SLEEP REST PATTERN

SLEEP REST PATTERN
Afroz Lakhani, R.N., BScN

 What is sleep?
 SOMNOLOGY: Study of sleep
 Basic human need
 We spend about 8 hours/day, 56 hours/week, 224 hours/month and 2,688 hours/year sleeping (1/3 of our lives)
 We need sleep
 To cope with daily stress
 To prevent fatigue
 To conserve energy
 To restore mind and body
 Healing of damaged tissue is greatest during sleep

Physiology of sleep

 Altered state of consciousness. (perception and reaction to the environment is decreased)
 Minimal physical activity
 Changes in physiologic processes
 Decreased responsiveness to (some) external stimuli
 The cyclic nature of sleep is controlled by neurons located within the reticular formation.


Reticular Formation

 A diffuse network of nerve fibers and cells in parts of the brainstem, important in regulating consciousness or wakefulness.
 Stimulation induces arousal
 Destruction induces sleep
 Neurotransmitters located within neurons affect sleep-wake cycles.
 Acetylcholine (Ach antagonist and Ach agonist)
 Serotonin (lessen to sensory response)
 Histamine (keeps us awake)


Sleep is sensitive to darkness

 Decreases stimulation of RF
 Pineal gland secretes melatonin, and the person feels less alert,
 GH released, cortisol inhibited
 Beginning of daylight, melatonin is at its lowest level and stimulating cortisol at its highest, also Ach , dopamine and nonadrenaline.

 Types of Sleep
 Two types
 NREM
 REM

NREM: 75% to 80% of sleep during a night
Divided into 4 stages
 Stage 1: very light sleep, few mins, drowsy, relaxed, can easily awakened
 Stage 2: light sleep, 44% to 55%, 10 to 15 mins, requires stimuli to be awake
 Stage 3 & 4: deepest, difficult to arouse, not disturbed by sensory stimuli, reflex diminished, snoring.

REM: (paradoxical sleep)
occurs every 90 mins, lasts 5 to 30 mins, dreams, Brain highly active, Ach, dopamine at highest, eye movements, voluntary muscle tone decreased, sleeper difficult to arouse or wakes up spontaneously.
 Initially lasts 5-10 minutes, gradually lengthens until final REM period lasts 50minutes.
 Very important stage of sleep.


Sleep Cycles

 NREM and REM
 Lasting about 90 to 110 mins in adults
 In first sleep cycle: passes thru all 3 NREM stages in 20 to 30 mins,
 then stage 4 NREM for about 30 mins
 Sleep passes back through stage 3 and 2 for 20 mins
 Thereafter, the first REM occurs, lasting 10 mins
 This completes first sleep cycle.
 Healthy adult experiences 4 to 6 cycles in 7 to 8 hrs

Functions of sleep

 Restores normal levels of activity and balance among parts of nervous system
 Important of protein synthesis (repair )
 important psychological well-being ( emotionally irritable, poor concentration, difficulty making decisions)

Normal Sleep Patterns

 NEWBORNS: 16 to 18 hrs/day, enters REM immediately, sleep cycle about 50 mins, tuck in when sleepy.
 INFANTS: 14 to 15 hrs, awakens 3 to 4 hrs, eat and back to sleep. By 6 months sleeps entire night, nap patterns. Put them to bed when drowsy.
 TODDLERS: 12 to 14 hrs, afternoon nap, resistance going to bed and awakens during night. Nightmares common.
 SCHOOL-AGE CHILDREN: (5-12 yrs) needs 10 to 11 hrs, but they sleep less, avoid caffeinated drinks and late TV, have bedtime routine.
 ADOLESCENTS: (12-18 yrs), needs 9 to 10 hrs, few sleeps that long and sleepy at school results in lower grades, negative moods.
 ADULTS: needs 7 to 9 hrs but some can function well with 6 hrs as well.
 ELDERS: earlier bedtime and wake times, disturbed sleep impacts quality of life, mood and alertness.

Factors Affecting Sleep

 Sleep quality: subjective, person wakes up energetic or not.
 Sleep quantity: total time of sleep

 ILLNESS: pain, physical distress (arthritis, SOB, ulcers, low estrogen__hot flashes, elevated body temperature, urge to urinate)
 ENVIRONMENT: noise, unfamiliar, hospital, temperature, lack of ventilation, lights, snoring partner.
 LIFESTYLE: irregular am and pm schedule, late exercise, inability to relax before bedtime.
 EMOTIONAL STRESS: #1 cx of sleep disturbance, Anxiety increases norepinephrine.
 STIMULANTS AND ALCOHOL: coffee, caffeine stimulates CNS, excessive alcohol disrupts REM but hasten the onset.
 DIET: weight gain cx broken sleep and early awakening, weight loss in total sleep time and less broken sleep. Warm milk can help.
 SMOKING: Nicotine
 MOTIVATION: can increase alertness.
 MEDICATIONS: Hypnotics interfere deep sleep and suppress REM sleep. Beta blockers cx insomia, Narcotics suppress REM cx drowsiness, awakenings.

Common Sleep Disorders

 INSOMNIA: inability to fall asleep or remain sleep,
stimulus control, Cognitive therapy (positive sleep thoughts and beliefs), Sleep restriction, antihistamine.
 HYPERSOMNIA: sufficient sleep at night but still sleepy, cx CNS damage, metabolic disorder.
 NARCOLEPSY: sleep attacks or EDS, Ritalin
 SLEEP APNEA: frequent short breathing pauses during sleep. More than 5 episodes or longer than 10 seconds/hr is abnormal, loud snoring, frequent awakenings, morning headaches, EDS.

Nursing Management

History:
 Generally rested and ready for daily activities after sleep?
 Sleep onset problems
 Aids
 Dreams, nightmares
 Early awakening
 Rest_ relaxation period
 Nursing Diagnosis:
 Sleep Deprivation (prolong time without sleep)
 Sleep Pattern, Disturbance
 Insomnia (delayed onset of sleep)
Related to:
 Over stimulation prior to bedtime
 Pain
 Discomfort
 Anxiety
 Alcohol
 Fatigue r/t insufficient sleep
 Risk for impaired gas exchange r/t sleep apnea
 Activity intolerance r/t sleep deprivation or EDS

Goal:
 To maintain or develop sleep pattern that provides sufficient energy for daily activities.
 Improving quality and quantity of sleep.
 Keep the etiology in mind

Implementing: Largely non pharmacologic measures like health teachings about sleep habits, bedtime rituals, provision of restful environment, avoid heavy meals before bedtime.
 For hospitalized clients activities should be scheduled, less stimulus environment, support for anxious patients, safe use of sleep medications.

Evaluating:
 Goals and outcomes achieved?
 Observation about client’s sleep pattern
 How the client feels on awakening?
 Client’s level of alertness during the day
If desired outcomes not met then identify following:
 Etiologic factors were correct?
 Any change in medication therapy?
 Client’s compliance
 Were the measures effective?

References:

Carpenito, J.L. (2002). Nursing diagnosis: Application to clinical practice (9th edition) Philadelphia: Lippincott.
Kozier & Erb. (2008). Fundamentals of Nursing (8th edition) New Jersy: Pearson.
Ross and Wilson. (2006). Anatomy and physiology (10th edition) Churchill Livingstone

ASSESSMENT OF A NEWBORN

Assessment of a Newborn
Nuruddin Lakhani, M.D., M.P.H.
Pediatrician




HISTORY
Important to review Mother’s chart
- Mother’s age
- Mother’ s gravida / para status
- Pregnancy complications
- Labor events
- Rupture of membranes (SROM, AROM, PROM, PPROM)
- Mother’s labs (blood group, HBsAg, HIV, VDRL, GC / Chlam)
- ? Fever, medications (antibiotics, narcotics etc)
- Mode of delivery

Important to review the events immediately after birth
- Resuscitation
- Any medications given
- APGARS

SCORE 0 1 2
Heart Rate Absent < 100 >100
Resp Effort Absent/irr Slow, Crying Good
Muscle Tone Limp Some flexion Active motion
Reflex irritability No response Grimace Cough or sneeze
Color Blue. Pale Acrocyanosis Pink



NEONATAL EXAMINATION

General
- Appearance, size, color, vitals, gestational age assessment and growth parameters

Systemic
- Head and Neck - CNS
- Respiratory - Skin
- Cardiovascular - Musculoskeletal
- Abdominal - Primitive Reflexes
- Genitourinary


Size
- PAGA, PSGA, PLGA
- TAGA, TSGA, TLGA
- PTAGA, PTSGA, PTLGA
Gestational Age Assessment
- Ballard Score based on neuromuscular and physical maturity
- Ballard chart for the gestational assessment is used

HEAD
- Birth trauma (caput succedaneum, cephalhematoma)
- Size (microcephaly, macrocephaly)
- Fontanelles
EYES
- Red reflex
- Neonatal conjunctivitis

MOUTH / OROPHARYNX
- Cleft lip / palate
NOSE
- Obstructions
EARS
- Position
NECK
- Masses

RESP
- Rate, distress
- Apnea, cyanosis (? Causes)
- Auscultation
CVS
- Distress, apnea, cyanosis (? Causes)
- Palpation (apical impulse, thrills)
- Auscultation (murmurs)







ABDOMEN
- Abdominal wall defects, umbilical cord, shape
- Palpation
- Auscultation
- Check anal area for patency
GU
- Males – check for testes in scrotum or in the canal
- Females – check for ambiguous genitalia

MUSCULOSKELETAL
- Brachial plexus injury
- Range of motion
- Barlow’s and Ortolani test for hip dysplasia
- Check spine
CNS
- Movements and tone
- Primitive reflexes




SKIN
- Color (jaundice)
- Skin hair
- Texture
- Neonatal rashes
- Lower back hair or sacral dimple

NUTRITION AND METABOLIC PATTERN

What is Nutrition?
The study of foods and nutrients and their effect on health, growth and development of the individual.
Nutrition is the good we get from all the food we eat and it helps our bodies work.
Nutrients are the substances found in the food that is essential requirement for body functioning.
Body needs adequate food intake with balanced essential nutrients.

Essential Nutrients
water
carbohydrates
proteins
lipids
vitamins and
minerals.

Carbohydrates
Preferred source of energy
Include simple and complex carbohydrates
Promote fat metabolism, spare protein and enhance lower GI function
Major good sources milk, grains, fruits and vegetables
Inadequate carbohydrates intake affects metabolism

Carbs metabolism
Carbohydrates breaks into glucose
Some glucose circulate in the blood to maintain blood level and source of energy.
Reminder stored
Insulin enhances transport of glucose into cells

Proteins
Made of carbon, hydrogen, oxygen and nitrogen
Each protein molecule is made of amino acids
Essential: must supplied from diet and are necessary for tissue growth and maintenance.
Nonessential: body makes it and mix it with dietary protein to make new protein molecules

Classification of proteins
Complete proteins
Contains all essential and some non essential amino acids.
Found in animal, dairy, eggs

Incomplete proteins
Missing one or more essential amino acids.
Derived from vegetables
Balanced combination of food can provide essential amino acids e.g. maize and beans.
Protein metabolism

Three activities
Anabolism ( building)
Catabolism (breaking down)
Nitrogen balance (balance N intake = N output)

Lipids
Contains carbon, hydrogen and oxygen but more hydrogen than carbohydrates
Greasy, insoluble in water but soluble in alcohol
Fats are lipids that are solid at rtp
Oils are lipids that are liquid at rtp
Structured with fatty acids described as saturated and unsaturated fatty acids. (saturated, unsaturated fat)
Meat, butter, milk, coconut are saturated fat
Fish, oil, cereal, legumes (maize oil), breast milk are unsaturated fat.
Enzyme lipase converts fat into usable energy

Micronutrients
Vitamin are not manufactured by the bodies and needed to catalyze metabolic processes.
Fat soluble vitamins ( A, D, E and K)
Water soluble vitamins ( C, B-complex)
Minerals ( calcium, phosphorus, sodium, potassium, iron, iodine)

Energy Balance
Is the relationship between the energy derived from food and the energy used by the body.
Body obtains energy in the form of calories form carbohydrates, fat, protein and uses energy for daily voluntary and involuntary activities like walking, breathing.
Energy intake thru calorie value.
BMR by which body metabolizes food to maintain the energy requirements at awake and at rest.



Balanced Diet
Provides appropriate amounts of all nutrients in the correct proportions to meet body requirements which is achieved by eating variety of foods.
Any nutrient eaten in excess or deficient can affect health. (obesity, anemia)
Is important in maintaining a healthy body weight and can be assessed by body mass index (BMI)
Check out: wt kg divided ht squared (18.5---24.9)
Example: weight 60 kg ÷ height (1.52)² meters = 26 is the BMI.
http://www.cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/index.htm


Young children


(one serving )
Grain group 1 slice of bread, 1/2 cup of cooked rice or pasta, 1/2 cup of cooked cereal,
Vegetable group 1/2 cup of chopped or raw vegetables, or 1 cup of raw leafy vegetables.
Fruit group 1 piece of fruit or melon wedge, 3/4 cup of 100% fruit juice, 1/2 cup of canned fruit, or 1/4 cup of dried fruit.
Milk group 1 cup of milk or yogurt or 2 ounces of cheese.
Meat group 2 to 3 ounces of cooked lean meat, poultry or fish, 1/2 cup of cooked dry beans, substitute 2 tablespoons of peanut butter or 1 egg for 1 ounce of meat.

Elder’s:


NUTRITION AND METABOLIC PATTERN

Tuft's University adjusted the food pyramid for those over age 70 to include:
8 glasses of water a day and plenty of fiber to help manage constipation.
Calcium, vitamin D, and B12 supplements.



Fancy pyramid food possible in Africa?





Factors affecting nutrition
Accessibility
Affordability
Food safety
Traditions
Lifestyle
Medications and therapy
Health
Alcohol consumption
Psychologic factors


Assessment
ABCD
Anthropometric Data: Ht, wt, waist circumference, BMI

Biochemical Data: Hemoglobin, serum albumin

Clinical: Skin, Hair and nails, mucus membrane

Dietary Data: 24-hour food recall, food diary

Nursing Diagnosis
Imbalanced nutrition: Less than body requirements/intake of nutrients insufficient to meet metabolic needs

Imbalanced nutrition: More than body requirements related to excess intake and decreased activity expenditure

Low self-esteem related to obesity

Risk for infection related to immunosuppresion secondary to insufficient protein intake.

Therapeutic Diets
Clear liquid diet
Full liquid diet
Soft diet
Bland diet
Low residue/low fiber diet
High fiber diet
Fat controlled diet
High calorie diet
Sodium restriction diet
Protein restriction diet
High protein diet
Low calcium diet
High calcium diet
Low purine diet
High iron diet
Carbohydrate controlled diet

References
Carpenito, J.L. (2002). Nursing diagnosis: Application to clinical practice (9th edition) Philadelphia: Lippincott.
Kozier & Erb. (2008). Fundamentals of Nursing (8th edition) New Jersy: Pearson.
Ross and Wilson. (2006). Anatomy and physiology (10th edition) Churchill Livingstone.
Savage King and Burgess. (1993). Nutrition for developing countries (2nd edition) Oxford.
Images: google images

CLASSIFICATION OF NANDA NURSING DIAGNOSES BY GORDON’S

HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
Energy Field, Disturbed
Health Maintenance, Ineffective
Health-Seeking Behaviors (Specify)
Infection, Risk for
Injury, Risk for
Risk for injury, Suffocation
Risk for injury, Poisoning
Risk for injury, Trauma
Latex Allergy Response, Risk for and Actual
Management of Therapeutic Regimen, Effective
Management of Therapeutic Regimen (Individual, Family,
Community), Ineffective
Management of Therapeutic Regimen, Readiness for
Enhanced
Noncompliance (Specify)
Perioperative-Positioning Injury, Risk for
Protection, Ineffective
Surgical Recovery, Delayed

NUTRITIONAL-METABOLIC PATTERN
Adult Failure to Thrive
Aspiration, Risk for
Body Temperature, Imbalanced, Risk for
Breastfeeding, Effective
Breastfeeding, Ineffective
Breastfeeding, Interrupted
Dentition, Impaired
Fluid Balance, Readiness for Enhanced
Fluid Volume, Deficient, Risk for and Actual
Fluid Volume, Excess
Fluid Volume, Imbalanced, Risk for
Hyperthermia
Hypothermia
Infant Feeding Pattern, Ineffective
Nausea
Nutrition, Imbalanced, Less Than Body Requirements
Nutrition, Imbalanced, More Than Body Requirements,
Risk for and Actual
Nutrition, Readiness for Enhanced
Swallowing, Impaired
Thermoregulation, Ineffective
Tissue Integrity, Impaired
Skin Integrity, Impaired, Risk for and Actual
Oral Mucous Membrane, Impaired

ELIMINATION PATTERN
Bowel Incontinence
Constipation, Risk for, Actual, and Perceived
Diarrhea
Urinary Elimination, Readiness for Enhanced
Urinary Incontinence
Functional Urinary Incontinence
Reflex Urinary Incontinence
Stress Urinary Incontinence
Total Urinary Incontinence
Urge Urinary Incontinence, Risk for and Actual
Urinary Retention

ACTIVITY-EXERCISE PATTERN
Activity Intolerance, Risk for and Actual
Airway Clearance, Ineffective
Autonomic Dysreflexia, Risk for and Actual
Bed Mobility, Impaired
Breathing Pattern, Ineffective
Cardiac Output, Decreased
Disuse Syndrome, Risk for
Diversional Activity, Deficient
Dysfunctional Ventilatory Weaning Response
Falls, Risk for
Fatigue
Gas Exchange, Impaired
Growth and Development, Delayed
Development, Risk for Delayed
Growth, Risk for Disproportionate
Home Maintenance, Impaired
Infant Behavior, Disorganized, Risk for and Actual, and Readiness
for Enhanced Organized
Peripheral Neurovascular Dysfunction, Risk for
Physical Mobility, Impaired
Sedentary Lifestyle
Self-Care Deficit
Feeding
Bathing-Hygiene
Dressing-Grooming
Toileting
Spontaneous Ventilation, Impaired
Tissue Perfusion, Ineffective (Specify Type:
Renal, Cerebral, Cardiopulmonary,
Gastrointestinal, Peripheral)
Transfer Ability, Impaired
Walking, Impaired
Wandering
Wheelchair Mobility, Impaired

SLEEP-REST PATTERN
Sleep, Readiness for Enhanced
Sleep Deprivation
Sleep Pattern, Disturbed

COGNITIVE-PERCEPTUAL PATTERN
Adaptive Capacity, Intracranial, Decreased
Confusion, Acute and Chronic
Decisional Conflict (Specify)
Environmental Interpretation Syndrome, Impaired
Knowledge, Deficient (Specify)
Knowledge, Readiness for Enhanced (Specify)
Memory, Impaired
Pain, Acute and Chronic
Sensory Perception, Disturbed (Specify:
Visual, Auditory, Kinesthetic, Gustatory,
Tactile, Olfactory)
Thought Processes, Disturbed
Unilateral Neglect

SELF-PERCEPTION AND SELF-CONCEPT
PATTERN
Anxiety
Body Image, Disturbed
Death Anxiety
Fear
Helplessness
Loneliness, Risk for
Personal Identity, Disturbed
Powerlessness, Risk for and Actual
Self-Concept, Readiness for Enhanced
Self-Esteem, Chronic Low, Situational Low,
and Risk for Situational Low
Self-Mutilation, Risk for and Actual

ROLE RELATIONSHIP PATTERN
Caregiver Role Strain, Risk for and Actual
Communication, Readiness for Enhanced
Family Process, Interrupted, and Family Process,
Dysfunctional: Alcoholism
Family Process, Readiness for Enhanced
Grieving, Anticipatory
Grieving, Dysfunctional, Risk for and Actual
Parent, Infant, and Child Attachment, Impaired,
Risk for
Parenting, Impaired, Risk for and Actual, and
Parental Role Conflict
Parenting, Readiness for Enhanced
Relocation Stress Syndrome, Risk for and Actual
Role Performance, Ineffective
Social Interaction, Impaired
Social Isolation
Sorrow, Chronic
Verbal Communication, Impaired
Violence, Self-Directed and Other-Directed,
Risk for

SEXUALITY-REPRODUCTIVE PATTERN
Rape-Trauma Syndrome: Compound Reaction
And Silent Reaction
Sexual Dysfunction
Sexuality Patterns, Ineffective

COPING-STRESS TOLERANCE PATTERN
Adjustment, Impaired
Community Coping, Ineffective and Readiness
for Enhanced
Coping, Readiness for Enhanced
Family Coping, Compromised and Disabled
Family Coping, Readiness for Enhanced
Individual Coping, Ineffective
Coping, Defensive
Denial, Ineffective
Post-Trauma Syndrome, Risk for and Actual
Suicide, Risk for

VALUE-BELIEF PATTERN
Impaired Religiosity, Risk for and Actual
Spiritual Distress, Risk for and Actual
Spiritual Well-Being, Readiness for Enhanced

Gordon Functional Pattern

Organizing Data According to Gordon's 11 Functional Health PatternsFunctional Health Pattern
Pattern Describes
Examples

Health Perception/
Health Management
Client's perceived pattern of health and well-being and how health is managed.
Compliance with medication regimen, use of health-promotion activities such as regular exercise, annual check-ups.

Nutritional-Metabolic
Pattern of food and fluid consumption relative to metabolic need and pattern; indicators of local nutrient supply.
Condition of skin, teeth, hair, nails, mucous membranes; height and weight.

Elimination
Patterns of excretory function (bowel, bladder, and skin). Includes client's perception of normal" function.
Frequency of bowel movements, voiding pattern, pain on urination, appearance of urine and stool.

Activity - Exercise
Patterns of exercise, activity, leisure, and recreation.
Exercise, hobbies. May include cardiovascular and respiratory status, mobility, and activities of daily living.

Cognitive-Perceptual
Sensory-perceptual and cognitive patterns.
Vision, hearing, taste, touch, smell, pain perception and management; cognitive functions such as language, memory, and decision making.

Sleep-Rest
Patterns of sleep, rest, and relaxation.
Client's perception of quality and quantity of sleep and energy, sleep aids, routines client uses.

Self-Perception/
Self Concept
Client's self-concept pattern and perceptions of self.
Body comfort, body image, feeling state, attitudes about self, perception of abilities, objective data such as body posture, eye contact, voice tone.

Role-Relationship
Client's pattern of role engagements and relationships.
Perception of current major roles sand responsibilities (e.g., father, husband, salesman); satisfaction with family, work, or social relationships.

Sexuality-Reproductive
Patterns of satisfaction and dissatisfaction with sexuality pattern; reproductive pattern.
Number and histories of pregnancy and childbirth; difficulties with sexual functioning; satisfaction with sexual relationship.

Coping / Stress Tolerance
General coping pattern and effective of the pattern in terms of stress tolerance.
Client's usual manner of handling stress, available support systems, perceived ability to control or manage situations.

Value - Belief
Patterns of values, beliefs (including spiritual), and goals that guide client's choices or decisions.
Religious affiliation, what client perceives as important in life, value-belief conflicts related to health, special religious practices.