Slide 2 Trisha Economidis, MS, ARNP Lake-Sumter Community
College Fall, 2012 Slide 3 Sleep Quiz How many Americans suffer
from sleep disorders? A. 100,000 B. 1 million C. 50-70 million
Slide 4 How many sleep disorders have been identified? A. 10 B. 50
C. 90 Slide 5 Who has a greater incidence of insomnia? A. Men B.
Women Slide 6 For women, sleep disturbances are often related to
hormonal hallmarks (menstruation, pregnancy, menopause). A. True B.
False Slide 7 Sleep patterns of the older adult include which of
the following: (Select all that apply) A. Need more sleep than
younger adults B. Take longer to fall asleep than younger adults C.
Awake more frequently and stay awake longer than younger adults D.
Frequent awakening is often due to physical discomfort and nocturia
Slide 8 Physiology of sleep Biorhythms Biological Controlled within
the body Environmental Circadian rhythm- Biorhythm Day-night 24
hour clock Slide 9 Types of sleep Non-Rem REM (Rapid Eye Movement)
Occurs in 90-100 minute cycles Slide 10 Sleep Cycle Slide 11
Factors Affecting Rest & Sleep Comfort Anxiety Environment
Slide 12 Factors Affecting Rest and Sleep Lifestyle Work Exercise
Travel Diet Drugs Medications Slide 13 Average Sleep Requirements
Table 33-1 Page 814 Slide 14 Alterations in Sleep patterns
Dyssomnias Dyssomnias Insomnia Sleep-wake Schedule Restless Leg
Syndrome Sleep Deprivation Hypersomnia Narcolepsy Slide 15
Dyssomnias Sleep Apnea- airway occlusion Hypercapnia and hypoxemia
May have increased heart rate, increased bp S/S: excessive
sleepiness, fatigue, snoring, nocturia Diagnosis: Made by sleep
study Untreated can lead to : Hypertension Dysrhythmias Angina MI
Stroke Mood swings Impotence Personality changes Slide 16 Sleep
Apnea Obstructive Sleep Apnea caused by occlusion of the airway
during sleep. TX: CPAP Continuous Positive Air Pressure Central
Sleep Apnea Dysfunction in central respiratory control Mixed Apnea
combination of Obstructive and Central Sleep Apneas Slide 17 CPAP
Slide 18 Altered Sleep Patterns Parasomnias Sleepwalking
(Somnambulism) Occurs during Stage 3-4 of sleep Sleep talking
Bruxism-teeth grinding or clenching Night Terrors Nocturnal
Enuresis Slide 19 What is the Risk? Slide 20 Sleep Hygiene
Practices Assessment of Sleep Patterns and rituals Relaxation
Eliminate stressful situations before bed Muscle relaxation
Activities that relax rather than stimulate Warm bath Slide 21
Sleep Hygiene Environment Adjust light, noise, temp to promote
sleep Use bedroom for sleep & sex only Go to bed at same time
each night Help client to understand what things can affect sleep
patterns Slide 22 Pharmacologic Interventions for Sleep Be aware of
potential side effects and possible dependency issues Shouldnt mix
with alcohol and most are not recommended for long-term use Slide
23 Pharmacologic Interventions Non-benzodiazepines: Ambien, Sonata,
Lunesta Benzodiazepines: Valium, Ativan, Klonopin, Xanax Caution:
Hazardous in elderly; must use cautiously in children; can cause
ADDICTION Slide 24 Pharmacologic Interventions, cont. Barbiturates:
sedative/hypnotic/anticonvulsants; Seconal, Luminal, Nembutal
Tricyclic Antidepressants: major side effect is drowsiness. Elavil,
Tofranil OTC Sleep aids Antihistamines Herbal remedies Melatonin
Slide 25 Nutrition Impact on Sleep No large fatty meals before
sleep L-tryptophan increases sleep (milk & cheese) Protein
increases alertness (not a good before bed snack) Carbohydrates
promote sleep crackers, bread, cereal Slide 26 Nursing Diagnoses
for Sleep Sleep Deprivation: Occurs over long periods of time and
symptoms more severe (confusion, even psychosis) Disturbed Sleep
Pattern: time limited sleep pattern. Ex.: related to
hospitalization can be treated by nursing therapy Slide 27 A
patient is diagnosed with narcolepsy. The nurses primary
intervention should address the patients: A. Inability to provide
self-care B. Impaired thought processes C. Potential for injury D.
Excessive fatigue Slide 28 Correct Answer: C Narcolepsy is
excessive sleepiness in the daytime that can cause a person to fall
asleep uncontrollably at inappropriate times (sleep attach) and
result in physical harm to self or others Slide 29 The nurse is
planning a teaching program for a patient with a diagnosis of
obstructive sleep apnea. Which is the most common intervention that
the nurse should plan to discuss with this patient? A. Encouraging
sleeping in the supine position B. Using devices that support
airway patency C. Positioning two pillows under the head D.
Administering sedatives Slide 30 Answer: B. A continuous positive
airway pressure (CPAP) mask worn over the nose when sleeping keeps
the upper airway patent through continuous positive airway
pressure. Slide 31 Which is the most important nursing intervention
that supports a patients ability to sleep in the hospital setting?
A. Providing an extra blanket B. Limiting unnecessary noise on the
unit C. Shutting off lights in the patients room D. Pulling
curtains around the bed at night. Slide 32 Answer: B Noise is a
serious deterrent to sleep in a hospital. The nurse should limit
environmental noise (distributing fluids, providing treatments,
rolling drug and linen carts) and staff communication noise.
(Turning off the lights is unsafe. You may dim the lights or put a
night light on to provide enough illumination for safe ambulation
to the bathroom ) Slide 33 What concept associated with sleep
should the nurse consider to best plan nursing care for a
hospitalized patient? A. People require eight hours of
uninterrupted sleep to meet energy needs B. Frequency of nighttime
awakenings decreases with age C. Fear can contribute to the need to
stay awake. D. Bed rest decreases the need for sleep. Slide 34
Answer: C Fear of loss of control, the unknown, and potential death
results in the struggle to stay awake, which interferes with the
ability to relax sufficiently to fall asleep. Slide 35 Slide 36
Comfort/Pain True or False? The nurse is the best judge of a
patients pain Slide 37 Answer: False Pain is SUBJECTIVE only the
client can judge the level and severity of pain Slide 38 TRUE OR
FALSE? You should wait until pain has reached the maximum amount
bearable before medicating. Slide 39 Answer: False Pain
control/relief is much more effective when given when pain begins
Slide 40 True or False? True pain always produces observable
signs/symptoms such as grimacing or moaning Slide 41 Answer: False
Many people are stoic when it comes to expressing pain. Ones
culture may also have an impact on the expression of pain. Slide 42
True or False? If the patient doesnt look like hes in pain, its ok
to withhold medications or decrease the dose. Slide 43 Answer:
False Pain is a subjective experience. Only the patient knows how
much pain he/she is experiencing. Slide 44 True or False? Clients
taking pain medications will become addicted. Slide 45 Answer:
False While it does happen, it is unlikely when analgesics are
administered and monitored carefully Slide 46 So.What IS Pain? A
sensation that HURTS A SUBJECTIVE experience An interference : a
multi-dimensional experience and impact Protective Slide 47 Types
or Origins of Pain Cutaneous - superficial Somatic - ligaments,
joints, muscles Visceral internal organs/body cavities Neuropathic
nerve pain Radiating Starts at origin, but extends to other
locations Referred Pain felt distant to origin Phantom Slide 48
Slide 49 Duration of Pain Acute Pain - Sudden onset/short duration
(up to 6 months) Chronic Pain Has lasted 6 months or longer
Intractable Pain Chronic and very resistant to relief
http://www.youtube.com/watch?v=Hs kbfhiVJro
http://www.youtube.com/watch?v=Hs kbfhiVJro Slide 50 Quality of
Pain What does it feel like? Sharp? Dull? Aching? Stabbing?
Burning? Crushing? Tingling ? Slide 51 Intensity or Severity of
Pain How much does it hurt????? Pain Rating Scales imperative
Allows assessment of level of pain and effectiveness of
interventions 0-10 scale Faces Pain Rating Scale Poker Chips -
pieces of pain Slide 52 Faces Slide 53 Numeric. Slide 54 Assessment
of Pain: The Who, What, When, Where, and How Who? The patient
self-report is the most reliable indicator of pain What if its a
child? The parent/caregiver knows the child best Slide 55 What?
What the patient says AND Your observations which may include:
Physiological responses: Acute pain - Increased blood pressure,
pulse and respirations; dilated pupils, rapid speech Behavioral
responses: Moaning, facial grimacing, crying, agitation, guarding,
withdrawing from painful stimuli Psychological responses: Anxiety,
depression, anger, fear, exhaustion, irritability Slide 56 When? On
admission Before and after procedures or treatments With each
assessment/vital signs When the patient is resting as well as
during activity Before you give pain meds and 30 minutes after When
the patient complains of pain Slide 57 Where? Where ever the
patient is and whatever is going on? Resting in bed Ambulating
Before, during, after procedures whether in the patients room or in
another location Slide 58 How? Begin with a pain history Do you
have pain now? When did the pain begin? (Onset) Where is the pain
located? (Location) How do you rate your pain? (use a pain scale)
(Intensity) How would you describe your pain? (Quality) Slide 59
How? (Pain History) How often do you have pain? (Frequency) What
makes the pain better? (Alleviating Factors) What makes it worse?
(Aggravating Factors) Do you have any other symptoms when you are
experiencing pain, i.e. nausea/vomiting? (Associated Factors) Slide
60 How? (Pain History) Have you experienced this type of pain in
the past? If so, how did you manage/cope with it? (History of
Previous Pain Experience) Have you used any medications to treat
the pain? If so, what have you used and was it effective? What, if
any, alternative treatments have you used for pain? Slide 61
Review: Assessing Pain How do we assess? Onset of symptoms Location
Intensity Quality Frequency Alleviating Factors Aggravating Factors
Associated Factors History of Previous Pain Experience Slide 62
How? Combine your pain history with your observations of:
Physiological responses Behavioral responses Psychological
responses Slide 63 Factors That May Affect Perception of Pain Age
Child may not recognize sensation of pain or may have paradoxical
reaction Adolescent may be expressed as attitude, anger, aggression
Older adult may have trouble verbalizing because of perception that
pain is normal part of aging Slide 64 Factors that may Affect Pain
Culture May impact level of pain one is willing to endure Need to
use assessment tools that are culturally sensitive Slide 65
Perception of pain is impacted by age and culture. Slide 66
Analgesics Used for Pain 3 common groups of drugs used for pain
management Opioids Nonopioids Adjuvants Slide 67 Pain Medications:
Opioid Analgesics Work on pain by blocking receptors in the Central
Nervous System Slide 68 Opioid Analgesics morphine sulfate
methadone meperidine HCl (Demerol) hydromorphone (Dilaudid)
Fentanyl oxycodone (Percocet) hydrocodone (Vicodin) Slide 69 Opioid
Analgesics Indications/Uses: More effective for visceral pain
Side/Adverse Effects: Respiratory depression N/V, constipation,
drowsiness, pruritis (itching), dry mouth, difficulty urinating,
tachy/bradycardias, hypotension Slide 70 Opioid Analgesics Nursing
Considerations: Assess respiratory status frequently. If
respiratory depression occurs, administer Narcan to reverse
effects. Monitor blood pressure. Monitor for constipation and make
appropriate interventions (pg 741) Treat other symptoms as
indicated Slide 71 Nonopioid Analgesics Used to relieve mild to
moderate pain, acute or chronic (also may relieve inflammation and
fever) Acetaminophen (Tylenol) (minimal anti-inflammatory effect)
NSAIDS (nonsteroidal anti-inflammatory drugs) aspirin ibuprofen
(Motrin, Advil) naproxen (Aleve) Prescription NSAIDS: Celebrex,
Voltaren, Indocin and others Slide 72 Side/Adverse Effects of
Nonopioids Acetaminophen Can cause liver toxicity especially in
patients who consume alcohol or who have liver disease. Current
recommendation: maximum of 3000 mg (3g) per day as of July, 2011
Aspirin regular use can cause prolonged clotting time (bruise
easily and bleed more) Other NSAIDS gastric irritation and
bleeding, use with caution in patients with impaired clotting and
renal disease Slide 73 Nursing considerations for Nonopioids
Tylenol teaching regarding maximum daily dose. Importance of
reporting overdose (liver damage occurs rapidly) NSAIDS importance
of taking with food. Use of enteric-coated pills if gastric
irritation occurs. Monitor for gi bleeding. Be aware of the
possibility for drug interactions. Slide 74 Adjuvant Medications
Enhance the analgesic effect of opioids Anticonvulsants
Antidepressants Sedatives Steroids Slide 75 Non-pharmacological
Interventions for Pain Management(see pgs. 736- 738) Relaxation
Guided imagery Distraction Therapeutic Touch Hypnosis Cutaneous
Stimulation: TENS units, PENS units, Spinal Cord stimulator,
Acupuncture, Acupressure, Massage, Heat/Cold Application,
Contralateral stimulation Slide 76 A patient has a total abdominal
hysterectomy for Stage 4 ovarian cancer. What should the nurse do
first when on the second postoperative day this patient reports
abdominal pain at level 5 on a 1 to 10 pain scale? A. Reposition
the patient B. Offer a relaxing back rub C. Use distraction
techniques D. Administer the prescribed analgesic. Slide 77 Answer:
D Major abdominal surgery involves extensive manipulation of
internal organs and a large abdominal incision that require
adequate pharmacological intervention to provide relief from pain
Slide 78 A patient states, The pain moves from my chest down my
left arm. Which characteristic of pain is associated with this
statement? A. Pattern B. Duration C. Location D. Constancy Slide 79
Answer: C This is a description of referred pain, which is pain
felt in a part of the body that is at a distance from the tissues
causing the pain. Referred pain is related to location of pain.
Slide 80 A patient has a history of severe chronic pain. Which is
one of the most important guidelines associated with providing
nursing care to this patient? A. Asking what is an acceptable level
of pain B. Providing interventions that do not precipitate pain C.
Determining the level of function that can be performed without
pain D. Focusing on pain management intervention before pain
becomes excessive Slide 81 Answer: D Administration of analgesics
around the clock at regularly scheduled intervals or by long-acting
controlled-release transdermal patches maintains therapeutic blood
levels of analgesics, which limit pain at levels of comfort
acceptable to patients.
