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NR226 Exam 2 study guide

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Calculate intake and output for a patient 30mL = 1oz  Sleep o Nursing diagnosis – 3 part (PES)  Etiology / contributing factors/causative factors  Signs and symptoms / assessment data ... o Assessment, Diagnose, Plan, Implement and Evaluation of sleep disorders o Tools for assessment  PSQI- Pittsburgh Sleep Quality Index  ESS- Epworth Sleepiness Scale  Fulmer SPICES: An Overall Assessment Tool for Older Adults  MNA- Mini Nutritional Assessment  Katz Index of Independence in Activities of Daily Living (ADL)  The Hendrich II Fall Risk Model- Fall Risk Assessment for Older Adults  Braden Scale- Predicting Pressure Ulcer Risk o Planning care for sleep disorders o Patient outcomes  Patient will take sleep meds as directed.  Patient will accomplish sleep SMART goal. o Nursing interventions  Asthma- Obtain a history of allergic reactions to medications before administering medications. Assess respiratory status. Assess the patient's respiratory status by monitoring the severity of symptoms, breath sounds, peak flow, pulse oximetry, and vital signs. Assess medications.  Apnea- The absence of respirations lasting for 15 seconds or longer.  Insomnia  Nocturia- Patient urinates at night. Not normal. o Age specific requirements and patterns for all age groups o Sleep cycle/circadian rhythm  Stages- 1, 2, 3, 4 and REM (rapid eye movement) sleep. These stages progress cy [Show More]

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