L1 Nursing Process

- An organized sequence of problem-solving steps used to identify and to manage the health
problems of clients.
- Formulate individualized nursing case
- Accepted standard for clinical practice by the American Nurses Association
- Promote individualized care, client participation and autonomy
- Promote eAiciency, collaboration, continuity and coordination of care
- Help people understand what nurses do
- Increase job satisfaction

Characteristics of Nursing Process

- Universally applicable
- Client – centered
- Continuous, but overlapping and interrelated
- Prioritized, planned, goal/outcome-directed
- Evidence- based
- Flexible
- Interactive and collaborative

5 Phases

1. Assessment
- Biological, physical and behavioural needs

- An idea when starting to know the client from medical records and infor. collected from colleagues
Types of assessment

- Initial / Baseline / Screening assessment

n Comprehensive
n Collect predetermined set of data and make initial problem list
n E.g Gordon’s functional health patterns
- Ongoing assessment
n Focus assessment (specific problem)
n Evaluate outcomes achievement and problem resolution
n Identify new problem

Data collection methods

- Interview
- Physical assessment
n Head-to-toe assessment
u Inspection
u Auscultation
u Percussion
u Palpation
u Vital signs
- Observation
- Diagnostic test results
- Clinical records

Classification of data:

- By type
n Subjective (covert data/ symptoms)
n Objective data (Overt data/ signs)
- By source
n Primary data
n Secondary data

After collection

- Organize data
n Nursing models/ theoretical framework
u Gordon’s functional health patterns
u Body systems examination
u Maslow’s Hierarchy of needs
- Record data (fact)
n Avoid vague generalities
- Validate data
n Ensure infor. Complete, accurate and facual
- Ethical and legal consideration
2. Diagnosis
- Identify significant cues
- Cluster cues and identify data gaps
- Draw conclusion about present health status
- Determine etiologies and categorize problems
- Verify diagnoses
- Label diagnoses

Type

- Problem- focused diagnosis

- Risk diagnosis
- Health promotion diagnosis
- Syndrome

Label: clear and concise that convey meaning of diagnosis

Definition: add clarity to diagnostic label

Defining characteristics:

- Major: at least one must be present for validation

- Minor: provide supporting evidence

Related factors

- Pathophysiologic, biologic, psychological

- Treatment- related
- Situational (personal, environmental)
- Maturational (age-related)
Type and components of a ND

Parts of ND Label

Writing diagnostic statements

P.E.S. format

- 3 part statement
- E.g Anxiety/ related to change in environment/ as evidenced by insomnia and restless
Risk nursing diagnosis

- 2 part statement
- Risk for problem related to risk factors
- E.g Risk for impaired skin integrity (pressure sores) related to immobility secondary to casts and
traction

Health-Promotion/ Syndrome nursing diagnosis

- 1 part statement
- E.g Readiness for enhanced family processes

Unknown etiology

- Used when defining characteristics of nursing diagnosis are present but the etiologic and
contributing factors are unknown

Functional health patterns with common nursing diagnosis

1. Health perception—health management

- Health maintenance, ineAective
2. Nutritional –- metabolic
- Infection, risk for
- Nutrition, imbalanced: less than body requirements
3. Elimination
- Constipation
- Diarrhoea
4. Activity –-exercise
- Activity intolerance
- Physical mobility
- Impaired falls, risk for
5. Sleep—rest
- Sleep pattern, disturbed
6. Cognitive – perceptual
- Acute pain
- Risk for aspiration
7. Self-perception-Self-concept
- Anxiety
- Disturbed body image
- Roles—relationships
8. Communication
- Impaired verbal
- Social isolation
9. Sexuality—reproductive
- Breastfeeding, ineAective
- Sexuality patterns, ineAective
10. Coping—stress tolerance
- Coping, ineAective
11. Values— beliefs
- Spiritual distress

Nursing diagnosis

- Not sounds like

- Not another way of explaining the medical diagnosis
- Not something that goes with a particular medical diagnosis

Collaborative problem

- Certain physiologic complications that nurses monitor to detect onset or changes of status
- Implement both physician-prescribed and nursing-prescribed interventions to minimize the
complications of the event
- Diagnostic statement
- E.g Risk for complications of haemorrhage
- Potential complication: haemorrhage

Decision tree for nursing diagnosis and collaborative problems

3. Planning
- Establishing priority diagnoses
n Preservation of life
u High: life- threatening
u Medium: physical/emotional changes
u Low: minimal nursing support
n Maslow’s hierarchy of human needs
u Physiologic > safety and security > social > esteem > self-actualization
n Client preference

**Priorities change as client’s condition changes

**Problem- focused diagnosis should not be viewed as more important than risk diagnosis

- Planning goal and expected outcomes

n Standards or criteria used to evaluate the client’s progress
n Goal: broadly defined
u Client goal
u Nursing goal
u Short-term goal
u Long-term goal
n SMART (specific, measurable, achievable, realistic, time)
n More specific, observable criteria to evaluate whether the goal has been met
n Nursing sensitive outcome
u Can be achieved or influenced by nursing interventions

Example: acute pain

- Goal: the client will experience decreased pain

- Expected outcome
1. Client will identify three non-pharmacological pain-relieving methods within one day
2. Client will rate pain as lea than 3 on a 1-10 scale within 3 days
- Prescribing nursing interventions (enhance patient outcomes)
n Type of interventions
u Independent
u Dependent
u Collaborative
n Nursing interventions classification
u Basic physiological, complex physiological, behavioural, safety, family, health system,
community
 n Problem-focused nursing diagnosis
u Reduce/eliminate contributing factors or diagnosis
u Promote higher-level wellness
u Monitor and evaluate status
n Risk nursing diagnosis
u Reduce/eliminate risk factors
u Prevent problem
u Monitor and evaluate status
n Collaborative problem
u Monitor for changes and evaluate status
u Manage change changes in status

Writing nursing orders

- Nursing order are written, detailed instructions for performing nursing interventions indicated for
nursing diagnosis or correcting the related factors

Nursing intervention

Ethical and legal consideration

- Autonomy
- Accountable
- Balance the values of cost and care

Writing outcome statements

- Individualized
- SMART
- Client and family agree with the goal
- Address all important client needs
- Designating evaluation methods
*writing up nursing care plans

4. Implementation
- Nursing assessment
- Perform or assist activities for client
- Health teaching
- Consultation
- Referral
- Documentation e.g Format: SOAP/SOAPIER
- Oral report
5. Evaluation
- Client’s health status, progress toward goals and the nursing care plan
- EAectiveness of the nursing care plan
Review desired outcomes

- Outcomes of the care plan

- Client’s outcome
- Compare and draw a conclusion
- Write the evaluative statement

Types

- Process evaluation (Care plan quality)

- Impact evaluation (Immediate)
- Outcome evaluation (long term)

Area of evaluation

- Cognitive
- Psychomotor
- AAective
- Body function and appearance

Factors aJecting diagnostic accuracy

- Critical-thinking abilities
- Clinical reasoning skills
- Analytical and inference skills
- Be open-minded
- Truth-seeking disposition
- Availability of knowledge sources
- Complexity of patient’s situation
- Diagnostic education and resources in nursing practice
- Hospital policy and diagnostic environment
L2 Documenting and reporting of care; Focused interviews

What is nursing documentation?

- Accurate account of what and when

- Complete documentation of client’s symptoms, observation, care, services provided
- Written / electronically-generated record

Why we need Nursing documentation?

- Integral part of clinical documentation

- Fundamental nursing responsibility
- Balance with respect to legal imperatives
- Allows interdisciplinary communication

Principle of nursing documentation

1. Follow local policies, procedures and protocols of documentation in practice setting at all time
2. Ensure clear, concise, accurate, complete, objective, legible and timely documentation to fulfil
both clinical and legal imperatives
3. Exercise professional judgment and apply necessary knowledge and skills in the context of the
situation

Responsibilities

- Follow local policies and practices

- Ensure accurate and timely ND
- Make corrections to ND
- Take accountability for ND
- Establish interdisciplinary communication channel
- Keep confidentiality of ND
- Upkeep knowledge of ND

ND vs nursing process

- ND: aligned with NP

- Reflect principles of assessment, planning, implementation and evaluation
- Continuous

Standardized terminologies

- Terms used to describe planning, delivery and evaluation of nursing care to patient
- In diverse settings
- Permit data to be aggregated and analysed
Progress notes

- Record all patient related activities

- End shift report
n Summarize client’s conditions/ changes of condition within a specific shift
n Assessment data, treatment given and plan of care
n Provide infor. To ensure continuity of care
n Progress and updated treatments for client
n Any pending investigation results
n Any upcoming appointment
n Discharge planning

Chart

- Infor. Associated with routine care e.g. MEWS chart, IO chart, turning chart, e-vital
- Help in show patterns or tends of conditions
- Goods for recording simple data, treatment plants, symptoms management
- Enhance continuity care

Standardized care plants/ flow chart

- Outline standard care for specific problem

- Disadvantage: provision of standardized care
n Not fit individual’s needs

Methods of documentation

1. Source-oriented record
- Data arranged according to discipline of assessor
n Admission
n Doctor
n Nurses
n Physiotherapist
- Convenient
- X find particular data in scattered records so as to obtain views from various professionals
2. Narrative approach
- Data arranged by problem but not source
- Component
n Data
u Nursing assessment, history, social, family data
u Result of physical examination
 u Baseline diagnostic test
n Problem
u Derived from problem list in database
n Plan of care
- SOAP Method

- Story telling
n Record every details of clients conditions chronologically
n lear and coherent manner
n time consuming, need to read all notes b4 knowing patient condition
- Content that covered
n Relevant assessment data
n Completed nursing intervention
n Evaluation of intervention (health outcome/ client’s response)
3. Problem-oriented approach
4. Focus charting
- Cues during charting
a. Individual’s record
b. Date/time in each entry
c. Written legibly with black ink
d. No blank lines between entries
e. Clear concise and specific
f. Correcting errors
g. Signature

9 type of ND errors

- Sloppy / illegible handwriting

- Failure to date, time, sign a medical entry
- Lack of documentation for omitted medication/ treatment
- Adding entries later on
- Documenting subjective but incorrect data
- Not questioning incomprehensible orders
- Using wrong abbreviation
- Entering infor. Into wrong chart

Other important principle

- Confidentiality
- Accuracy and completeness
- Logical organization
- Timeliness
 n Delayed entries within reasonable time are acceptable

Focused interview

Structured interview

- Component of health assessment

- Planned communication / conversation with purpose
1. Get / give infor.
2. Identify problems of mutual concern
3. Evaluate change
4. Teaching/ education
5. Provide counselling or conduct therapy

Factors influencing communication

- Development
- Values and perception
- Personal space
n Intimate : touching to 45cm
n Personal: 45cm to 1.2m
n Social: 1.2-3.6m
n Public:3.6-4.5m
- Territory
- Roles and relationships
- Environment
Approaches in interview

Directive Non-directive
Highly structured, elicits specific infor. Rapport building
Nurse establishes purpose of and control Allow client to control the purpose, subject
interview matter, pace
Gather infor. When time is limited
Combined approach is common

How to communicate with client?

- Questions clearly spoken

- Avoid using technical definitions, use slang only if necessary
- Questions consistent with patient level of understanding
- One question one time
- Be attentive to patient’s feeling
- Sensitive and sensitivity issues
n Explain b4 ask
n Ensure safe to talk

Techniques that enhance data collection

- Facilitation
n Verbal and nonverbal phrases to encourage patients to continue talking further
- Restatement/paraphrasing
n Repeating what patient says in diAerent words to confirm interpretation
- Clarification
n Restate basic message
n Confess confusion and ask client to repeat / restate the message
- Confrontation
n When inconsistencies are noted between patient report and nurse’ observations
n Use tone of voice to convey confusion / possible misunderstanding
- Reflection
n Repeating what patient said and encourages elaboration / more infor.
n Enable them to explore their own ideas and feelings about situation
- Summarizing
n Condenses and orders data to clarify sequence of events for patient
n Emphasizes data related to health promotion, disease protection, resolving health problem
u What is the purpose of interview
Techniques that discourage data collection

- Using medical terminology / jargons

- Expressing value judgments
- Interrupting while patient talks
- Having authoritarian / paternalistic demeanor
- Ask why question that may threaten patient and make them defensive

Nonverbal communication

- Tone of voice / silence

- Body language
- Facial expression
- Posture and gait
- Gestures
- Appearance
n Professional and nest
- Demeanor
n Do not be overwhelmingly friendly
- Attitude
n Non-judgmental
n Empathic

More clues to note during interview

Physical attending (SOLER)

- Sit facing person

- Adopt an open posture
- Lean toward personal
- Maintain good eye contact
- Try to be relatively relaxed

Attentive listening

- Use all senses, energy, concentration

- Absorb content and feeling of client conveying without selectivity
- Convey attitude of caring and interest --- encourage to talk
- Client rather than nurse should decide when to close conversation
- Common responses : nodding head, uhhuh, mmm, repeating, I see what u means
L3 Promoting hygiene

Hair care: Pediculosis capitis (Head Lice)

- Infestation caused by pediculus humanus capitis

- Found on scalp and hair
- 3 stage: eggsà nymphsà adults
- Both nymphs and adults suck blood
- Adult louse (size like sesame seed): greyish white colour that moves fast among hair
- Lice eggs (oval shape, yellow to white colour ) easily found
- Common site of infestation: occiput, ears, neck

Life cycle

- Eggs hatch: 7-10 days

- Nymphs à adult: 7-13 days
- Once mature, they reproduce and increase in number rapidly
- Lifespan lasts: 28-30 days
- But usually die 2 days after falling oA from host

Route of transmission

- Direct head to head contact

- Sharing articles harboring lice
- Upholstered furniture used by person with head lice

Signs and symptoms

- Oval particles clinging to hair

- Frequent scratching caused by allergic reaction to bites
- Haemorrhagic spots on skin where lice has sucked blood
- Itching skin excoriation in aAected area
- On pillow
n Fine black powders (louse feces)
n Pale coloured materials (cast lice skin)
- On scalp
n Tiny oval shaped white / clear dots (lice eggs)
n Tickling feeling like sth moving in hair

Diagnosis

- Dry-combing with closed set tooth comb

- Wet-combing after applying conditioner
- Direct scalp inspection by parting hair
- Scalp inspection by using magnifying glass
n Small haemorrhagic areas
n Scratches
n Insect-type bites behind ears / hairline
n Small dandruA-like particles

Treatment

- Topical pediculicides (e.g. malathion 5% solution)

n Direction for using
u Shake well and rub onto dry hair until thoroughly moistened
u All hair to dry naturally and remain uncovered
u Wash hair with shampoo with conditioner 12 hr after
u Comb hair thoroughly from hair roots
u Repeat combing every 2-3 days for 2-3 weeks
n Precautions
u Treat all family members
u Cover pillow during treatment
- Decontamination
n Wash all clothes and beddings used by infested client separately in hot water (60 up) for not
less than 20 mins
n Disinfect combs in a mixture of bleaching agent and water (1:1) for 30 mins
n Seal stuAed toys and other non-washable articles in plastic bag for 2 weeks
n Thoroughly vacuum all rugs, mattresses, pillows, furniture

Skin care

Bathing

- Remove accumulated oil, perspiration, dead skin cells, some bacteria and unpleasant odour
- Restore cleanliness and promote comfort
- Stimulate circulation
- Promote sense of well-being, morale, appearance, self-respect, and body image
- Provide mild exercise
- Allow assessment of skin condition, joint mobility, muscle strength

Type of bath

- Cleansing bath (43-46)

n Complete/ self-help bed bath
 n Tub bath / shower
n Bag bath
u Commercial products containing no-rinse cleansing solution
u Packet can be warmed in microwave to promote comfort
n Towel bath
- Therapeutic bath
- Medicated bath

Assessment

- Physical and emotional factors

- Condition of skin
n Texture, turgor, temperature, lesions, bruises
- Presence of pain
- Range of cooperation
- Other aspect of health
n Mobility, strength, cognition, vital signs

Planning

- General considerations
n Location
n Timing
n Assistance needed
n Toileting n4 bathing
n Protection of casts / IV sites
n Environment
u Temperature
u Privacy
- Equipment
n Basin with warm water
n Bath mitt and towels
n Soap/ bathing gel
n Bed linen
n Personal care items (lotion, topical medication)
n Laundry bag
n Shaving equipment
Implementation

- Prepare bed, position client, lower bed side rail, assist client to move near
- Cover client with bath blanket, remove client’s clothes
- Make bath mitt with washcloth

Precautions

- Inspect for any abnormality

- Provide relevant health education
- Perform assisted ROM during bed bath
- Clean and dry skin fold area carefully
n Groin, skin under breasts, skin between fingers and toes
- Dress the injured / immobilized side first
- For clients with deep vein thrombosis / blood clotting disorder, should not wash with long firm
strokes for lower extremities

Scabies

- Skin infestation of itch mite sarcopte sscabiei

- Small arthropod burrows just below surface of skin
- Adult female mites lay 2-3 eggs a day at the enf of tunnel
- Eggsàadult mites : 10-17 days
- Mites will die within 48-72 hrs once away from the body

Transmission

- Skin to skin contact in crowed conditions, especially in hospitals, old age homes, child care
centres
- Infected sex partners and household members
- Sharing clothes, towels, beddings
- Incubation period : 2-6 weeks
Signs and symptoms

- Burrows
n Greyish-white / pink threadlike lines (0.5-1 cm) long found between fingers, on palm and
sides of wrist
- Intense itching
n Worsens at night
- Papules
n Small elevated reddish papules and some with tiny vesicles on the top seen on skin
- Common site
n Webs between fingers, around nipples, backs of elbows, wrisits, sides and backs of feet,
knees, around waist and umbilicus, genital area, axillary folds, buttocks

Norwegian scabies

- Highly contagious as it associates with hundred to thousands of mites present on body

- Marked scales and thick crust are present on palms and soles
- Occurs in frail elderly, history of steroid treatment and immunocompromised patient
- Itching may be severe / absent

Diagnosis

- Examining burrows / rash

- Ink test
n Ink applied on itchy spot and wiped oA with alcohol pad
n Remaining ink will track into burrows and dark lines will show
- Microscopic examination of skin scraping
n Identification of mites / eggs / fecal pallets
n Skin specimen should be collected from multiple site
n Non-excoriated, non-scratched, non-inflamed area (burrows and papules) should be chosen

Treatment

- Classic scabies
n Permethrin 5% cream
n Crotamiton 10% lotion / cream
n Sulfur ointment
n Lindane 1% lotion
n Ivermectin (oral drug)
- Norwegian scabies
n Permethrin 5% cream
 n Benzyl benzoate 25% ointment
n Keratolytic cream
n Ivermectin (oral drug)

Topical scabicides

- Implement contact precautions

- Apply medication from neck to toes, except for lips and eyelids
- Pay particular attention to skin folds, webs between fingers and toes, and nails
- Reapply scabicide if it is washed oA during treatment period
- Leave scabicide for recommended period and take bath to rinse oA medication

Permethrin 5% cream

- Approved for treatment of scabies in person who are at least 2 months of age
- Kill both scabies mite and eggs
- 2 (or more) applications, each about a week apart, may be necessary to eliminate all mites

Infection control

- Infested patient should be isolated b4 treatment, single room / isolated area is recommended
- Number of visitors should be limited, visitors should wear personal protective equipment during
defined treatment period
- Patient should avoid close body contact with other until treatment completed
- Contact precaution can be discontinued after bathing to remove scabicide
- Simultaneously (within 24 hrs) treat all members of household, close contacts and sexual partners
with tropical scabicide (even without symptoms)
- Separate belongings of infested persons and close contacts for decontamination
- Decontaminate cloths, towels, beddings (used during 3 days b4 treatment) by machines wash in
hot water(60) for 10 mins and dry in dryer for 20 mins
- Non-washable items of infested person should be replaced in plastic bags and sealed up for more
than 14 days b4 use

Pressure injury

- Localized injury to skin/ underlying tissue usually over bony prominence, as result of pressure /
pressure in combination with shear

Aetiology

- Compression of soft tissue over bony prominence for a prolonged period of time
- Prolonged compression occluding blood flow
- Tissue ischaemia
- Skin discoloration
- Continued tissue breakdown resulting in pressure injuries

Risk factors

NPIAP pressure injury staging

- Localized damage to skin and underlying soft tissue over a bony prominence / related to medical /
other device
- Present as intact skin / open ulcer and painful
- Occurs because of intense / prolonged pressure / pressure in combination with shear
- Tolerance of soft microclimate, nutrition, perfusion, co-morbidities and condition of soft tissue

Stage 1

- Intact skin with localized area of non-blanchable erythema, may appear diAerently in darkly
pigmented skin
- Presence of blanchable erythema / changes in sensation, temperature, firmness may precede
visual changes
- Color changes not include purple / maroon discoloration; these may indicate deep tissue pressure
injury

Stage 2

- Partial-thickness loss of skin with exposed dermis

- Wound bed is viable, pink / red, moist, may present as intact / ruptured serum-filled blister
- Adipose (fat) and deeper tissues not visible
- Granulation tissue, slough and eschar not present
Stage 3

- Full-thickness loss of skin, where adipose is visible in ulcer and granulation tissue and epibole
(rolled wound edges) present
- Slough and eschar may visible
- Depth of tissue damage varies by anatomical location; area of significant adiposity develop deep
wound
- Undermining and tunneling may occur

Stage 4

- Full-thickness skin and tissue loss with exposed / directly palpable fascia, muscle, tendon,
ligament, cartilage / bone in ulcer
- Slough and eschar may be visible
- Epibole, undermining, tunneling occur
- Depth varies by anatomical location

Unstageable pressure injury

- Full-thickness skin and tissue loss where the extent of tissue damage within ulcer cannot be
confirmed as it is obscured by slough / eschar

Deep tissue pressure injury

- Intact / non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple
discoloration / epidermal separation revealing a dark wound bed / blood-filled blister
- Pain and temperature change often precede skin color changes
- Discoloration may appear diAerently in darkly pigmented skin

Risk assessment

- Norton scale
- Braden scale
- Indicator for risk : <16

**Preventive measures

- Relieve pressure
n Provide protective and pressure relieving device
u Alternating pressure mattress (ripple bed)
u Pillows
u Protectors
u Foam
 u Gel positioners
n Frequent change of position
u Make turning schedule
u Assess skin condition during change of position
u Record position changes
n Alert to external source of pressure
u Wrinkled linen or clothes, tubing, small parts
- Minimize friction and shearing force
n Proper positioning with adequate support and pressure relieving device
n Proper turning and lifting techniques without dragging of patient across surface
n Protect patient from sliding in bed by using well-padded footboard
- Improve mobility
n Encourage patient to remain active and ambulate
n Remind patient to change position frequently if he can move independently
n Set uo turning and exercise
n Schedules for at risk patient
n Encourage perform self-care activities (bathing, grooming, eating, turning)
n Perform passive ROM exercise, if unable to move
n Refer to physiotherapist and occupational therapist
- Improve nutritional status
n Support patient with adequate nutritional and fluid intake
n Provide high-protein diet with vitamin supplements
n Encourage relative to bring preference food items
n Assist in feeding if required
n Refer dietitian for extra supplement
- Minimize moisture
n Change linen and clothes once they become soiled or wet
n Maintain skin clean and free from irritants e.g. urine, stool, sweat, body fluids (drainage)
n Dry skin thoroughly after cleansing
n Lubricate dry skin with cream or lotions
n Apply topical barrier ointment (e.g zinc oxide cream)
- Improve sensory perception
n Help patient to recognize and compensate for decreased sensation
n Teach patient and caregiver knowledge and skill for assessing potential pressure area and
development of pressure ulcer
n Encourage patient to participate self-care
- Improve tissue perfusion
n Exercise, massage, maintain adequate physical activity to improve tissue perfusion
u Not message reddened area
n Elevate edematous body part, protect these area from injury (e.g. heel protector)
L4a Promoting rest and sleep

Sleep

- Belong to basic human need

- 1/3 lifespan on sleeping
- Essential for optimizing cognitive, psychological, physiological function
- Determine quality of life
- Altered state of unconsciousness

Sleep / wake cycle

- Regulated by reticular activating system (RAS) located at upper part of reticular formation
- Cerebral cortex and RAS essential for sleep regulation and waking states
- AAected by neurotransmitters and exposure to darkness
- Melatonin secretes from pineal gland and make person less alert

Circadian rhythms

- Mean about a day

- Refer to 24 hrs internal biologic clock in humans
- Regulated by light / darkness of surroundings

Types of sleep

1. NREM(Non-rapid eye movement) sleep

- Contribute to 75-80% of sleep
2. REM(Rapid eye movement) sleep
- Usually recurs about every 90mins
- Duration of REM sleep increase with each REM cycle
- Paradoxical sleep as EEG activity resemble of wakefulness
- Dream primarily occurs during REM sleep
- Brain activity is highly active

Factors aJecting sleep

- Illness cause pain leading to sleep problem

- Environment can either promote / hinder sleep
- Alcoholic Consumption disrupt REM sleep
- Tobacco smoking à nicotine stimulating eAect on body
Medication aJecting sleeping quality

Medication Example
Antidepressants Tricyclic antidepressants
Antihistamines Piriton
Beta-blockers Propranolol, bisoprolol, atenolol, metoprolol
Decongestants Clarityne
Narcotics (opioid analgesics) Morphine, codeine
Common sleep disorders

1. Sleep apnea
- Defined as > 5 apneic episodes / breathing pauses (lasting for > 10 secs) per hr
- Signs and symptoms
n Lound snoring
n Episodes of breathing cessation during sleep
n Frequent nocturnal awakenings
n Excessive daytime sleepiness
n DiAiculties falling asleep at night
n Morning headaches
n Memory, cognitive problem, irritability
- Types
n Obstructive sleep apnea (OSA)
n Central sleep apnea (CSA)
n Mixed apnea syndrome
2. Excessive daytime sleepiness
- Hypersomnia: suAicient sleep at night but still cannot stay awake during day
- Narcolepsy
3. Parasomnias
- Behavior that may interfere with sleep
- Characterized by physical movement / emotional experiences during sleep
4. Insomnia
- Inability of fall asleep / remain asleep
Sleep assessment

History taking ( focus assessment)

- Sleep pattern
n Bedtime rituals
n Sleep duration: average hrs of sleep per night
n Sleep onset latency: time taken to fall asleep
n Number of awakenings during night
- Environment
n Sleep environment: noise level, light exposure, mattress comfort
n Sleep position
- Social history
n Alcohol
n Nicotine
n CaAeine
- Current medication
- Psychological factors
n Stressor / anxiety
n Recent traumatic event
- External factors
n Illness that may interfere sleeping quality
n Suboptimal pain control
n Use of sleep pills
n Assess for any underlying factors that may aAect sleep
- Observation
n Mental status (E.g. excessive daytime sleepiness, dozing during interview)
n Mood changes (E.g. irritability, anxiety)
n Observe sleep behaviour (E.g. snoring during sleep, frequency of insomnia)
Tools for measuring sleep quality

- Pittsburgh sleep quality index (PSQI)

n Assess the sleep quantity and sleep quality over past month
n Contain of 19 self-reported items from 7 aspects
n Each component score ranges from 0 to 3
n Global PSQI score ranges from 0 to 21 (by adding sub-score in each aspect)
n Global PSQI score of >5 indicates significant level of sleep disturbance
n Higher scores indicate more severe complaints and higher level of sleep disturbance
- General sleep disturbance scale(GSDS)
n Assess the quality of sleep in past week
n Consists of 21 items from 7 aspects
n Each item rates on 0 to 7
n Total score is sum of seven subscale scores and ranges from 0 to 147
n Higher total and subscale scores indicated higher levels of sleep disturbance
n Total score of> 43 (cutoA) indicates significant level of sleep disturbance

Sleep diary

- Keep log for 1-2 weeks by patient

- Activities performed 2-3 hrs b4 bedtime
- Consumption of caAeinated beverages, alcohol
- Any prescribed medications, OTC medications, herbal remedies taken during day
- Bedtime rituals b4 sleep
- DiAiculties remaining awake during day
- Worries believes aAect sleep
- Factors perceived to have positive / negative eAect on sleep

Laboratory investigation

Sleep study (polysomnography)

- Involve recording of physiological parameters (E.g. brain waves, eye movement, muscle activity)
during period
- Diagnose sleep disorders
- Activity including movements struggling, respiration, will be also assessed

Potential diagnostic labels

- Disturbed sleep pattern

- Fatigue / Insomnia
- Readiness for enhanced sleep
Interventions

- Goals : develop sleeping pattern enabling client with suAicient energy for daily activities as well as
achieve a balance between activity and rest
- Sleep hygiene: refer to interventions promoting sleep
1. Crate a sleep -conducive environment
- Keep noise to minimum
- Maintain comfortable room temperature, appropriate ventilation and lighting
2. Provide comfort measures
- Essential to help client fall asleep and stay asleep
- Provide loose-fitting nightwear
- Assist with hygienic routines b4 bedtime
- Administer analgesics as prescribed to ensure adequate pain control
- Keep bed linen smooth, clean, dry
- Encourage void b4 sleep
3. Health education
- Advice on reduce the consumption of caAeine and nicotine
- Avoid heavy meals 2-3 hrs b4 bedtime
- Teach stress reduction and relaxation techniques
- Advice on light snack to alleviate hunger
4. Organize nursing care to provide for uninterrupted sleep periods
- Cluster nursing care to minimize disturbance to client
5. Medication
- Only consider when environment measures fail to resolve
- Prescribed as PRN basis
- Well informed with eAects and potentials side eAect prior to medication administration
- Instructed to take smallest eAective doses
- Avoid regular use of sleep medications to minimize risk of developing drug dependency
1. Sedative hypnotics
- Induce CNS depression and unnatural sleep by altering REM/NREM sleep pattern
- E.g. zolpidem, zopiclone
2. Antianxiety medication
- Decrease level of arousals
- Contraindicated in pregnant and breastfed women
- E.g. Ativan
L4b Maintaining body temperature

Body temperature

- Balance between heat produced and lost from body

Thermoregulation

- Bogy temperature maintained within normal homeostatic range by gain / loss of heat in diAerent
environmental conditions
- Age, exercise, diurnal variations, hormones, stress

Normal range of body temperature

- Rectal : 36.6-38
- Oral : 36.1-37.2
- Axillary : 35.9-36.7
- Tympanic (ear) and temporal artery (forehead) : 36-37.8
- Ha : 36-37.5

Pyrexia (fever) 38-40

- Set point of hypothalamic thermostat changes suddenly to higher value as eAects of tissue
destruction, pyrogenic substances / dehydration on hypothalamus
- Febrile : with fever

Type of fever

- Intermittent fever
- Remittent fever
- Relapsing fever
- Constant fever
- Fever spike

Stages of fever

1. Onset
- Increased HR , RR
- Shivering (chills , rigor)
- Pallid cold skin
- Complaints of feeling cold
- Cyanotic nail beds
- Gooseflesh
2. Course
- Increased HR , RR
- Absence of shivering
- Warm skin dehydration
- Photosensitivity
- Drowsiness, loss of appetite, fatigue, muscle ache
3. Defervescence
- Sweating
- Flushed and warm skin
- Possible dehydration

Complication of fever

- Dehydration
- Electrolyte imbalance
- Febrile seizure
- Brain damage
- Death

Management of fever
Hyperpyrexia (Hyperthermia) : >40

- Hypothalamic thermoregulation collapses leading to uncontrolled increases in bogy temperature

that does not respond to antipyretics
- Without diurnal variation
- Mortality: 33-80%

Signs and symptoms

- General
n High body temperature
n Dizziness and faintness
n Nausea, vomiting, diarrhoea
n Poor muscle control / weakness
n CNS disturbance : decreasing level of consciousness, confusion, seizures
- Specific
n Heat stroke
n Absence of sweating
n Hot red dry skin
n Fast strong pulse
n Heat exhaustion
n Heavy sweating
n Cold pale clammy skin
n Fast weak pulse

Management

- Provide basic life support

- Seek professional assistance
- Cooling management (>5yo)
n Immerse in cold water (1-17oC) foe 15 mins
n Wet with cold / cool water
n Apply ice pads (groin, armpits, facial cheeks, palms, soles)
n Repeatedly moisten skin
n Fan continuously
- Cooling management (>5yo)
n Cool in tepid sponge bath (32oC)
n Repeatedly moisten skin
n Fan continuously
- Hydration management
 n Encourage fluid intake (if tolerated)
n Consider carbohydrate electrolyte drink

Hypothermia < 36

- Core body temperature below lower limit of normal range

- Physiologic mechanisms
n Excessive heat loss
n Inadequate heat production to counteract heat loss
n Impaired hypothalamic thermoregulation
- Signs and symptoms

Management

- Monitor
n Vital signs
n Skin condition
n Sensory and motor function of extremities
n Urine output
- Re-warm
- Educate
n Prevention
n Early recognition
Nursing intervention
L5a facilitating relief from pain

Definition of pain

- Unpleasant, sensory and emotional experience associated with actual / potential tissue damage /
described in term of such damage
- Nature of pain
n Complex
n Subjective and individualized

Classification of pain

1. Location
- Headache, back pain
- Problematic when pain radiates, known as referred pain
2. Duration
- Acute / chronic
3. Intensity
- Mild, moderate / severe in pain rating scale
4. Etiology
- Nociceptive
n Result from tissue damage
n Somatic pain
u Pain originates in skin, muscle, bone, joints, tendons
u E.g. laceration, sprained ankle
n Visceral pain
u Pain of internal organs / cavities
u Poorly located and radiated to other sites
u Nature: cramping / throbbing pain
u E.g. labor pain / angina pectoris / irritable bowel
n Physiological process of pain
u Related to pain perception
u Neurologic events and reflex responses caused by noxious stimuli
u Noxious stimuliàactivate nociceptoràtransmitted to brainàmodified and felt
n Divided into 4 processes
u Transduction
u Transmission
u Perception
u Modulation
- Neuropathic
n Result from lesion / disease aAecting somatosensory nervous system
n As damage / malfunctioning nerves
n Typically described as burning, tingling pain, dull, aching
- Cancer
n Result from malignant disease
- Psychogenic
n Without visible signs of disease
- Chronic pain
n Longer duration than expected for healing / no identifiable cause

Gate control theory of pain

- Factor determining if gate open / close

1. Activity in pain fibres: open gate
2. Activity in other sensory nerves: close gate
3. Message from brain: concentrating on pain / trying not to think about it
Conditions that open / close pain gate

Concepts related to pain

- Pain threshold
n Least amount of stimuli to arouse pain sensation
n Vary diAerent person as age, gender, race
- Pain tolerance
n Maximum amount of pain that can withstand
n Vary considerably at diAerent times and in diAerent circumstances

Pain assessment : history taking

Pain assessment tool

1. Numeric rating scale

- Ask patient to rate their pain using score
- Strengths
n Easy to administer and score
n Used with greater variety of patient
- Limitation
n Lack of research comparing NRS with other measures
2. Visual analogue scale
- 10 cm straight line can be vertical / horizontal
- Ask patient to place cross on the line to indicate pain level
- Strengths
n Independent of language
n Easily understood
n Readily reproduced
- Limitations
n Require certain amount of visual and motor coordination, so diAicult to administer for post-
operative patient
3. Wong-baker faces rating scale
- Ask to point the face which can best represent pain level
- Strengths
n Useful for children / elderly who lack language skills
4. Verbal rating scale
- Ask to express pain level verbally
- Strengths
n Easy to administer and understand
- Limitation
n Assume equal intervals between description
n Patient may be forced to choose a category that may not describe pain satisfactorily
5. PQRSTU pain assessment

Pain management

1. Pharmacological intervention
- Non-opioids: indicated for mild to moderate pain
- Acetaminophen (Panadol)
n No anti-inflammatory / anti-platelet eAect
n Major adverse eAect: Hepatotoxicity
- Nonsteroidal anti-inflammatory drugs (NSAIDS)
n Anti-inflammatory eAect
n Inhibit synthesis of prostaglandins, responses to inflammation
n Not depress central nervous system
n Major adverse eAect: gastrointestinal bleeding
- Opioids (narcotics): indicated for moderate to severe pain
n Relieve pain and induce sense of euphoria by binding to opiate receptoràsuppress CNS
n For severe pain: morphine sulphate, pethidine
n For moderate pain: codeine
- Adjuvant / co-analgesic drug
n Drug not belonged to analgesics but can reduce pain
n Anti-convulsant, muscle relaxant

Administration of pain medication

1. Nurse-administrated analgesics
- Regular(scheduled) / PRN(as required)
- Can be oral drugs / injections
2. Intravenous syringe pump
- Continuous intravenous infusion to maintain symptom for client who cannot take oral drugs
3. Patient-controlled analgesia
- Prescribed by Acute Pain Service (APS) team in hospital
- APS involves multidisciplinary team, including pain nurses and anesthetists, to ensure eAective
pain management
- Usually set up at operation theatre (OT) for post-operative patients
- Pros: enable patients to control intravenous delivery of an analgesia by pressing a button on
handpiece, thus clients experience less anxiety
- Cons: risk of malfunction
- Controlled by patients under some pre-set conditions:
n Loading dose: dose given at the beginning of the PCA therapy
n Bolus dose: dose given each time of successful delivery
n Lock-out time: period during NO further analgesic can be given
n 4-hour limit: limit the max. dose to prevent overdose
n Continuous infusion: seldom used
- Education on PCA use is essential for clients before surgery
- Common regimen: Morphine
- Close monitoring of vital signs (Q1H) for possibility of morphine overdose and adverse eAects:
n Respiratory depression
n Nausea & vomiting
n Hypotension
2. Non- pharmacological intervention
- Increase patients’ pain threshold and reduce stress
- Physical intervention
1. Positioning
u Proper positioning prevent triggering pain
u Avoid pressure and friction to reduce stimulation of pain and pressure receptors
2. Quite environment
u Minimize unnecessary noise in ward setting
u Promote a relaxed feeling to enhance
l Perception of healing environment
l Satisfaction scores recovery
- Cutaneous stimulation
1. Massage
u Superficial circulation to pain area to reduce pain intensity, produce relaxation and
 improve circulation
u Enhance therapeutic eAect of pain-relief medication
2. Transcutaneous electrical nerve stimulation
u Apply low-voltage electrical stimulation directly over pain area for pain relief
3. Heat therapy
u Promotes circulation
u Relieve muscle spasm and joint rigidity
u Promotes muscle relaxation
u Indicated for management of chronic pain
4. Cold therapy
u Causes vasoconstriction
u Prevent / reduces swelling
u Induce sensation of numbness to reduce pain
u Indicated for management of acute injuries
- Safety issues
n 20 min on and oA rule
n Never apply ice/hot packs directly onto the skin
n Never use heat for pain relief on clients with mental status changes or on clients who are
sedated without supervision
- Cognitive-behavioural interventions
1. Health education
u Teach and explain etiology of pain to patient
u Discuss factor leading to increased pain and provide options of pain management
u Reduce fear and enhance compliance to treatment
2. Progressive muscle relaxation exercise
u Focus on slowly tensing, relaxing muscle from diAerent parts
u EAective in reducing pain and anxiety
3. Acupressure
u Practice of applying finger pressure to specific acupuncture points throughout body to
balance its internal function
4. Distraction
u Diverts patients’ attention and lessens perception of pain
u Various modalities: listening to music, watching tv, virtual reality

Evaluation

- Evaluate the eAectiveness of pain-relieving intervention

- E.g overall goals and outcomes are achieved?
Documentation

- Time & nature of the intervention, for example,

n For analgesics: Record the drug, dosage, frequency, route & exact time taken
- Level of pain (e.g. pain score) before & after the intervention
- Adverse eAects (if any)

Take home message

- Pain is a subjective experience and unique to every individual

- Use of pain assessment tool is determined by the characteristics of your client
L5b Process of wound healing and wound care

Process of wound healing

Stage 1 haemostasis

- Characterized by microvascular injury and extravasation of blood into wound

- Formation of fibrin clot aids to stop bleeding
- Scabs consist of clots and dead tissues are formed on wound surface to aid haemostasis and
prevent entry of microorganism

Stage 2 inflammation

- Vasodilation which can destroys bacteria & remove cellular debris by cellular response and
vascular responses.
- Divided into early and late phases, depending on:
n time and duration of response
n type of inflammatory cell
- Early inflammatory phase (days 1–2)
n Leukocytes are attracted to the wound site
- Late inflammatory phase (days 2–3)
n Monocytes are attracted to the wound and become tissue macrophages

Stage 3 proliferation

- Start at about day 3 and lasts for 2–4 weeks after tissue injury
- Characterized by fibroblast migration, deposition of the extracellular matrix and formation of
granulation tissue
- Edges of wound grow at the bottom & the sides to decreases the wound size and epithelial cells
migrate from the wound margins to seal the wound
- Epithelialization of the wound represents the final stage of the proliferative phase

Stage 4 maturation (Remodeling)

- Fibroblasts continue to produce collagen. With the reorganization of collagen matrix, avascular
scar tissue formed to replace granulation tissue as protective barrier against external
environment. Avascular scar resolve gradually and the wound is healed.
- Remodeling is initiated concurrently with the development of granulation tissue and the process
takes ~21 days
Types of wound healing

1. Primary intention
- Minimal or no tissue loss for clean wound
- Wound edges are well approximated
- Sutures, staples or skin closure adhesive strips for wound closure
- Healing usually occurs with minimal scarring. clean incision
2. Secondary intention
- Considerable amount of tissue loss for extensive wound
- Wound is lay open for natural healing process.
- Deposition of granulating tissue & fills the wound from the bottom & the sides.
- Healing process takes longer time & with more scarring
3. Tertiary intention
- A full thickness wound is left open for 3-5 days to allow edema or infection to resolve until optimal
conditions are met.
- A time delay before the wound is suturedà Late closure may cause more scarring.

Factor aAecting wound healing

Nursing care for client with wound

- Ongoing assessment & monitoring

- Monitor client’s vital signs (BP, P, RR & Temp)
- Early detection & interventions to prevent wound complications.
- Assess client’s lab. results
n White blood cells (WBC), serum protein levels which may indicate signs of infection &
nutritional insuAiciency
- Assess wound conditions regularly
- Health education of wound care

Wound assessment: TIME