis B and hepatitis C viruses, syphilis, and West Nile virus, which reduces the risk of acquiring these bloodborne infections. • [Shown is Figure 42-18: Filling tubing for blood administration.] Interventions • In addition to the administration of prescribed medical therapies, nursing interventions may be performed to preserve or restore electrolyte imbalance. Teach patients the reasons for their therapies and the importance of balancing electrolyte I&O to prevent imbalances in the future. • Nursing interventions to promote acid-base balance support prescribed medical therapies and aim at reversing the existing acid-base imbalance while providing for patient safety. Patients with acid-base imbalances often require repeated arterial blood gas (ABG) analysis. • Determination of a patient’s acid-base status requires obtaining a sample of arterial blood for laboratory testing. ABG analysis reveals acid-base status and the adequacy of ventilation and oxygenation. A qualified RN or other health care provider draws arterial blood from a peripheral artery (usually the radial) or from an existing arterial line (see agency policy and procedures). Before an arterial blood draw, perform an Allen test, which assesses arterial circulation in the hand. • When performing the Allen test, apply pressure to both the patient’s ulnar and radial arteries in the selected hand. The fingers to the hand should be pale and blanched, indicating a lack of arterial blood flow. Release the pressure on the ulnar artery and observe for color to return to the fingers and hand, which indicates that there is adequate circulation to the hand and fingers via the ulnar artery. • The Allen test ensures that the patient will have adequate blood flow to the hand if the radial artery is damaged. If color does not return, do not perform radial artery puncture on that arm. After the ABG puncture, apply pressure to the puncture site for at least 5 minutes to reduce the risk of hematoma formation. A longer time is necessary if the patient takes anticoagulant medications. 62 • Reassess the radial pulse after removing the pressure. After obtaining the specimen, take care to prevent air from entering the syringe because this alters the blood gas values. To reduce oxygen usage by blood cells, submerge the syringe in crushed ice and transport it immediately to the laboratory. 65 Physiology of Sleep: Sleep Regulation • Sleep is associated with changes in the peripheral nervous, endocrine, cardiovascular, respiratory, and muscular systems. • Specific physiological responses and patterns of brain activity identify each sequence. Instruments such as the electroencephalogram (EEG), which measures electrical activity in the cerebral cortex; the electromyogram (EMG), which measures muscle tone; and the electrooculogram (EOG), which measures eye movements provide information about some structural physiological aspects of sleep. • The major sleep center in the body is the hypothalamus. It secretes hypocreatins (orexins) that promote wakefulness and rapid eye movement sleep. Prostaglandin D2, L- tryptophan, and growth factors control sleep. • Researchers believe that the ascending reticular activating system (RAS) located in the upper brainstem contains special cells that maintain alertness and wakefulness. The RAS receives visual, auditory, pain, and tactile sensory stimuli. Activity from the cerebral cortex (e.g., emotions or thought processes) also stimulates the RAS. Arousal, wakefulness, and maintenance of consciousness result from neurons in the RAS releasing catecholamines such as norepinephrine. • The homeostatic process (Process S), which primarily regulates the length and depth of sleep; and the circadian rhythms (Process C: “biological time clocks”), which influence the internal organization of sleep, timing and duration of sleep-wake cycles, operate simultaneously to regulate sleep and wakefulness (Daroff et al, 2012). Time of wake up is defined by the intersection of Process S and Process C. • [Shown is Figure 43-1: Two-process model of sleep regulation shows the time course of the homeostatic process (Process S) and the circadian process (Process C). Process S rises during waking and declines during sleep. The intersection of Process S and Process C defines the time of wake-up.] Stages of the Adult Sleep Cycle • The normal sleep pattern for an adult begins with a presleep period during which the person is aware only of a gradually developing sleepiness. This period normally lasts 10 to 30 minutes; however, if a person has difficulty falling asleep, it lasts an hour or more. • Once asleep, the person usually passes through four or five complete sleep cycles per night, each consisting of four stages of nonrapid eye movement (NREM) sleep and a period of rapid eye movement (NREM) sleep. • A person usually reaches REM sleep about 90 minutes into the sleep cycle. Seventy-five to 80% of sleep time is spent in NREM sleep. 66 • With each successive cycle stages 3 and 4 shorten, and the period of REM lengthens. REM sleep lasts up to 60 minutes during the last sleep cycle. Not all people progress consistently through the stages of sleep. • Sleep becomes more fragmented with aging, and a person spends more time in lighter stages. 67 Functions of Sleep • NREM sleep contributes to body tissue restoration. • During sleep the heart rate falls to 60 beats/min or less, which benefits cardiac function. Other biological functions decreased during sleep are respirations, blood pressure, and muscle tone. • The body needs sleep to routinely restore biological processes. During deep slow-wave (NREM stage 4) sleep, the body releases human growth hormone for the repair and renewal of epithelial and specialized cells such as brain cells. Protein synthesis and cell division for renewal of tissues such as the skin, bone marrow, gastric mucosa, or brain occur during rest and sleep. NREM sleep is especially important in children, who experience more stage 4 sleep. • Another theory about the purpose of sleep is that the body conserves energy during sleep. The skeletal muscles relax progressively, and the absence of muscular contraction preserves chemical energy for cellular processes. Lowering of the basal metabolic rate further conserves body energy supply. • REM sleep is necessary for brain tissue restoration and appears to be important for cognitive restoration and memory. • A loss of REM sleep leads to feelings of confusion and suspicion. • Although dreams occur during both NREM and REM sleep, the dreams of REM sleep are more vivid and elaborate; and some believe that they are functionally important to learning, memory processing, and adaptation to stress. • The ability to describe a dream and interpret its significance sometimes helps resolve personal concerns or fears. • Another theory suggests that dreams erase certain fantasies or nonsensical memories. Physical Illness • Respiratory disease—such as chronic obstructive pulmonary disease (COPD), emphysema, asthma, allergies, or the common cold—often interferes with sleep. • Connections between heart disease, sleep, and sleep disorders exist. Sleep-related breathing disorders are linked to increased incidence of nocturnal angina (chest pain), increased heart rate, electrocardiogram changes, high blood pressure, and risk of heart diseases and stroke. • Nocturia disrupts the sleep cycle. • Restless leg syndrome (RLS) can occur before sleep onset. RLS symptoms include recurrent, rhythmical movements of the feet and legs. Patients feel an itching sensation deep in the muscles. Relief comes only from moving the legs, which prevents relaxation and subsequent sleep. 70 • Excessive daytime sleepiness is the most common complaint. • Feelings of sleepiness are usually most intense on awakening, right before going to sleep, and about 12 hours after the midsleep period. • Causes a serious decline in arterial oxygen saturation level. 71 • Central sleep apnea (CSA) involves dysfunction in the respiratory control center of the brain. • The impulse to breathe fails temporarily, and nasal airflow and chest wall movement cease. • The oxygen saturation of the blood falls. The condition is common in patients with brainstem injury, muscular dystrophy, and encephalitis. Less than 10% of sleep apnea is predominantly central in origin. • People with CSA tend to awaken during sleep and therefore complain of insomnia and excessive daytime sleepiness (EDS). Mild and intermittent snoring is also present. • Treatment includes therapy for underlying cardiac or respiratory complications and emotional problems that occur as a result of the symptoms of this disorder. • Narcolepsy is a dysfunction of mechanisms that regulate the sleep and waking states. • During the day a person suddenly feels an overwhelming wave of sleepiness and falls asleep; REM sleep occurs within 15 minutes of falling asleep. Cataplexy, or sudden muscle weakness during intense emotions such as anger, sadness, or laughter, occurs at any time during the day. • Sleep paralysis is another symptom. • Sleep deprivation is a problem many patients experience as a result of dyssomnia. Causes include fever, difficulty breathing, pain, emotional stress, medications, and disturbances in the health care setting. Owing to long work schedules and rotations, health care providers are prone to sleep deprivation. Hospitalization makes patients prone to sleep deprivation caused by environmental noises and interruptions for care. • [Review Box 43-3, Sleep Deprivation Symptoms, with students.] • Parasomnias are sleep problems that are more common in children. These include sleepwalking, night terrors, nightmares, bed-wetting, body rocking, and tooth grinding. When adults have these problems, it often indicates more serious disorders. Sleep and Rest • Rest does not imply inactivity. When rested, people experience feelings of rejuvenation, feeling refreshed, and able to carry out of activities of daily living. • Illness and unfamiliar health care routines affect the usual rest and sleep patterns of hospitalized patients. It will be important to allow patients periods of rest. • Nurses frequently care for patients who are on bed rest to reduce physical and psychological demands on the body in a variety of health care settings. However, these people do not necessarily feel rested. Some still have emotional worries that prevent complete relaxation. • You must always be aware of a patient’s need for rest. Lack of rest for long periods causes illness or worsening of existing illness. 72 Normal Sleep Requirements and Patterns 75 • Weight loss or gain influences sleep patterns. Weight gain contributes to OSA because of increased size of the soft tissue structures in the upper airway. • [Review Box 43-4, Drugs and Their Effects on Sleep, with students.] Assessment • Assess patients’ sleep patterns by using a nursing history to gather information about factors that usually influence sleep. Sleep is a subjective experience. Only the patient is able to report whether or not it is sufficient and restful. If the patient is satisfied with the quantity and quality of sleep received, you consider it normal, and the nursing history is brief. If a patient admits to or suspects a sleep problem, you need a detailed history and assessment. If a patient has an obvious sleep problem, consider asking if his or her sleep partner can be approached for further assessment data. • A poor night’s sleep for a patient often starts a vicious cycle of anticipatory anxiety. • Usually patients are the best resource for describing sleep problems and how they represent a change from their usual sleep and waking patterns. • In addition, bed partners are able to provide information about patients’ sleep patterns that helps reveal the nature of certain sleep disorders. • When caring for children, seek information about sleep patterns from parents or guardians because they are usually a reliable source of information. • Two effective subjective measures of sleep are the Epworth Sleepiness Scale and the Pittsburgh Sleep Quality Index. • Another brief subjective method to assess sleep is a numeric scale with a 0 to 10 sleep rating. • When suspecting a sleep problem, assess the quality and characteristics of sleep in greater depth by asking the patient to describe the problem. This includes recent changes in sleep pattern, sleep symptoms experienced during waking hours, use of sleep and other prescribed or over-the-counter medications, diet and intake of substances such as caffeine or alcohol that influence sleep, and recent life events that have affected the patient’s mental and emotional status. • If a patient’s sleep is adequate, assess his or her usual bedtime, normal bedtime ritual, preferred environment for sleeping, and usual preferred rising time. • When a patient has a sleep problem, conduct a complete sleep history. Diagnosing sleep problems depends on identifying factors that impair sleep. • A general description of the problem followed by more focused questions usually reveals specific characteristics that are useful in planning therapies. To begin, you need to understand the nature of the sleep problem, its signs and symptoms, its onset and 76 duration, its severity, any predisposing factors or causes, and the overall effect on the patient. • [Review Box 43-5, Nursing Assessment Questions, with the students.] • Proper questioning helps to determine the type of sleep disturbance and the nature of the problem. 77 • [Review Box 43-6, Questions to Ask to Assess for Specific Sleep Disorders, with the students.] • As an adjunct to the sleep history, have the patient and bed partner keep a sleep-wake log for 1 to 4 weeks. • Ask the following questions to determine a patient’s sleep pattern: • What time do you usually get in bed each night? • How much time does it usually take to fall asleep? Do you do anything special to help you fall asleep? • How many times do you awaken during the night? Why? • What time do you typically wake up in the morning? • On average, how many hours do you sleep each night? • Patients with sleep problems frequently show patterns drastically different from their usual one, or sometimes the change is relatively minor. • Determine whether the patient has any preexisting health problems that interfere with sleep. A history of psychiatric problems also makes a difference. If the patient has recently had surgery, expect him or her to experience some sleep disturbance. Patients usually awaken frequently during the first night after surgery and receive little deep or REM sleep. Depending on the type of surgery, it takes several days to months for a normal sleep cycle to return. • In your assessment learn if the patient is experiencing any changes in lifestyle that disrupt sleep. A person’s occupation often offers a clue to the nature of the sleep problem. • A patient’s emotions and mental status affect the ability to sleep. When a sleep disturbance is related to an emotional problem, the key is to treat the primary problem; its resolution often improves sleep. • Ask patients what they do to prepare for sleep. • Pay special attention to a child’s bedtime rituals. Some young children need a special blanket or stuffed animal when going to sleep. • Observe for behaviors such as irritability, disorientation (similar to a drunken state), frequent yawning, and slurred speech. If sleep deprivation has lasted a long time, psychotic behavior such as delusions and paranoia sometimes develop. • [Review Figure 43-3, Critical thinking model for sleep assessment, with students.] Planning • Professional standards are especially important to consider in developing a care plan. • As you plan care for a patient with sleep disturbances, creation of a concept map is another method for developing holistic patient-centered care. 80 • In the home, it helps to encourage patients to stay physically active during the day so they are more likely to sleep at night. Increasing daytime activity lessens problems with falling asleep. 81 • The inability to sleep because of emotional stress also makes a person feel irritable and tense. When patients are emotionally upset, encourage them to try not to force sleep. Otherwise insomnia frequently develops, and soon bedtime is associated with the inability to relax. • Preschoolers have bedtime fears (fear of the dark or strange noises), awaken during the night, or have nightmares. • Cultural tradition causes families to approach sleep practices differently. • [Review Box 43-10, Cultural Aspects of Care: Co-sleeping, with students.] • Some people enjoy bedtime snacks, whereas others cannot sleep after eating. A dairy product such as warm milk or cocoa that contains L-tryptophan is often helpful in promoting sleep. A full meal before bedtime often causes gastrointestinal upset and interferes with the ability to fall asleep. • Warn patients against drinking or eating foods with caffeine before bedtime. • Melatonin is a neurohormone produced in the brain that helps control circadian rhythms and promote sleep. It is a popular nutritional supplement that is found to be helpful in improving sleep efficiency and decreasing nighttime awakenings. The recommended dose is 0.3 to 1 mg taken 2 hours before bedtime. • Several other herbal products assist in sleep. Valerian is effective in mild insomnia and RLS. It effects the release of neurotransmitters and produces very mild sedation. Kava helps promote sleep in patients with anxiety. It should be used cautiously because of its potential toxic effects on the liver. Chamomile, an herbal tea, has a mild sedative effect that may be beneficial in promoting sleep. • The use of nonprescription sleeping medications is not advisable. Patients need to learn the risks of such drugs. Over the long term these drugs lead to further sleep disruption, even when they initially seemed effective. • In a hospital, the nurse controls the environment in several ways. • [Review Box 43-11, Evidence-Based Practice: Sleep Hygiene in Hospitalized Patients, and Box 43-12, Control of Noise in the Hospital, with students.] • When planning interventions to promote sleep, consider the usual characteristics of the patient’s home environment and normal lifestyle. • Patients in acute care settings have their normal rest and sleep routine disrupted, which generally leads to sleep problems. In this setting, nursing interventions focus on controlling factors in the environment that disrupt sleep, relieving physiological or psychological disruptions to sleep, and providing for uninterrupted rest and sleep periods for the patient. • In a hospital or extended care setting it is difficult to provide patients with the time needed to rest and sleep. The most effective treatment for sleep disturbances is elimination or correction of factors that disrupt the sleep pattern. • [Review Box 43-12, Control of Noise in the Hospital, with students.] 82 • When the patient’s condition demands more frequent monitoring, plan activities to allow extended rest periods. • Patients with OSA are at risk for complications while in the hospital. Surgery and anesthesia disrupt normal sleep patterns. After surgery, patients reach deep levels of