NR 226 EXAM 2 sleep, fluid and electrolytes Questions and Answers

NR 226 EXAM 2 sleep, fluid and electrolytes Questions and Answers sleep an altered state of consciousness where perception of and reaction to environment is decreased sleep deprivation condition of not having enough sleep, can be either chronic or acute chronic sleep deprivation restricted state can cause fatigue, daytime sleepiness, clumsiness and weight gain, adversely affects the brain and cognitive function sleep pattern disturbance due to decreased physical activity, fear, anxiety, inability to assume usual sleep position, frequent assessments or treatments, unfamiliar environment, and discomfort resulting from current illness/injury circadian rhythms biological clock, synchronized to light-dark cycles, and cues in organisms environment, going to bed at the same time every night sleep regulation regulated by a sequence of physiological states integrated by CNS activity stages of sleep 1,2,3,4 and REM sleep cycle once asleep a person passes through 4 to 5 sleep cycles stage 1: NREM lightest level of sleep, lasts a few minutes, decreased physiological activity beginning with a gradual fall in vital signs and metabolism, person easily aroused by sensory stimuli such as noise, in person awakes, feels as though daydreaming has occurred, reduction in a autonomic activities, stage 2: NREM sleep period of sound sleep, relaxation progresses, arousal still easy, lasts 10 to 20 minutes, body functions still slowing, at this stage, you might want to leave them sleeping, if it is possible try not to wake them up for vital sign checks or other routine testing stage 3: NREM initial stages of deep sleep, sleeper difficult to arouse and rarely moves, muscles completely relaxed, vital signs decline but remain regular, lasts 15 to 30 minutes, hormonal response includes secretion of growth hormone (especially in children in stage 3 &4) stage 4: NREM deepest stage of sleep, very difficult to arouse sleeper, if sleep loss has occurred, sleeper will spend considerable portion of night in this stage, VS are significantly lower than during waking hours, stage last approx. 15-30 minutes, sleepwalking and enuresis sometimes occur REM sleep stage of vivid, full-color dreaming, first occurs approx, 90 minutes after sleep has begun, thereafter occurs at end of each NREM cycle, typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increased fluctuating blood pressure, loss of skeletal muscle tone, responsible for mental restoration, stage in which sleeper is most difficult to arouse, duration of REM sleep increases with each cycle and averages 20 minutes functions of sleep restores normal levels of activity, restores normal balance among parts of the nervous system, necessary for protein synthesis (energy for body and muscle growth), psychological well-being , dreams purpose of sleep physiological and psychological restoration and maintenance of biological functions dreams occur in NREM and REM sleep and important for learning, memory and adaptation to stress physical illiness cardiac, respiratory, pain, sleep disorders (BOX 42-3), classification of select disorders select disorders insomnia's, sleep apnea, narcolepsy, parasomnias (talking), sleep deprivation vs. alteration in sleep (nursing student), sleep related movement disorders, see box 42-3 sleep disorders in clients with coronary artery disease insomnia is common with the elderly, older age, females insomnia difficulty falling asleep or staying asleep, walking up frequently (fatigue, low energy), daytime sleepiness, difficulty concentrating, irritability sleep apnea short breathing pauses during night, more than 5 apneic episodes greater than 10 seconds an hour considered abnormal, symptoms include snoring, frequent awakenings, difficulty falling asleep, morning headaches, memory and cognitive problems, irritability, types are obstructive, central and mixed obstructive sleep apnea when something partly or completely blocks your upper airway during shut-eye, that makes your diaphragm and chest muscles work harder to open the obstructed airway and pull air into the lungs central sleep apnea disorder in which your breathing repeatedly stops and starts during sleep, occurs because your brain doesnt send proper signals to the muscles that control your breathing mixed sleep apnea combination of obstructive and central sleep apnea CPAP continuous positive airway pressure, increases pressure in your throat so that your airway doesn't collapse when you breathe in BiPAP bi-level positive airway pressure machine uses different air pressure when you breathe in than when you breathe out Narcolepsy neurological disorder that affects the control of sleep and wakefulness, caused by lack of hypocretin in CNS that regulates sleep, clients have sleep attacks, sleep at night usually begins with sleep-onset REM period, people experience excessive sleepiness and intermittent, uncontrollable episodes of falling asleep during the daytime parasomnia behavior that may interfere with or occur during sleep, with arousal disorders (sleepwalking, sleep terrors), sleep-awke transition disorders (sleep talking), associated with REM sleep (nightmares), and others like bruxism (teeth grinding) hypersomnia sufficient sleep at night but cannot stay awake during day, caused by medical or psychological disorders physiologic signs and symtoms of sleep deprivation hand tremors, decreased relfexes, slowed response time, reductions in work memory, decrease in reasoning and judgement, cardiac dysthythmias psychological signs and symptoms of sleep deprivation mood swings, disorientation, irritability, decreased motivation, fatigue, sleepiness, and hyperaexcitability drugs and their effect on sleep (BOX 42-5, page 1036) hypnotics, antidepressants and stimulants, alcohol, caffeine, diuretics, Beta-adrengeric blockers, benzodiazepines, naroctics, anticonvulsants sleep pattern assessment sleep history, sleep diary, health history, physical exam, if warranted, a sleep diary and diagnostic studies sleep diary may be asked to keep track of; time factors associated with sleep, activities performed 2-3 hours prior to sleep, consumption of caffeine, alcohol, medications, bedtime rituals, difficulty remaining awake during day, any worries or fears that may be contributing NANDA nursing diagnoses disturbed sleep patter with specific description such as difficulty falling asleep or difficulty staying asleep, various etiologies may be involved and specified NANDA nursing diagnoses for sleep patter disturbances as etiology of other diagnoses risk for injury, ineffective coping, fatigue, risk for impaired gas exchange, deficient knowledge, anxiety, activity intolerance outcomes for clients with sleep disturbances maintain (or develop) a sleeping pattern that provides sufficient energy for daily activites, enhance of well being, improve the quality and quantity of the clients sleep general nursing interventions for sleep disturbances schedule nursing care to promote uninterrupted sleep, teach stress reduction, relaxation techniques or good sleep hygiene, limit interruptions, provide quiet environment with comfortable room temperature, limit the number of visitors/duration of visits, carry out all procedures withing a given time froame sleep and rest implementation preparing patient for rest and sleep, wash pts back, massage back, change the linens, make certain the pt. warm enough, offer decaffeinated beverage like milk, change soiled dressing, have pt. void, environmental stimuli should be decreased by dimming the lights and decreasing the noise level bedtime rituals altering or eliminating routines can affect sleep, adults can listen to music, read, soothing bath, pray, children need to be socialized into pre-sleep routine, and usually preceded by hygienic ritual client education the importance of sleep, conditions that promote sleep, conditions that interfere with sleep, safe use of sleep medications, effects of prescribed medications on sleep, effects of disease states on sleep acid substance that releases H+ ions when dissolved in water, when pH is lower than 7.35 base substance that will bind with H+ ions when dissolved in water, when pH is higher than 7.45 arterial blood gas (ABG) the best way to evaluate acid-base balance and oxygenation pH measure of acidity, normal pH is 7.35-7.45 for optimal cell function what excrete acid they kidneys and lungs, lungs excrete carbonic acid and kidneys excrete metabolic acids buffers the kidneys kick in when the lungs cannot keep up compensation when the acidic blood hits the kidneys, the kidney will sense this and will try to flush out more acid through the urine, compensation when kidneys sense that you don't have enough acid they send out less acid in the urine pa CO2 values (basic) 35-45 (acidic) mm hg, how well the lungs are exceting CO2 HCO3 values (acidic) 22-26 mEQ/liter, how well the kidneys are excreting metabolic acids respiratory alkalosis bowing off too much CO2, pt presents with numbness, muscle twitches, seizures, caused from deep and fast breathing, anxiety, pain, high altitude, pregnancy, and fever when carbon dioxide levels are too low respiratory acidosis not breathing enough, holding on to CO2, pt presents with altered LOC, tachycardia, diaphoresis, headache, caused by insufficient ventilation from impaired gas exchange, impaired neuromuscular function, dysfunction of brainstem respiratory control like hypoventilation, COPD, airway obstruction, drug overdose, chest trauma, pulmonary edema, and neuromusclar disease metabolic alkalosis too much bicarbonate, disorder that elevates the serum bicarbonate, presents with seizures, headache, dysrthmias, and caused by increase of bicarbonate, and loss of metabolic acid like loss of gastric secretions (losing stomach acids), overuse of antacids (retain bicarbonate) and K+ wasting diuretics (hypokalemia as well as metabolic alkalosis) metabolic acidosis when body produces too much acid, not enough oxygen rich blood circulating, kidneys are not removing enough acid from the body, presents with tachycardia, pulmonary edema, tachypnea confusion, coma, caused by increase of metabolic acids and loss of bicarbonate like diabetic ketoacidosis, diarrhea, renal failure, shock, aspirin overdose, sepsis respiratory acidosis levels low pH, high CO2, and HCO3 normal respiratory alkalosis levels high pH, low CO2, normal HCO3 metabolic acidosis levels low pH, normal CO2, and low HCO3 metabolic alkalosis levels high pH, normal CO2 and high HCO3 hypotonic solution any solution that has a lower osmotic pressure than another solution, less solute and more water than another solution, less concentration than plasma, will shift and flow into a more concentrated solution like 0.45 normal saline isotonic soution two solutions having the same osmotic pressure across a semipermeable membrane, state allows for the free movement of water across the membrane without changing the concentration of solutes on either side, same concentration of plasma, examples are 0.9 normal saline hypertonic solution contains more dissolved particles (like sald and other electrolytes) than is found in normal cells and blood, like used for soaking wounds, greater concentration than plasma, fluid will pull a less concentrated solution into itself an example is 5% dextrose, D10W, 3% normal saline first fluid spacing do not use it in nursing documentation, normal distribution of fluid in ICF and ECF second fluid spacing abnormal accumulation of interstitial fluid also known as edema which is retention of fluids starts in dependent areas often reabsorb in the vascular system third spacing fluid accumulation in part of the body where it is not easily exchanged with ECF and very difficult to get rid of like anasarca, ascites, and most likely have an underlying disease like CHF, liver issues fluid bolume deficit hypovolemia or dehydration, fluid intake is less than fluid output hypovolemia water and electrolyte losses about equal clinical dehydration more water lost than electrolytes, fluid volume deficit and hypernatremia causes of fluid volume deficit prolonged fever, GI losses like watery diarrhea, vomiting, drainage from tubes, loss of plasma or whole blood from burns, hemorrhage, traumas, surgery, excessive seating, renal failure, hyperglycemia, inability to drink or express thirst (confused), concentrated tube feedings, third space shifts, use of diuretics lab values of hypovolemia loss of fluids and electrolytes, hemorrhage has increased hematocrit and hemoglobin while blood is extremely concentrated with increased BUN, and elevated specific gravity lab values for dehydration elevated hematocrit, elevated sodium from clinical dehydration, increased serum osmolality, urine specific gravity greater than 1.030, patient lost water and less electrolytes, body retains more particles, less fluids so fluids will be more concentrated treatment of dehydration replace missing fluids with oral fluids or IV treatment for clinical dehydration low sodium so hypotonic like 0.45 normal saline why is blood concentrated with clinical dehydration sodium level is high, so hypotonic solutions will draw fluid into cells and swell them if given too quickly, administer gradually treatment for hypovolemia isotonic fluids like 0.9 normal saline or lactated ringers, blood transfusion PRN to restore blood volume and normalize blood pressure fluid volume excess: over hydration excessive retention of either just water or water and sodium fluid volume excess causes by organ damage of kidney, heart or liver failure, too rapid infusion of IV, cortiosteroids can cause sodium retention (adrenal gland deficiency-moon face) fluid volume excess labs hemodilution, more water than particles, low H and H, low or normal Na, decresaed serum osmolality (low concentration due to hemodilution), increased BUN fluid volume excess treatment restrict sodium and water intake, may give hypertonic fluids like concentrated sodium chloride 3%, 5% or dextrose in water d20%, d30%, d50% to draw fluid from the intracellular to the extracellular compartment, thereby reduce cellular edema treatment of fluid volume excess vital sighs, respiratory status, i/o, lab values for hemodilution, daily weights, raise HOB, safety and comfort (if altered mental status), meds as needed to help organ function, teaching and prevention conditions that affect homeostasis sweating, altered fluid intake, vomiting, diarrhea, diabetes, organ failure measureable intake oral tube feeding, oral fluids, enemas, retained irrigants nonmeasureable intake solid food, metabolism non measureable output sweating and vaporization measurable output urine, emesis, feces, drainage from body cavity electrolytes help regulate intake, output, acid/base balance, hormones sodium controls and regulated water balance, 135-145 hypernatremia greater than 145, water loss, excess sodium, decreased na excretion from renal failure, cortiocosteroids or incrased water loss, fever, infection, hyperventilation, sweating, diarrhea s/s of hyternatremia FIRED, fever, restless, increased fluid retention, edema, and decreased urine output, for extreme hypernatremia mental status change, fever, seizures tx of hypernatremia diuretics, na restriction, avoid na foods, seizure precautions