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Nursing Fundamentals

sleep - hygiene - immobility - skin (wound)

TermDefinition
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