1. I. Nutrition
A. Food guidelines
1. Nutritional needs through the life cycle
a. infants - fluid needs: adequate to maintain hydration (approximately 6
wet diapers per day)
b. infants - protein needs are 2.2 gm/kg/day
c. breast milk or formula is adequate for the first six months of life
i. whole milk is difficult for young infants to digest
ii. the first food introduced is rice cereal (less likely to develop
allergy to rice)
d. childhood - gradual increasing of all nutrients
e. adult - unchanged except for
i. pregnancy - add per day: 300 calories, 15 mg iron, 30 g
protein, 400 g calcium, and 200 ug folic acid
ii. lactation - add 500 calories and 2 quarts extra fluid per day
f. elderly: over age 65 - adequate protein to maintain immune system
2. Factors affecting dietary patterns
a. health status
b. ability to chew, swallow, and drink
c. culture and religion
d. socioeconomic status
e. personal preference
f. psychological factors
g. alcohol and drugs
3. Energy needs
a. basal metabolism: amount of energy (measured in calories) required
to sustain life in a resting individual
b. basal metabolic rate (BMR)
i. influenced by genetic and environmental factors, e.g., gender,
age, activity level, body surface area, body fat percentage,
diet

2. ii. several different formulas can be used to determine BMR
Review the MyPyramid Food Guidance System.
Learn more about Healthy People 2020, which is a statement of
national health objectives and goals to reduce preventable threats
to health.
B. Essential nutrients
1. Carbohydrates
a. includes sugars, starches and fibers (cellulose)
b. simple sugars (monosaccharides and disaccharides) are most easily
metabolized
c. starches are more complex in structure and metabolism
d. functions of carbohydrates
i. quickest source of energy (4 kcal/gram)
ii. main source of fuel for brain, peripheral nerves, WBCs, RBCs, and
healing wounds
iii. protein sparer
e. dietary sources: plant foods, except for lactose
f. recommended daily intake:
i. factors influencing recommended intake of carbohydrates include
body structure, energy expenditure, basal metabolism and general
health status
ii. ideally, 50 to 60% of total calories should be complex carbohydrates
g. excessive carbohydrate calories are stored as fat
2. Lipids
a. basic lipids are composed of triglycerides and fatty acids
b. includes saturated fatty acids (from animal sources) and unsaturated fatty
acids (vegetables, nuts and seeds)
c. essential polyunsaturated fatty acids: linoleic and linolenic fatty acids are the
only fatty acids that are essential to humans
d. deficiencies lead to skin, blood and artery problems
e. functions
i. most concentrated source of energy (9 kcal/gram)
ii. major form of stored energy
iii. insulation
iv. component of cell membranes
v. carries fat-soluble vitamins A, D, E and K
f. recommended dietary intake: total fat intake should not exceed 30% of daily
calories with saturated fats not exceeding 10% of total daily caloric intake
Take care of yourself when preparing to take the NCLEX exam.
Get plenty of rest, exercise regularly, eat nutritious meals, and stay
hydrated with noncaffeinated beverages.
3. Proteins
a. complex organic compounds comprised of amino acids

3. b. body breaks protein down into 22 amino acids
c. all but eight amino acids are produced by the body
d. "complete protein" food - contains the eight essential amino acids not produced by
the body (most meat, fish, poultry and dairy products)
e. "incomplete protein" food - lacks one or more of the eight amino acids (most
vegetables and fruits)
f. incomplete proteins can be combined to yield a complete protein: for example,
beans and rice
g. functions of protein
i. secondary energy source (4 kcal/gram)
ii. essential for cell growth
iii. efficiency can affect all of body - organs, tissues, skin, muscles
iv. recommended protein intake: 0.8 grams per kg of body weight per day
v. the body's only source of nitrogen
vi. negative nitrogen balance can occur with infection, burns, fever, starvation,
and injury
4. Vitamins
a. organic substances essential for body growth and metabolism
b. found only in plants and animals; body cannot synthesize them; depends on dietary
intake
c. types (according to their solvent)
i. water soluble: vitamin C and B-complex vitamins (thiamin, riboflavin, niacin,
pantothenic acid, biotin, B6, folate, B12)
cannot be stored in body
require daily intake
ii. fat soluble: A, D, E, K
stored primarily in the liver and adipose tissues
absorbed by the body from the intestinal tract
5. Minerals
a. inorganic substances essential as catalysts in biochemical reactions
b. form most inorganic material in the body
c. functions:
i. catalyst for many body reactions such as regulation of acid-base balance
ii. help cells metabolize, tissues absorb nutrients, and heart muscle respond
iii. minerals work synergistically; a deficiency of one mineral can disturb the
action of other minerals
iv. types - grouped according to amount found in body
major minerals - calcium, magnesium, sodium, potassium,
phosphorus, sulfur, chlorine (function is known)
trace minerals - iron, copper, iodine, manganese, cobalt, zinc and
molybdenum (function unclear)
another group of trace minerals; found in even smaller amounts
(function is unclear)
6. Water
a. critical body component essential for cell function
b. accounts for 60 to 70% of total body weight in adults; 70 to 75% of total body
weight of children
c. provides normal turgor
d. regulates body temperature

4. e. dietary sources: liquids and solids, such as fresh fruits and vegetables
f. deficiency: severe deficiency leads to dehydration and death
g. fluid intake normally equals fluid output
Learn more about nutrition from the Amercian Dietetic Association.
Fluid and electrolyte balance
1. Total volume of fluid and amount of electrolytes remain relatively constant in the body
2. Fluid balance and electrolyte balance is interdependent
3. Body balances fluid and electrolytes primarily by adjusting output and secondarily by
adjusting intake
4. Fluid balance is also maintained by osmosis
5. Major electrolytes
a. cations
i. sodium - most abundant cation in extracellular fluid
regulates cell size via osmosis
essential in maintaining water balance, transmitting nerve impulses,
and contracting muscles
regulates acid-base balance by exchanging hydrogen ions for sodium
ions in kidney
normal lab value for serum sodium is 135 to 145 mEq/L
sodium is regulated by salt intake, aldosterone, and urinary output
sources include table salt, processed meats, snacks and canned food
ii. potassium - most abundant cation of intracellular fluid
potassium pump draws potassium into cell
essential for polarization and repolarization of nerve and muscle
fibers
regulates neuromuscular excitability and muscle contraction
sources include whole grains, meat, legumes, fruits and vegetables
regulated by kidneys
normal lab value for serum potassium is 3.5 to 5.3 mEq/L
iii. calcium - essential for healthy bones and teeth, cell membrane integrity,
blood clotting, cardiac contraction, blood pressure, functioning of nerves and
muscles and maintaining immune defenses
iv. magnesium - normal constituent of bone; cofactor for enzymes in energy
metabolism, neurochemical activities, muscular excitability
b. anions
i. chloride - most abundant anion in extracellular fluid; part of hydrochloric acid
found in stomach and necessary for proper digestion; helps balance sodium;
normal lab value for serum chloride is 100 to 106 mEq/L
ii. bicarbonate - part of bicarbonate buffer system; limits the drop in pH by
combining with an acid to form carbonic acid and a salt
iii. phosphate - participates in cellular energy metabolism, combines with
calcium in bone, assists in structure of genetic material
Maintenance of fluid volume
a. osmoreceptor system
i. balances fluid intake volume by the regulation of water output volume

5. ii. dehydration stimulates osmoreceptors which activate the thirst control center;
person feels thirsty and seeks water
iii. also stimulates antidiuretic hormone (ADH) secretion which decreases urinary
output by causing the reabsorption of water in the tubules
b. circulatory system
i. increases in fluid intake increase circulatory volume
ii. this increased volume stimulates the kidneys for an increased glomerular
filtration rate
iii. end result is an increase in urine output to decrease the initial circulatory volume
c. thirst center
i. located in hypothalamus
ii. stimulated by
increased plasma osmolality
angiotensin II
dry pharyngeal mucous membranes
decreased plasma volume
depleted potassium
psychological factors
d. Maintenance of electrolyte balance
i. aldosterone - hormone (mineralocorticoid)
when extracellular fluid sodium decreases or potassium levels increase
adrenal cortex secretes aldosterone
kidneys stimulated by aldosterone to increase reabsorption of sodium and
decrease reabsorption of potassium
results in water reabsorption and increased blood volume
ii. renin/angiotensin - hormone affecting renal tubule reabsorption of water
iii. atrial natriuretic peptide (ANP) - hormone affecting renal tubule reabsorption of
water
iv. parathyroid
parathyroid secretes parathyroid hormone (PTH), also called
parathormone
stimulates release of calcium from bone, reabsorption in small intestine
and kidney tubules
when serum calcium level is low, PTH secretion increases
when serum calcium level rises, PTH secretion falls
high levels of active vitamin D inhibit PTH and low levels or magnesium
stimulate PTH secretion

6. D. Normal and therapeutic diets
1. Guidelines:
a. dietary reference intakes (DRIs) - average daily nutrient intake of apparently
healthy people over time
i. recommended dietary allowance (RDA)
ii. adequate intake (AI)
iii. tolerable upper intake level (UL)
iv. estimated average requirement (EAR)
b. ethnic food patterns
c. religious considerations in meal planning
d. personal choice, e.g. vegetarian
Types of vegetarian diets:
Vegan: refrains from eating animal products
Lacto-ovo vegetarian : consumes eggs and dairy products but
excludes meat, poultry, seafood
Lacto vegetarian : consumes dairy products, but excludes eggs,
meat, poultry, seafood
2. Therapeutic nutrition
a. modification of the nutritional needs based on disease condition
b. considerations for administering therapeutic diets
i. condition of client - physical, emotional, mental ability of client to tolerate diet
ii. willingness of client to follow dietary guidelines
c. types of therapeutic diets
i. diabetic
goals of nutritional management

7.  providing all essential nutrients
 meeting energy needs
 achieving and maintaining a reasonable weight
 preventing wide daily fluctuations in blood glucose levels
 decreasing serum lipid levels
diet individualized according to client's age, build, weight, and activity
level
recommended caloric distribution: 50-60% carbohydrates, 20-30%
fat, and 10-20% protein
The American Diabetes Association provides comprehensive
information about diabetes.
ii. low protein diet
for renal disease such as pyelonephritis, uremia, kidney failure
limit protein less than 40 g/day (0.5 g/kg/day) instead of normal protein intake of
40 to 60 g/day (1g/kg/day)
restricted foods: meats and other foods high in protein such as legumes, fish,
dairy
iii. high protein diet
for conditions such as burns, anemia, malabsorption syndromes, ulcerative colitis
include high quality proteins or protein supplements such as Sustagen®
promote high protein intake more than 60 g/day (1.5 g/kg/day) instead of normal
protein intake of 40 to 60 g/day (1g/kg/day)
iv. low calcium diet
limit to 400 mg per day instead of normal 800 mg
restricts dried fruits and vegetables, shell fish, cheese, nuts
v. acid ash diet
prevents kidney stone formation
restricts carbonated beverages, dried fruits, banana, figs, chocolate, nuts, olives,
pickles
vi. low purine diet
prevents uric acid stone; used for clients with gout
lowers levels of purine, the precursor of uric acid
restricts glandular meats, gravies, fowl, anchovies, beer and wine (see gout
dietfor more details)
vii. gluten-restricted or gluten-free
used for people with sensitivity to glutens (proteins) in wheat, oats, rye, and
barley
may eat rice, corn and millet products
viii. low cholesterol
used for cardiovascular disease, high serum cholesterol levels
normal amount of cholesterol intake - 250 to 300 mg/day
restricts eggs, beef, liver, lobster, ice cream
ix. low sodium
used in congestive heart failure, hypertension
used for correcting the retention of sodium and water
levels of restriction

8. i. mild (2 g sodium)
ii. moderate (1000 mg sodium)
iii. strict (500 mg sodium)
restricts table salt, canned vegetables, smoked meats, butter, cheese
x. high fiber
used to correct constipation, lower risk of colon cancer
30 to 40 gram fiber/day recommended
increased intake of fruits, vegetables, bran cereals
xi. low residue
used for conditions such as diarrhea, diverticulitis
reduce fiber intake: canned fruit, refined carbohydrates, pasta, strained
vegetables
foods high in refined carbohydrates are usually low fiber
increased use of ground meat, fish, broiled chicken without skin, white bread
xii. mechanical soft
used with difficulty in chewing, such as poorly fitted dentures or endentulous
clients (no teeth)
includes any foods which can be easily broken down by chewing
xiii. puree diet
used with dysphagia or difficulty in chewing
used for tube feedings, small babies
food is blended to smooth consistency
xiv. liquid diets
clear liquid: coffee without cream, tea, popsicles, fruit juices, including apple,
cranberry, grape, and carbonated beverages
full liquid: includes all clear liquids plus milk, cream, ice cream, pudding, yogurt,
vegetable juice, creamy peanut butter
xv. Nutritional assessment
weight change
appetite
food intolerance
chewing and swallowing
indigestion
elimination habits
eating behaviors
nutrient-drug interactions
anthropometric measurements
xvi. Feeding tubes
indications - inability to ingest, chew, or swallow food, but GI tract intact
tube inserted through nose into stomach or small bowel; or inserted
endoscopically; gastrostomy tube or PEG tube, jejunostomy tube
types of tubes and feedings

9. i. small bore feeding tube: 8 to 12 Fr and 36 to 43 inches long
i. difficult to aspirate stomach contents
ii. may be impossible to auscultate an air bolus or air bolus may be
heard even when tube is not in stomach
iii. tubes may become displaced even when securely taped
iv. hard to verify placement; therefore best initial method is by x-ray;
thereafter routine check of stomach contents pH
xvii. enteral tube feedings
keep head of bed raised at least 30 degrees, to prevent aspiration

10. assess placement of tube (confirm technique used, as required by agency policy)
i. obtain radiologic (x-ray) confirmation before instilling any feedings or
medications or if there are concerns about other forms of assessment
ii. recommended practice is to aspirate gastric contents and check if pH is
acidic (pH should be below 6)
iii. injecting ten mL air into nasogastric tube (NG tube) and listening with
stethoscope for rush of air over stomach is no longer an accepted method
to verify placement
administer enteral feeding
i. may be continuous or intermittent
ii. to prevent bacterial growth, change bag and tubing every 24 hours and
tube feeding formula every 4 to 8 hours
iii. to prevent fluid and electrolyte imbalances, administer tube feedings at a
rate of no more than 300 mL/hr
assess gastric residual
i. every 4 hours if continuous feeding or
ii. before you begin intermittent feedings
xviii. tube feeding formulas: Vivonex®, Isocal, Portagen®, etc.
xix. complications
aspiration
gastrointestinal complications (diarrhea)
electrolyte or metabolic problems
xx. Nutritional supplements and liquids for dehydration or diarrhea
infants: Infalyte, Pedialyte®, Ricelyte®
older children: sports electrolyte replacement drinks
infant formulas: standard and high-calorie
specialty formulas:
i. predigested, e.g., Pregestimil, Nutramigen
ii. high-calorie supplements, e.g., Scandishake, Carnation Instant Breakfast
xxi. Parenteral nutrition: see Lesson 6 of this course
xxii. Measures to improve nutrition intake of client
frequent small feedings
feeding assistance
offering preferred foods
ethnic foods
It is more productive to review materials frequently in short
intervals, such as one-to-two hours at a time. Be sure to take a
short break every half hour or so.
Mobility
A. Prevent complications of immobility
1. Skin changes - decubitus ulcers
a. turn and reposition client every 2 hours
b. use heel/elbow protectors
c. use alternate pressure mattress or other skin care devices
d. do not massage reddened areas; doing so increases potential damage to
tissues

11. e. limit sitting in a chair to 2 to 4 hours or as tolerated with a shift in weight at
least every 30 to 60 minutes
2. Musculoskeletal changes, especially contractures
a. perform range of motion exercises to joints on a scheduled basis daily
b. provide foot board and/or foot cradle or high-topped tennis shoes to prevent
foot drop
c. reposition every 2 hours
d. maintain correct body alignment
3. Respiratory changes - pneumonia, atelectasis
a. instruct client to cough and deep breathe every 2 hours, or more frequently
b. turn every 2 hours
c. suction if needed
d. chest physiotherapy (percussion & drainage) as ordered
4. Cardiovascular system changes-decreased cardiac output, clots,emboli
a. orthostatic hypotension
i. instruct client to change position slowly, moving progressively from
lying to sitting to standing position
ii. highest risk is from supine to standing position
b. increased cardiac workload
i. instruct client to avoid bearing down (Valsalva's maneuver)
ii. minimize coughing
iii. limit sitting in high Fowler's position to 1 to 2 hours
c. thrombus/emboli formation
i. apply thigh or knee-high anti-embolic stockings as ordered and/or
intermittent pneumatic compression devices
ii.turn every 2 hours
iii.monitor anticoagulation therapy, as indicated
iv. initiate ambulation or assist client with dorsiflexion and plantar flexion
of the foot
v. limit sitting with feet in a dependent position to 1 to 2 hours
5. Urinary changes

12. a. renal, calculi, urinary tract infection, glomerular nephritis
b. increase fluid intake (2000 to 3000 mL/day)
6. Psychosocial changes
a. interact with client and orient as needed
b. develop and follow mutually agreeable activity schedule with client to help
maintain mental sharpness
B. Types of exercise
1. Passive: carried out by the health care provider without assistance from client;
purpose is to retain joint mobility and blood circulation
2. Resistive: carried out by the client working against resistance; purpose is to increase
muscular strength; enhance bone integrity
3. Isometric: carried out by the client with no assistance by contracting muscle group for
ten seconds and then relaxing muscle group; purpose is to maintain muscular
strength when the joint is immobilized
4. Range of motion (ROM): joint is moved through entire range of motion; purpose is to
maintain joint mobility
Use of mechanical aids to promote mobility
1. Crutches - provides support and assists ambulation for people with weight-bearing
restrictions
a. keep tips of crutches 8 to 12 inches to side of feet
b. adjust handbars to allow 15 to 30 degrees of elbow flexion
c. use well fitting shoes with nonslip soles
d. use non-skid, rubber tips on crutches
i. inspect weekly
ii. replace when worn
e. may be used temporarily or permanently
f. teach client crutch walking
2. Cane - provides stability when walking and relieves pressure on weight-bearing joints
a. adjust cane with handle at level of greater trochanter, elbow flexed at 30 degree
angle
b. teach client to hold cane close to body, and hold in hand on stronger side
c. move cane at same time as the weaker leg
3. Walker - provides support, stability, and balance for people without weight-bearing
restrictions
a. client must be strong enough to pick walker up and move it forward before taking the
next step (walkers with wheels are available for clients who are not strong enough to
lift a walker but who can slide it forward)
b. teach client how to sit, stand and turn
c. do not allow client to place hands on walker to stand from sitting position (it is
unstable)
4. Gait belt
a. usually a canvas belt, with or without handles, positioned over the client's clothing
b. the gait belt should fit tightly around the waist
c. safety devices for ambulatory clients who may have some balance problems
5. Prosthetic devices - used to replace a missing body part
6. Brace - support for weakened muscles
7. Elimination
a. Promotion of normal elimination
i. Urination
1. adequate fluid intake

13. 2. adult urinary output - minimum 30 mL/hour
3. alternative methods to promote client voiding include running water
ii. Bowel elimination
1. adequate fluid intake
2. regular exercise
3. regulate fruit juices, raw fruits and vegetables as needed
4. normal bowel evacuation varies in healthy individuals; no more than 3
movements per day to 3 times a week
b. Urinary incontinence: involuntary release of urine
i. Types
1. stress incontinence: sudden increase in intra-abdominal pressure
(such as sneezing, coughing) causes urine to leak from bladder
2. overflow (reflex) incontinence: bladder empties incompletely, so urine
dribbles constantly
3. urge incontinence: uncontrolled contraction of the bladder results in
leakage of urine before one reaches the bathroom
4. functional incontinence: incontinence not due to organic reasons; for
instance, impaired mobility may prevent the client from reaching the
bathroom in time
Remember the reversible causes of urinary incontinence using the
mnemonic D.R.I.P.
D elirium
R estricted mobility (or Retention [urinary])
I nfection (or Inflammation or Impaction [fecal])
P harmaceuticals (or Polyuric states)
2. Diagnosis of urinary incontinence
a. history and physical examination
b. urinalysis - tells whether blood or infection present
c. cystoscopy - tells whether abnormalities are present
d. post-void residual - measures amount of urine remaining in bladder after voiding
e. stress test - determines if urine leaks after bladder is stressed due to coughing,
lifting etc.
3. Treatment
a. pharmacologic therapy
i. antispasmodics and anticholinergics - relax and increase capacity of bladder
ii. alpha-adrenergic agonists - increase urethral resistance
b. Kegel exercises strengthen weak muscles around the bladder
c. behavioral training - client learns different way to control urge to urinate
d. bladder retraining
e. surgery - repair of weakened or damaged pelvic muscles or urethra
4. Nursing interventions
a. provide skin care, protective undergarments
b. establish toileting schedule - provide easy access to bathroom and privacy
c. teach client Kegel exercises:
i. stop and start urinary stream while voiding
ii. hold contraction for 10 seconds and relax for 10 seconds
iii. work up to 25 repetitions three times a day

14. d. prevent infection
i. cleanse urethral meatus after each void
ii. acidify urine
iii. increase daily intake of fluids
Learn more about incontinence from the National Association for
Continence
C. Catheterization
1. Purposes
a. relieve acute urinary retention
b. relieve chronic urinary retention
c. drain urine preoperatively and postoperatively
d. accurately measure output in the critically ill
e. continuous or intermittent bladder irrigation
2. Types of catheters and general guidelines
a. indwelling catheter
i. use a closed drainage system
ii. advance catheter almost to bifurcation of catheter, especially in male
clients
iii. inflate balloon within guidelines of manufacturer only after urine is
draining properly, then slightly withdraw catheter
iv. secure catheter to patient's thigh, allowing for some slack to
accommodate movement and to lessen drag on patient; ensure
tubing is over client's leg
v. monitor intake and output
vi. care of indwelling catheter:

15. cleanse around area where catheter enters urethral meatus,
using soap and water
catheter care should be done during the daily bathing routine
and after defecation
do not pull on catheter while cleansing
do not use powder or spray around perineal area
maintain a closed drainage system
avoid raising the drainage bag above the level of the bladder
avoid clamping the drainage tubing
catheter is only irrigated when an obstruction, usually
following prostate or bladder surgery when blood clots are
anticipated
remove catheter when no longer medically necessary - use a
decision-making algorithm for determining when to remove
the catheter
The Centers for Disease Control and Prevention (CDC) Guideline
for Prevention of Catheter-associated Urinary Tract Infections
(CAUTI) is an excellent resource for the prevention of CAUTI.
Listen to a CDC podcast about catheter-associated CAUTIs.
b. suprapubic catheter
i. placed to drain the bladder
ii. achieved via a percutaneous catheter or by way of an incision through the
abdominal wall
c. intermittent self-catheterization
i. purpose: to drain the bladder
ii. employed by the client with spina bifida and other neuromuscular diseases; can
be taught to children ages 6 to 8 years-old
iii. procedure:
gather equipment: catheter, water-soluble lubricant, soap, water, urine
collection container
wash hands
cleanse urethral meatus and surrounding area
lubricate tip of catheter
insert catheter until urine flows
withdraw catheter when urine flow stops
clean off residual lubricant from meatus
dispose of urine
wash hands
Ostomies
1. Types of ostomies
a. ileostomy
i. liquid to semi-formed stool, dependent upon amount of bowel removed
ii. may skew fluid and electrolyte balance, especially potassium and sodium
iii. digestive enzymes in stool irritate skin

16. iv. do not give laxatives
v. ileostomy lavage may be done if needed to clear food blockage
vi. may not require appliance; if continent ileal reservoir or Kock pouch
b. colostomy
i. ascending - must wear appliance - semi-liquid stool
ii. transverse - wear appliance - semi-formed stool
iii. loop stoma
proximal end - functioning stoma
distal end - drains mucous
plastic rod used to keep loop out
usually temporary
iv. double barrel
2 stomas
similar to loop but bowel is surgically severed
v. sigmoid
formed stool
bowel can be regulated so appliance not needed
may be irrigated
2. Stoma assessment
a. color - should be same color as mucous membranes
b. edema - common after surgery
c. bleeding - slight bleeding common after surgery
3. Psychological reaction to ostomy
a. disturbed body image
b. anxiety related to feared rejection
c. ineffective coping related to ostomy care
Sleep
A. Factors affecting sleep

17. 1. Physical illness
2. Drugs
3. Lifestyle
4. Excessive daytime sleep
5. Emotional stress
6. Environment
7. Exercise/fatigue
8. Food intake
B. Sleep disorders
1. Bruxism: tooth grinding during sleep
2. Insomnia: chronic difficulty with sleep patterns
a. initial insomnia: difficulty falling asleep
b. intermittent insomnia: difficulty remaining asleep
c. terminal insomnia: difficulty going back to sleep
3. Narcolepsy: fall asleep without warning
4. Sleep apnea: intermittent periods of not breathing while asleep
a. usually due to problems with upper airway
b. can be treated with a continuous positive airway pressure (CPAP) machine at
bedtime
5. Sleep deprivation: decrease in the amount and quality of sleep
6. Somnambulism: sleepwalking, night terrors, or nightmares
7. Depression
a. secondary to disease process
b. can occur with any sleep disorder
C. General nursing interventions for promoting restorative sleep
1. Comfort measures
2. Pharmacologic: sedatives, hypnotics
3. Sleep routine
4. Encourage daytime activity
5. Eliminate naps

18. 6. Relaxation techniques
7. Environmental control
8. Limit alcohol, caffeine, and nicotine in evening
D. Pain
1. Theories of pain
a. Specificity theory proposes that pain can be initiated only by painful stimuli
b. Pattern theory - stimulus goes to receptors in the spinal cord, which signals
the brain to perceive pain and muscles to respond.
c. Gate control theory - pain impulses can be altered or regulated by gating
mechanisms along nerve pathways;it explains how past and present
experiences can influence the perception of pain
2. Variables influencing the perception of pain
a. Culture and social groups shape attitude towards pain
b. Religious beliefs regarding reasons for pain
c. Previous experience with pain
d. Age
e. Gender
f. Coping style
g. Family support
3. Types of pain
a. Acute pain
A. may last up to 6 months
B. due to an identifiable cause, for example, surgery, injury, trauma
C. if not relieved can lead to chronic pain conditions
D. clients may exhibit changes in vital signs
b. Chronic pain
A. lasting beyond the expected healing period
B. lasting longer than 6 months
C. intermittent or constant
D. cause is not easily identified since physical evidence may not be
evident
E. changes in vital signs may not occur
F. affects all areas of a patient's life
G. often associated with depression
PainEdu.org includes standards of care, interactive learning
activities with case studies and resources for pain management.
American Society of Pain Management Nursing is used by nurses
for education, resources, and to access pain management
courses.
The American Chronic Pain Association provides resources and
coping strategies for those affected by chronic pain. Be sure to
refer to the Relaxation Guide.
Medical treatment
1. Pharmacologic intervention (discussed in Lesson 6: Pharmacological and Parenteral
Therapies)

19. 2. Complementary and alternative therapies: used not only for pain management but to
improve sleep, reduce anxiety, improve mood, and increase the patient's sense of control
over the environment
a. Acupuncture
i. several methods of stimulation at specified body sites, including, insertion of
fine needles or electro stimulation or laser beams or ultrasound waves
ii. despite being one of the most widely researched of all CAM/complementary
and alternative therapies it remains unknown how acupuncture works
physiologically
b. relaxation techniques - biofeedback, visualization, meditation and hypnosis
c. electronic stimulation such as transcutaneous electric nerve stimulation (TENS) -
electrodes applied over the painful area or along nerve pathway
d. distraction - focusing client's attention on something other than pain; more useful with
short term pain rather than long term pain
e. massage - generalized cutaneous stimulation of the body
f. cooling and heating therapies
i. uses for cooling or heating vary with the origin of the pain
ii. cooling or heating are both useful for well-localized pain
iii. ice may decrease prostaglandins which intensify the sensitivity of pain
receptors
g. guided imagery
i. mental images imagined by the patient or suggested by the clinician may be
used for relaxation or distraction
ii. some methods of imagery are designed to reduce pain
h. music therapy
i. uses rhythmic sound to create a feeling of well-being, encourage healing,
enhance relaxation
ii. includes singing, moving to music, listening, creating music, drumming solo
or group drumming

20. i. osteopathic manipulation: takes the perspective that structure directly influences
function and uses physical manipulation to stimulate the body's self healing
j. yoga: promotes health and wellness through integration of body, mind, and spirit
i. useful in circumstances of chronic pain
ii. useful for any patient age group
iii. may be adapted for use by patients with physical limitations
3. Nursing interventions in pain
a. assess using pain assessment scale (faces for children or cognitively impaired
[Wong-Baker FACES scale] or number scale ranging from 0 to 10)
b. assess client's coping strategies and factors that produce ineffective coping
c. teach client appropriate strategies to deal with pain
Communication
A. Cross-cultural communication guidelines
1. Findings of a nontherapeutic communication
a. efforts to change the subject - client may not understand what the nurse is
saying
b. lack of questions - client may not understand what was said
c. nonverbal cues - blank expression, lack of eye contact
2. Nursing interventions and therapeutic communication
a. use simple sentence structure and gestures while talking
b. use visual aids
c. discuss one topic at a time
d. use any words you know in the client's language
e. use a medical interpreter service for verbal communication - avoid using
family members as interpreters
f. obtain phrase books or use flash cards
3. Cultural interpretations
a. silence
b. touch
c. eye contact
B. Client with hearing loss
1. Findings of hearing loss
a. speech deterioration
b. indifference
c. social withdrawal
d. suspicion
e. tendency to dominate conversation
2. Nursing interventions
a. speak slowly and distinctly; do not shout
b. face client directly
c. make sure your face is clearly visible
d. before the discussion, tell client the topic you are going to discuss
e. insure that client has access to hearing aid and that it is functional
f. keep sentences short and simple
g. use written information to enhance spoken word
C. Client with aphasia
1. Injured cerebral cortex blocks some language-related functions
2. Types of aphasia
a. global aphasia: individuals can neither read nor write

21. b. Broca's aphasia ("non-fluent" aphasia): speech is affected; the client may
understand speech and be able to read but has limited writing ability
c. Wernicke's aphasia ("fluent" aphasia): inability to understand the meaning of
spoken words and reading and writing is impaired; able to speak but speech
is not normal
3. Nursing interventions
a. face client and establish eye contact
b. avoid completing client's statements
c. use gestures, pictures, and communication boards
d. limit conversation to practical matters
e. use the same words and gestures for objects
f. keep background noise to a minimum and turn off competing sounds, e.g.,
radio, television
g. do not shout or speak loudly
h. give the client time to understand and respond
i. if client has problems speaking, ask "yes" or "no" questions
When you are taking the NCLEX-RN® exam, NEVER guess!
Instead, maintain a reasonable pace (no more than one to two
minutes on each item) and carefully read and consider each item
before answering.
D. Client with stroke
1. Approach client from side of intact field of vision
2. Remind client to turn head in direction of visual loss to compensate for loss of visual
field
3. Explain location of object when placing it near the client
4. Always put client care items in same places
5. Put objects within client's reach, and on unaffected side
6. Encourage client to repeat sounds of the alphabet
7. Speak slowly and clearly
8. Use simple sentences with gestures or pictures
9. Reorient client to time, place, and situation
10. Provide familiar objects
11. Minimize distractions
12. Repeat and reinforce instructions
E. Client with dementia
1. Be calm and unhurried
2. Keep conversations short and focused
3. Do not ask the client to make decisions
4. Be consistent
5. Avoid distractions
6. Use reality orientation techniques
Communication with individuals with aphasia or dementia is
enhanced if you remember
the K.I.S.S. technique: K eep I t S hort and S imple!
Alternative and Complementary Medicine

22. A. Herbal therapy
1. Used as dried herbs in capsules or tablets, tinctures, teas, ointments
2. Over 600 herbal products, many of which interact with prescribed drugs, particularly
cardiac drugs and antidepressants
3. St. John's Wort is the number one herbal product
a. interacts with over 60 percent of all prescription drugs
b. the interaction is to make drugs less effective, including digoxin,
cyclosporine tamoxifen, highly active antiretroviral therapies (HAART) and
combined oral contraceptives
4. Client assessment
a. ask client directly about use of herbal preparations including name of herb
and manufacturer, dosages, schedule, effectiveness, rationale for use
b. assess client's understanding of use of herbal preparations in conjunction
with traditional Western medications and assess for interactions, adverse
effects, effectiveness
B. Aromatherapy
1. Over 70 therapeutic grade essential oils currently available with more being
discovered and researched
2. Examples of essential oils: lavender, rose, peppermint, sandalwood
3. Methods of delivery
a. inhalation - for example, use of diffuser or humidifier
b. topical - for example, direct application of oil onto skin or in bath water
c. internal use - for example, in capsule form, use in cooking, taken with food
4. Used for physical, mental, emotional, and spiritual conditions, i.e., relaxation and
sleep; improved concentration and mental focus; soothing minor irritations and
inflammation; easing stress and despair; improving ability to visualize
5. May be used in conjunction with other modalities to increase their effectiveness
C. Therapeutic massage
1. Manipulates the soft tissue of the body and assists with healing
2. Physiologic effects: primarily improves circulation, oxygenation, perfusion
3. Research findings indicate: muscle relaxation, reduction of some types of pain,
sedative effect on nervous system, increased peristalsis, increased lymphatic
circulation
4. Can be relaxing or energizing
5. Is contraindicated for a client with phlebitis, thrombosis, varicose veins, diabetes,
pitting edema
D. Reflexology
1. Pressure applied to specific areas of the feet thought to correspond with all the
different parts of the body
2. Uses - relieves stress and muscle tension; promotes relaxation and sleep
3. Research - significant reduction of symptoms of premenstrual syndrome
E. Relaxation therapy
1. Examples
a. Rhythmic breathing
b. Progressive relaxation
c. Hypnosis with suggested deep relaxation
2. Relaxation response results in the following:
a. decreased oxygen consumption
b. decreased metabolism
c. decreased cardiac and respiratory rates
d. increased alpha brain waves associated with a feeling of well-being
e. decreased blood lactate (associated with skeletal muscle metabolism and
anxiety)

23. Explore: The Journal of Science and Healing is a bi-monthly
interdisciplinary periodical with free online access to full text
articles. Articles explore the relationship between health and the
healing arts, consciousness, spirituality, eco-environmental issues,
and basic science.
F. Hypnosis: used in the treatment of many disorders, including osteoarthritis,
rheumatoid arthritis, sciatica, whiplash, chronic pain; also used to replace traditional
surgical anesthesia
G. Yoga
1. Treatment of the mind-body connection
2. Can tone the muscles that balance all parts of the body and control the emotions and
mind through correct posture and breathing
H. Acupuncture - a traditional Chinese therapy using tiny needles placed in the skin to
help regulate the flow of (qi) vital energy through the body
Nutrition & Fluid Intake
All individuals require the same nutrients, but the amounts vary according to factors such
as age, weight, activity level, and health state.
The energy value of foods is defined in calories; only proteins, fats and carbohydrates
provide calories.
Essential amino acids cannot be synthesized; they must be ingested daily.
Weight is maintained when daily food intake equals energy expenditure.
Weight loss is a long-term process and patients need long-term support.
Increased fiber in the diet may cause flatulence.
The normal thirst mechanism in the elderly may be diminished and they may need
encouragement to drink sufficient water to prevent dehydration.

24. The average adult drinks 2 to 3 liters of water per day.
Normal lab values to know:
Sodium: 135 - 145 mEq/L
Potassium: 3.5 - 5.1 mE1/L
Chloride: 98 - 107 mEq/L
Bicarbonate: 22 - 29 mEq/L
Elimination
In constipation, increase fluid to 3000 mL/day (unless contraindicated).
Small frequent loose stools or seepage of stool are often indicative of a fecal impaction.
Use transparent drainage bag initially for assessment of stoma and drainage.
Avoid foods that cause odor, gas, diarrhea, or may block ileostomy.
The majority of residents in nursing homes are incontinent but incontinence is not a
normal sequela of aging.
Pain
Allow the client to rate the degree of pain (typically using a 10 point scale) and later to
assess (and chart) degree of relief from pain relief measures.
Self-control methods to manage pain: distraction, massage, guided imagery, relaxation,
biofeedback, and hypnosis.
Initiate pain relief before the pain becomes unbearable.
Patient controlled analgesia (PCA) is effective at controlling pain and avoiding the peaks
and valleys of nurse-administered narcotics; clients typically use less pain medication
overall than clients receiving nurse-administered narcotics.
Be sure to assess and monitor respiratory rate for client on PCA; have Narcan ready to
reverse effects of the narcotic.
Mobility
There should be at least two inches between axilla and top of arm piece of crutch to
prevent pressure on the brachial plexus.
Prevent deformities and complications such as contractures, thrombophlebitis, and
pressure ulcers by regularly turning and positioning the client in good alignment.
Discontinue ROM exercises at point of pain.
Use non-skid, rubber tips on crutches and canes to prevent slipping.