N105: Essentials of Nursing Care - Health Differences

Essentials of Nursing Study Guide

• Assign patient care activities to other members as appropriate, such as the nursing assistant to administer a backrub to patient beforesleep. Implementation: • Use nursing measures to promote rest and sleep. Promote bedtime rituals and sleep routines like an evening stroll, listening to music, watching television, taking a soothing bath and praying. Children enjoy a bedtime story, holding a favorite toy or blanket, and kissing everyone goodnight. Encourage normal hygienic routines, such as washing the face and hands, brushing teeth and voiding. Provide a massage, plumping of pillows, and extra blankets as needed. • Administer prescribed medications as ordered. Whenever possible non-pharmacologic interventions to induce and maintain sleep are the preferred interventions. Use of sedative- hypnotics, which induce sleep, and anti-anxiety drugs or tranquilizers, which decrease tension and anxiety, should be avoided. Tolerance may develop with long term use resulting in rebound insomnia. • Use nursing measures to create a restful environment. Eliminate noises, create a comfortable room temperature, use appropriate lighting, and ensure proper ventilation. Reduce environmental distractions, reduce sleep interruptions, and ensure a safe environment. Place beds in low positions, use night lights as needed, and place call bells within easy reach. • Provide information and instruction regarding rest and sleep. Teach conditions that promote sleep and interfere with sleep. Discuss safe use of sleep medications. Promote a regular bedtime and exercise schedule. Discuss appropriate diet consumption to contribute to restful sleep, including avoiding caffeine, heavy meals within 3 hours of sleep, and alcohol. Discourage an increased fluid intake at bedtime or spicy snacks. Teach relaxation techniques. • Nursing measures should promote continuity of care, such as patient teaching, referrals to sleep clinics, and community resources. Evaluation: • Record and report the patient’s response to sleep medications, alteration in sleep patterns, resolution of sleep pattern disturbance, and enhanced relaxation with use of relaxation techniques. • Reassess and revise care plan as necessary. Use further teaching and modify the outcome. • Determine patient’s response to care given by other team members.

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