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Nursing Fundamentals
sleep - hygiene - immobility - skin (wound)
| Term | Definition |
|---|---|
| Circadian Rhythm | 24 hour; day-night cycle -also called Diurnal Rhythm |
| BIOLOGICAL CLOCK | cyclical nature of body functions controlled from within the body are synchronized w/ environmental factors; biorhythm |
| ELETROENCEPHALOGRAM (EEG) | measures electrical activity in the cerebral cortex |
| ELECTROMYOGRAM (EMG) | measures muscle tone |
| ELECTROOCULOGRAM (EOG) | measures eye movement |
| HYPOTHALAMUS | -major sleep center in the body -controls sleep-wake & coordination w/ circadian |
| REM | rapid eye movement |
| HOMEOSTATIC PROCESS | regulates the length and depth of sleep |
| SLEEP ALLOWS FOR WHAT??? | restore biological processes in the body |
| 2 STAGES OF NORMAL SLEEP | NREM REM |
| NREM | -non-rapid eye movement -4 stages (nrem1, nrem2, nrem3, nrem4) |
| NREM 1 & 2 | lighter sleep |
| NREM 3 & 4 | deeper sleep (slow-wave) |
| REM | -rapid eye movement -dream vividly, sleep walking, bed wetthing -lasts between 20-60 minutes |
| EACH 4-6 SLEEP CYCLE LAST APPROX. 90-110 MIN. | HEART RATE DROPS TO APPROX. 60 BPM OR LESS |
| SLEEP DEPRIVATION CAUSES/EFFECTS | -immune function -metabolism -nitrogen balance -protein catabolism -quality of life |
| SLEEP | a recurrent, altered state of consciousness that occurs for sustained periods (cyclical process) |
| NEONATES REQUIRE HOW MUCH SLEEP | 16 hrs./day - 50% REM |
| INFANTS REQUIRE HOW MUCH SLEEP | 9-11 hrs./day - 30% REM |
| TODDLERS/PRESCHOOLERS REQUIRE HOW MUCH SLEEP | 12 hrs. /day - 20% REM -preschoolers (bedtime fears, waking during the night, nightmares) |
| SCHOOL AGE REQUIRE HOW MUCH SLEEP | 9-10 hrs./day |
| ADOLESCENTS REQUIRE HOW MUCH SLEEP | 7 1/2 hrs./day |
| YOUNG ADULTS REQUIRE HOW MUCH SLEEP | 6 - 8.5 hrs./day |
| MIDDLE ADULTS REQUIRE HOW MUCH SLEEP | 4 - 6 or less |
| OLDER ADULTS REQUIRE HOW MUCH SLEEP | 4 - 8 hrs./day |
| EXCESSIVE DAYTIME SLEEPINESS (EDS) | extreme fatigue felt during the day |
| FACTORS AFFECTING SLEEP | -physical illness -drugs/substances -lifestyle -usual sleep patters & EDS -emotional stress -environment -exercise/fatigue -food/calorie intake |
| NOCTURIA | nighttime urination |
| INSOMNIA | chronic inability to sleep or remain asleep |
| SLEEP APNEA (obstructive) | cessation (stop) of breathing for a time during sleep; partial airway is blocked |
| NARCOLEPSY (hypersomnia) | syndrome involving sudden sleep attacks that a person cannot control |
| SLEEP DEPRIVATION | decrease in the amount, quality, and consistency of sleep |
| PARASOMNIAS | abnormal/unusual behavior of the nervous system during sleep (sleep walking, terrors, nightmares, sleep paralysis) |
| MELATONIN | neuro-hormone produced in the brain that helps control circadian rhythms |
| SEDATIVES/HYPNOTICS | groups of drugs that induce and/or maintain sleep |
| CPAP | continuous positive airway pressure |
| CATAPLEXY | sudden muscle weakness during intense emotions such as anger/laughter that occurs at any time during the day |
| CENTRAL SLEEP APNEA | central nervous system, drugs/substances, medication condition |
| WHAT IS THE SAFEST SLEEP AID? | non-benzodiazepines |
| OUTERMOST LAYER OF THE SKIN | epidermis |
| MIDDLE LAYER OF THE SKIN | dermis |
| INNER MOST LAYER OF THE SKIN | hypodermis |
| EPIDERMIS | outermost layer of skin tissue that shields underlying tissues against water loss and injury and prevents entry of disease; generates new cells to replace the dead cells shed |
| BACTERIA | normal flora; reside on epidermis |
| DERMIS | provides support for the epidermis and contains nerve fibers, blood vessels, sebaceous and sweat glands, and hair follicles |
| SEBACEOUS GLANDS | secrete sebum (oily fluid that softens and lubricates the skin) |
| SUBCUTANEOUS TISSUE | heat insulator; supports upper skin against stresses & pressure, anchors skin loosely to underlying structures such as muscle |
| SKIN'S PHYSICAL FEATURES INCLUDE: | -color -thickness -texture -turgor -temperature -moisture |
| GINGIVITIS | inflammation of the gums |
| DENTAL CARIES | tooth decay produced by interaction of food w/ bacteria that form plaque |
| FACTORS LIMITING MOBILITY: | physical injury, psychosis, weakness, surgery, pain, prolonged inactivity, medications, catheters, IVs, stroke, brain injury, dementia |
| EDENTULOUS | without teeth |
| ORAL MUCOSITIS | oral erythema, ulceration, pain |
| GLOSSITIS | inflammation of the tongue |
| HALITOSIS | bad breath |
| CHELITIS | cracked lips |
| ORAL MALIGNANCY | mouth lumps/ulcers |
| PEDICULOSIS CAPITIS | head lice |
| ALOPECIA | loss of hair |
| CERUMEN | yellow ear wax |
| XEROSIS | abnormal dryness of the skin |
| DANDRUFF | scaling of the scalp |
| PEDICULOSIS CORPORIS | body lice |
| PEDICULOSIS PUBIS | crab lice |
| SKIN TEARS | traumatic wounds in which the epidermis separates from the dermis |
| STOMATITIS | ulcers & inflammation |
| MUCOSITIS | painful inflammation of oral mucous membranes |
| DENTURE STOMATITIS | inflammation of the oral mucosa in contact w/ denture surface |
| MACERATION | softening & breaking down of skin from prolonged exposure to moisture |
| 60 % OF LOWER LIMBS | result in amputations for non-traumatic reasons are associated with diabetes |
| 2 % CHG | no rinse disposable cleansing cloths |
| PERINEAL CARE | cleansing a patient's genital/anal area |
| CALLUS | thickened portion of the epidermis; consisting of mass of horny, keratotic cells, usually flat and painless |
| CORNS | keratosis caused by friction and pressure from shoes; mainly on toes over bony prominences |
| PLANTAR WARTS | fungating lesion that appears on sole of foot; caused by papillomavirus |
| ATHLETE'S FOOT (tinea pedis) | fungal infection of the foot; scaliness and cracking of skin between toes and on soles of feet |
| INGROWN NAILS | toenail/fingernail growing inward into soft tissue around nail |
| PARONYCHIA | inflammation of tissue surrounding nail after hangnail or other injury |
| FOOT ODORS | result of excess perspiration promoting microorganism growth |
| NAIL FUNGAL INFECTION | results from excess moisture; use of artificial nails |
| TICKS | small gray-brown parasites that burrow into skin and suck blood |
| MOBILITY | body to move freely; requires the Nervous & Muscoskeletal system; coordinated body mechanics |
| BODY ALIGNMENT | the positioning of the joints, tendons, ligaments and muscles while standing, sitting, or lying |
| 4 PATHOLOGICAL INFLUENCES THAT AFFECT MOBILITY | -posture abnormalities (congenital defects, hip dysplasia) -muscle abnormalities (muscular dystrophy, ALS, injuries) -damage to the DNS (concussion, stroke, meningitis) -direct trauma to the muscoskeletal system (osteoporosis) |
| TORTICOLLIS | inclining of the head to affected side, in which sternocleidomastoid muscle is contracted |
| LORDOSIS | exaggeration of anterior convex curve of the lumbar spine |
| KYPHOSIS | increased convexity in curvature of thoracic spine |
| SCOLIOSIS | lateral S- or C- shaped spinal column with vertebral rotation; unequal heights of hips and shoulders |
| CONGENITAL HIP DYSPLASIA | hip Instability with limited abduction of hips and occasionally adduction contractures |
| KNOCK-KNEE (genu valgum) | legs curved inward so knees come together while walking |
| BOWLEGS (genu varum) | one or both legs bent outward at the knee |
| CLUBFOOT | 95% medial deviation and plantar flexion of foot 5% lateral deviation and dorsiflexion |
| FOOT DROP | inability to dorsi-flex and invert foot because of peroneal nerve damage |
| PIGEON TOES | internal rotation of forefoot or entire foot |
| BED REST | placement of the patient in bed for therapeutic reasons for a prescribed period |
| IMMOBILITY | inability to move about freely |
| ATELECTASIS | collapse of the alveoli |
| HYPOSTATIC PNEUMONIA | inflammation of the lungs from stasis or pooling of secretions |
| NEGATIVE NITROGEN BALANCE | condition occurring when the body excretes more nitrogen than it takes in |
| DIURESIS | increased urine excretion; causes body to lose electrolytes such as potassium and sodium |
| ORTHOSTATIC HYPOTENSION | abnormally low blood pressure occurring when a person stands up |
| THROMBUS | an accumulation of platelets, fibrin, clotting factors and cellular elements of the blood attached to the interior wall of a vein or artery |
| 3 FACTORS CONTRIBUTING TO VENOUS THROMBUS FORMATION (VIRCHOW'S TRIAD) = DVT | -loss of integrity of the vessel wall -abnormalities of blood flow -alterations in blood constituents |
| DVT | deep vein thrombosis (asses q8h) |
| ACTIVITIES OF DAILY LIVING (ADLs) | activities performed during a normal day |
| IMMOBILITY CAUSES 2 SKELETAL CHANGES | 1. joint contracture 2. disuse osteoporosis |
| JOINT CONTRACTURE | a preventable, abnormal and possibly permanent condition characterized by fixation of the joint |
| ROM | range of motion |
| DISUSE OSTEOPOROSIS | reductions in skeletal mass routinely accompanying immobility or paralysis |
| BONE RESORPTION | destruction of bone cells and release of calcium into the blood |
| PATHOLIGICAL FRACTURES | fractures resulting from weakened bone tissue; caused by osteoporosis or neoplasms |
| OSTEOPOROSIS | abnormal rarefraction of bone |
| ISCHMIA | temporary decrease of blood flow to tissue |
| URINARY STASIS | abnormalities in structure or innervation of the urinary outflow tract that result in incomplete emptying of the bladder or pooling of urine in diverticula; incrases UTIs, renal calculi, or calcium stones |
| PSYCHOLOGICAL EFFECTS OF IMMOBILIZATION | -depression -social isolation -sleep-wake disturbances -impaired coping |
| DEPRESSION | exaggerated feelings of helplessness/hopelessness, sadness, melancholy, dejection, worthlessness, and emptiness |
| HOW OFTEN DO YOU REPOSITION AN IMMOBILIZED PT.? | q2h (every 2 hours) |
| MOBILITY | person's ability to move about feely |
| ACTIVITY TOLERANCE | the type and amount of exercise or work that a person is able to perform |
| ANTHROPOMETRIC MEASUREMENTS | height, weight, mid upper-arm circumference and triceps skinfold measurement (determines muscle mass) |
| HOW TO AVOID RESPIRATORY PROBLEMS IN IMMOBILITY | -promote expansion of chest and lungs -reposition pt. q2h |
| HOW TO AVOID STASIS OF PULMONARY SECRETIONS | -reposition patient q2h -fluid intake of 2000 mL/day -coughing hourly -CPT (chest physiotherapy) draining secretions & coughing |
| SCDs | inflatable plastic sleeves that wrap around the legs and inflate and deflate; decreases venous stasis and increases venous return |
| HEPARIN | anticoagulant that suppresses clot formation |
| LMW (low-molecular-weight) | predictable heparin effect |
| WHAT DEGREE TO LIE A PATIENT AT RISK OF PRESSURE ULCERS? | 30* lateral position |
| TED HOSE | anti-embolic elastic stockings |
| BRADEN SCALE | scale for predicting pressure ulcer risk |
| PRESSURE ULCER | localized injury to the skin and/or underlying tissues, usually over a bony prominence, as a result of pressure |
| TISSUE ISCHMIA | decreased blood flow to the tissue from capillary blood flow obstruction; may lead to tissue death |
| REACTIVE HYPEREMIA | redness of the skin (will blanch) from dilation of superficial capillaries |
| BLANCHABLE HYPEREMIA | the area that appears red and warm blanches following palpation |
| NON-BLANCHABLE HYPEREMIA | redness that remains after palpation (doesn't blanch); tissue damage; Stage 1 pressure ulcer |
| RISK FACTORS FOR PRESSURE ULCERS | -shear -nutrition -friction -infection -moisture -age |
| SHEAR | force exerted against the skin while skin is stationary |
| FRICTION | surface damage caused by skin rubbing against another surface |
| MOISTURE | caused by incontinence/perspiration |
| NUTRITION | hypoalbuminemia (edema); malnutrition; decreased blood supply = decreased oxygenated blood |
| INFECTION | metabolic needs-hypoxic more suseptible |
| AGE | older = dermis thin; more vulnerable to skin abnormalities which can also occur in neonates |
| STAGES OF PRESSURE ULCERS | Stage 1 Stage 2 Stage 3 Stage 4 |
| STAGE 1 | skin is unbroken but inflamed |
| STAGE 2 | skin is broken to epidermis/dermis |
| STAGE 3 | ulcer extends to subcutaneous fat layer |
| STAGE 4 | ulcer extends to muscle/bone; underlying tunneling likely |
| OSTEMYLITIS | infection in the bone |
| UNSTAGEABLE | unknown depth of tissue loss in a pressure ulcer |
| SUSPECTED DEEP-TISSUE INJURY | suspect, when area is purple/maroon or blistered |
| PREVENTION OF PRESSUE ULCERS | -assess (Braden Scale) -skin care & early intervention (skin barriers, 30* lat. position) -pressure reduction (mattress, 2 hr. repositioning) -nutrition (finishing meal/supplement) -patient/caregiver (education) |
| FACTORS INFLUENCING HEALING OF PRESSUE ULCER | -age -tissue perfusion -diabetes -smoking -nutrition -radiation -obesity -immunosuppression -wound stress -extent of wound |
| COMPLICATIONS OF WOUNDS | -hemorrhage -infection -dehiscence -evisceration |
| DEHISCENCE | partial/total separation of layers of the skin/tissue |
| EVISCERATION | open wound with organ protruding |
| HEMOSTASIS | blood has stopped, by blood clotting or vasoconstriction |
| HEMATOMA | collection of blood under the tissue |
| INFECTION AFTER SURGERY | -does not start day of surgery -starts in 4-5 days -low grade temp. is normal after surgery (swelling, drainage, elevated white blood count) |
Created by:
Smccunn
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