N105: Essentials of Nursing Care - Health Differences

Essentials of Nursing Study Guide

©2017 Achieve Test Prep Page 127 of 160 6.5 Nursing Procedures Assessment: • Obtain patient’s personal history related to rest and sleep. Sleep diary will include the total number of sleep hours per day. It should also include all activities performed 2-3 hours before bed (type, duration, and time), bedtime rituals (ingestion of food, fluid, or medication before going to bed), time of going to bed, trying to fall asleep and approximate time of falling asleep. Also document instances of waking and the duration during the night. The diary will also contain any worries that concern the patient. Also include the patient’s knowledge of positive and negative beliefs of the effect on sleep. • Assess factors influencing rest and sleep such as age, individual preferences, physical conditions, cultural and spiritual practices, socioeconomic factors, environment of sleep, psychological factors, and medications used. • Obtain objective data to include in the physical examination. Assess facial appearance for darkened areas around eyes, puffy eyelids, reddened conjunctiva, and glazed or dull eyes. Assess behaviors to include irritability, restlessness, inattentiveness, slowed speech, slumped posture, hand tremor, yawning, withdrawal, and confusion. Assess for lack of energy as evidenced by lethargy or fatigue. Assess for alteration in vital signs and body position. • Review diagnostic studies. Use a sleep lab for polysomnography. This is where electrodes are placed on the scalp to record brain waves (EEG) and placed on the outer canthus of each eye to record eye movement (EOG). Electrodes are also placed on chin muscles to record electromyogram (EMG). Leg movements may be captured by an ECG. Oximetry is used to monitor oxygen saturation. The client’s activity such as, movements, struggling, and noisy respirations can be assessed during sleep. Analysis: • Fatigue related to sleep deprivation • Sleep deprivation related to uncomfortable environment Planning: • Establish patient centered goals (Patient will…). Have patient demonstrate decreased signs and symptoms of sleep deprivation, verbalize feeling refreshed after awakening, establish a satisfactory sleep and rest pattern, and identify the source of anxiety causing sleep pattern disturbance. Help with anxiety reduction, environmental management, comfort, sleep enhancement, simple massage, and simple relaxation therapy. • Plan nursing measures to help the patient achieve goals. Reduce environmental distractions such as noise and lighting, position the patient to aid in muscle relaxation, and provide sleep medications asneeded. • Incorporate factors influencing the patient’s rest and sleep in planning the patient’s care. Discourage the use of caffeine and stimulants prior to bedtime. Adhere to a child’s usual bedtime routine and eliminate stressful situations before bedtime. Give comfort measures and teach sleep-promoting techniques.