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Ambulating Clients
◦ Ambulation: act of walking; function that most
people take for granted
Preambulatory Exercises
Assisting Clients to Ambulate
Mechanical Aids in Walking
◦ Canes
◦ Walkers
◦ Crutches
Collect date relevant to the outcome criteria
previously established by asking the client to
demonstrate specific exercises, measure
muscle size, observe client’s activity
tolerance when performing self-care
activities, measure vital signs before and after
exercise and ambulation.. Etc.
AUGUST 20, 2013
© FUNDAMENTALS OF NURSING 5TH EDITION
Implies calmness, relaxation
without emotional stress, and
freedom from anxiety.
Restores a person’s energy;
allowing the individual to resume
optimal functioning.
Considered to be a basic human need
It is a universal process common to all
people.
More recently, sleep has come to be
considered a state of consciousness in which
the individual’s perception and reaction to
the environment is decreased.
Circadian Rhythm
◦ Biorhythms – In humans, these are controlled from
within the body and synchronized with
environmental factors.
◦ Circadian from circa dies, “about a day”
◦ The person is awake when the physiologic and
psychologic rhythms are most active.
Stages of Sleep
◦ Electroencephalogram (EEG) – provides a good a
picture of what occurs during sleep.
◦ Two types of sleep: NREM (Non-REM) sleep and REM
(Rapid Eye Movement) sleep
◦ NREM Sleep
Also referred to as slow-wave sleep
Most sleep during a night is NREM sleep.
Deep, restful sleep and brings a decrease in some
physiologic functions
Divided into four stages: Stage I (Very light sleep);
Stage II (Light sleep); Stage III (Parasympathetic
nervous system domination); Stage IV (deep sleep)
◦ REM Sleep
25% of the sleep of a young adult.
Most dreams take place during the REM sleep.
Brain is highly active (paradoxical sleep)
As the person becomes more rested through the
Sleep Deprivations
◦ prolonged sleep disturbances; not a sleep disorder
Sleep History
◦ Usual sleeping pattern
◦ Bedtime rituals
◦ Use of sleep medications
◦ Sleep environment
◦ Recent changes in sleep patterns or difficulties in
sleeping.
Sleep Diary
Physical Examination
Diagnostic Studies
◦ Polysomnography; EEG; Electromyogram (EMG);
Electro-oculogram (EOG)
NANDA nursing diagnosis given to clients
with sleeping problems: Sleep pattern
disturbance.
Maintain/develop a sleeping pattern that
provides sufficient energy for daily activities.
Interventions include reducing environmental
distractions; promoting bedtime rituals;
providing comfort measures; scheduling
nursing care to provide uninterrupted sleep
periods…etc.
Creating a restful environment
Supporting Bedtime Rituals
Promoting Comfort and Relaxation
Administering Sleep Medications
Client Teaching
To evaluate whether client outcomes have
been achieved, the nurse may observe the
duration of the client’s sleep, observe the
client’s signs of REM and NREM sleep
deprivation, question effectiveness of specific
interventions…etc.