Download Assessing Activities of Daily Living and Sleep Patterns

Assessing Activities of
Daily Living and Sleep
Patterns
Practicum of Health
Science Technology 2009 2010
Objectives
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Discuss the importance of balance between
activity and sleep in a patient’s life
Describe the factors affecting activities of
daily living
Identify interview questions used to assess
personal care, family responsibility, work,
school, recreational, and socialization
activities for an adult and for a child.
Describe rapid eye movement sleep and the
four stages of non-rapid eye movement
sleep
Objectives
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Describe the factors affecting sleep
Compare and contrast disorders of
initiating and maintaining sleep,
disorders of excessive sleepiness,
disorders of the sleep-wake cycle, and
parasomnias
Phrase representative interview
questions that assess a client’s sleep
patterns
Introduction
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Maintaining a constant balance
between daily activities and
sleep is vital to the promotion
and maintenance of physiologic
and psychosocial health.
Daily activity affects a person’s
ability to sleep soundly, and in
turn, the quality of sleep affects
a person’s ability to carry out
daily activities
Activities of Daily Living
(ADLs)
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Include five components:
- Personal Care
- Family Responsibility
- Work or School
- Recreation
- Socialization
Factors Affecting ADLs
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Age
Developmental status
Culture
Physiologic health
Cognitive function
Psychosocial function
Stress level
Biological rhythms
Age & Developmental Status
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A client’s age and developmental status
provide clues to the patient’s interests
and abilities, as well as how the patient
may react to an inability to perform ADLs
When progressing from infancy to
adulthood, an individual gradually shifts
from dependence to independence in
performing the five ADL components
Assess the clients age and developmental
level when assessing the level of
independence and ability to assume
responsibility for ADLs.
Culture
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A person’s culture – learned values,
beliefs, customs, and behaviors –
affects interests and roles, sometimes
depending on sex.
Remember, a groups values, and
beliefs can change over time, allowing
altered roles and relationships.
Determine the influence of a person’s
cultural heritage as well as any
changes in values and customs when
assessing ADLs
Physiologic Health
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A patient’s physiologic health
affects the ability to participate
in ADLs, consider the functional
status of each body system when
performing as assessment
Cognitive Function
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Cognitive function refers to the
process of perceiving,
organizing, and interpreting
sensory stimuli to think and
solve problems
Mental processes contributing to
cognitive function include:
attention, memory, and
intelligence.
Cognitive Function
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An alteration in any aspect of
cognitive function may interfere with
logical thinking or abstract reasoning
and therefore prohibit independent
performance of ADLs
During ADL assessment, analyze the
patient’s level of cognitive function,
then use that information to
formulate questions and to structure
teaching in a manner appropriate to
the patient
Psychosocial Function
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Refers to a person’s ability to
process past and present
information in a manner that
provides a realistic view of
oneself, one’s life, and others
Process involves a complex
interaction between
intrapersonal and interpersonal
behaviors
Intrapersonal Behaviors
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Those caused by an altered self
concept or emotional instability
Interpersonal Behaviors
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Communication problems,
impaired social interactions, or
dysfunctions in role performance
Stress Level
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Stress is a nonspecific, physical
response to any king of demand
The factors that produce stress are
called stressors, can originate from
within the body or from the
environment and can disrupt the
body’s equilibrium
Stressors can be physiologic, such as
injury, or psychological, such as the
loss of a loved one.
Stress Level
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Stress is necessary for normal
growth and development
It can have negative and positive
effects on a patient’s ability to
participate in ADLs
Positive vs Negative
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Whether a stressor produces positive or
negative results depends on several
factors, the first is perception.
Magnitude or the intensity of the stressor
affects the patient’s response
The number of concurrent stressors as
well as their frequency and duration also
affects the type of response
Experience with stress and past coping
measures influence how a patient will
face new stressors.
Assessment
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Stress affects people of all ages
and affects a patient’s stress
level is essential
To perform an accurate
assessment, evaluate the
characteristics of the stressor,
determine the patient’s
perception of the stressor, and
discover the patient’s method of
coping.
Biological Rhythms
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Rhythmic biological clocks, known
as biological rhythms, help
patients adjust to the surrounding
physical environment and maintain
internal homeostasis
Various biological rhythms
beginning by the third week of life
and continuing thereafter, operate
on cycles of hours, days or months
Biological Rhythms
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One type of rhythm, called a
circadian rhythm, operates on a
cycle of approximately 24 hours
Different circadian rhythms help
regulate biological and
behavioral activities, including
sleep and wakefullness, body
temperature, and hormone
levels.
Biological Rhythms
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Many factors contribute to an
individuals circadian rhythm
- Environmental
- Social
Environmental Factors
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Environmental factors such as
the hours of daylight and
darkness and the seasons of the
year regulate many daily
actitivies
These environmental cues
establish the appropriate times
to eat, work, and relax
Social Factors
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Social factors such as work or school
schedules, household routines, and social
activities also influence circadian rhythms
Hospitalization, shift work, or stress can
disrupt these circadian rhythms and can
result in physical illness, psychological
discomfort, or impaired cognition
Disrupted circadian rhythms can
compromise the muscle strength and
coordination required to perform a task or
the attention, memory, and concentration
needed to complete an activity
Once disrupted, a circadian rhythm may
require up to several weeks to return to
normal
Assessing ADLs
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During the interview, the health care
professional uses observation to
gather information on ADLs.
During the interview gather data from
the patient and family members, and
focus on their perceptions of the
patient’s ability to perform ADLs, and
identify the patient’s and family’s
goals for functioning.
Assessing ADLs
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Determine whether the patient and the
family have realistic views, have developed
attainable goals, and have similar
perspectives
Observe the patient performing ADLs when
possible
Use the assessment to ascertain the
patient’s functional status in performing
ADLs
Determine whether the patient can function
independently, if the client requires
assistance of a person or device, or if the
patient depends totally on others
Assessing ADLs
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If the patient needs assistance,
determine the amount and type
required
If the patient depends on
devices, inquire about the type of
device and its adequacy in
resolving the problem
Also evaluate the possible need
for other devices
Questions and Rationales
Personal Care Activities
Do you have any difficulty
standing, walking, or
climbing stairs? Can you
get in and out of a chair?
Can you get in and out of
bed? What assistive
devices do you use to aid in
mobility?
Rationale
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An alteration in mobility may
hinder a patient’s ability to
engage in other ADLs.
Can you open packages and
containers? Can you use
utensils for eating? Can you
cut your food? Do you have
any other problems feeding
yourself? What times do you
usually eat? Who prepares
your meals? Where do you eat
your meals? With whom do
you eat?
Rationale
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These questions help investigate
the patient’s ability to prepare
meals and to eat independently.
The ability to feed oneself is an
important personal care activity
Can you use the toilet alone, or do
you require assistance? Do you
have any problems with bowel or
bladder control? If so, how do you
manage these problems? Do you
use any assistive devices for
elimination, such as catheters or
colostomy bags? If so, can you
care for these devices? How have
elimination problems affected your
other activities?
Rationale
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An elimination problem can interfere
with work, school, recreational, and
socialization activities
These questions give the patient the
opportunity to discuss problems,
fears, and anxieties regarding
elimination, and give the health care
provider an opportunity to teach the
patient or family ways to manage
these problems.
Do you have any difficulties
with dressing and grooming?
If so, are these problems more
pronounced on the left side,
the right side, the upper part,
or the lower part of your body?
Can you fasten buttons, snaps
and zippers? Is dressing
easier with certain types of
clothing?
Rationale
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Musculoskeletal or
nueromuscular abnormalities can
disrupt fine or gross motor
coordination, making dressing
and grooming activities that
adults perform independently
difficult for the patient
Family Responsibilities
What are your living arrangements? Does your
home need structural changes so that you can fulfill
your family responsibilities and perform ADLs? Do
you have any problems with food management,
such as shopping or food preparation? Can you
complete your own laundry? What type of cleaning
can you do? Are you having any difficulties
managing your money, such as getting to a bank?
Does your family responsibility include caring for
any sick or disabled persons in the home? If so, do
you have any difficulties with this role? Do you
care for a pet in your home?
Rationale
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These questions help investigate the
structure and composition of the
patient’s family, the patient’s
developmental status, and the
responsibilities the patient has
assumed in the family
A client who cannot perform usual
family responsibility activities may
develop role and relationship
problems
Work and School Activities
What does your typical day involve?
Do you work outside the home?
Where and what type of work do you
do? How many hours per week do you
work? What is your work schedule
like? Do you have any conflicts
between your work schedule and other
responsibilities or ADLs? What is your
job like? Is work mainly a source of
satisfaction or frustration? Do you
participate in any volunteer work?
Rationale
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These questions help investigate
the type of work the client
participates in and the role of
work in the client’s life
A client with a heavy, stressful
work schedule may feel that he
or she is neglecting family and
self, causing guilt feelings that
add to the stress
What do you see yourself
doing in the future? How do
you feel about retirement?
What plans have you made
for retirement?
Rationale
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These questions help investigate
the patient’s point of view of
retirement, including alterations
in ADLs caused by retirement
Are your going to school?
If so, where and for what
purpose? What do you like
most about school? What
do you like least about
school? Do you have any
difficulties balancing school
activities with other life
responsibilities?
Rationale
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These questions help investigate the
nature and demands of any
schoolwork in which the client
participates, and help assess the
effects of school on other activities
A patient’s whose school activities
interfere with personal care activities,
family responsibilities, or work
activities may benefit from counseling
Recreational Activities
What do you do when you are
not working or in school? How
so your days off differ from
your work or school days?
How much recreational time do
you have in a day and in a
week? Are you satisfied with
the amount of recreational time
and what do you do during that
time?
Rationale:
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These questions help investigate
the type, amount, timing, and
purpose, and benefits of the
client’s recreational and physical
exercise activities. A decrease
in the usual activity levels may
results from a physical disorder,
and may lead to an emotional
problem, such as depression.
Socialization Activities
What kinds of things do you do
when you are alone? Can you use
a phone, write clearly, and see well
enough to enjoy reading or
watching television? Do you have
any close friends? Who would you
confide in if you had a problem?
Do you depend on your family to
help? Do you belong to any social
groups?
Rationale:
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These questions help investigate
the client’s role in society, the
structure of the client’s social
network, and any barriers to
socialization the client may have.
Illness, relocation, or the loss or
change of job can disrupt the
client’s usual social network,
leading to social isolation,
loneliness, and depression.
Sleep Patterns
What is sleep?
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Sleep is defined as a recurrent,
altered state of consciousness
that occurs for sustained periods.
What are some factors that
promote rest?
Conditions for Proper Rest
Physical Comfort:
 Eliminate sources of physical
irritation
 Control pain
 Control room temperature
 Maintain proper anatomical alignment
 Remove environmental distractions
 Provide adequate ventilation
Conditions for Proper Rest
Freedom from worry:
 Make own decisions
 Participate in personal health
 Have knowledge needed to
understand health problems and
implications
 Practice restful activities regularly
 Know that the environment is safe
Conditions for Proper Rest
Sufficient Sleep:
 Obtain hours of sleep needed to
feel refreshed
 Follow good sleep hygiene habits
Sleep Regulation
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The control and regulation of
sleep may depend on the
interrelationship between two
cerebral mechanisms that
intermittently activate and
suppress the brain’s higher
centers to control sleep and
wakefulness.
Reticular Activating System
(RAS)
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Located in the upper brain stem
Contains special cells to maintain
alertness and wakefulness
Receives visual, auditory, pain, and
tactile sensory stimuli
Activity from the cerebral cortex also
stimulates the RAS
Wakefulness results from neurons in
the RAS that release catecholamines
such as norepinephrine
Bulbar Synchronizing
Region(BSR)
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Sleep is produced by the release of
serotonin from specialized cells in the
pons and medial forebrain.
Whether a person remains awake or
falls asleep depends on a balance of
impulses received from higher
centers, peripheral sensory receptors,
and the limbic system
As people try to fall asleep stimuli to
the RAS declines and at some point
the BSR takes over.
Sleep Stages
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Most adults fall to sleep in about
15min, experience two to three
brief arousals during the night,
and then awake 6 to 10 hours
later
During sleep a person moves
about every 15 to 30 minutes,
remains immobile for 10 to 30
minutes, and then moves again
Sleep Stages
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Movement and short arousals
often occur with changes in sleep
stages
Two types of sleep occur:
- Rapid eye movement (REM)
- Non-rapid eye movement
(NREM) – occurs in 4 stages
Sleep stages occur in a repetitive
cycle throughout the night.
Sleep Stages
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Most adults
experience four
to six complete
sleep cycles per
night
NREM Sleep: Stage 1
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Marks the transition between
sleep and wakefullness
Eyes move in a slow, rolling
fashion; thinking slows;
reactions to external stimuli
decrease; and movement
becomes episodic and
involuntary
Constitutes 5 – 10% of normal
sleep
NREM Sleep: Stage 2
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Occurs within 1 to 7 minutes of
the onset of sleep
Thinking becomes fragmented
If awakened from this stage,
people correctly report they have
been sleeping
Constitutes approximately 50%
of nightly sleep
NREM Sleep: Stage 3 and 4
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30 to 45 minutes after the onset
of sleep
Last 15 to 30 minutes
During this period, people are
difficult to arouse, and once
awake, may need a few moments
to become alert and oriented
Compose 10 to 20% of nightly
sleep
REM Sleep: Dreaming Sleep
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Occurs approximately 75 to 90
minutes after sleep onset
Has decreased or absent muscle tone
Displays rapid eye movement
Person experiences dreams, thinks
illogical or bizarre thoughts
Body temperature drops, and the
respiratory rate, heart rate, and blood
pressure change
Occupies 20 – 25% of nightly sleep
Factors that affect sleep
patterns:
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Age
Exercise
Smoking
Caffeine
Alcohol
Diet
Environment
Emotional factors
Physical illness
Age
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Sleeping patterns change over
lifespan
Spend less time sleep as you get older
Infants sleep 16 – 20 hours a day
6 months old – 16 hours a day
Age four 10 – 12 hours
Age ten 9 – 10 hours
Adolescence – 7.5 hours
Adults – few problems until age 35
Older adults – increase sleep in
daytime
Exercise
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May inhibit
sleep if right
before bedtime
Little evidence
that exercise
improves sleep
Smoking
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Tobacco alters
normal sleep
patterns
Smokers require
almost twice the
amount of time to
fall asleep than
non-smokers
Lighter sleep with
more frequent
arousals
Caffeine
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Decrease the
amount and
quality of sleep
Elderly patients
experience a
reduction in
sleep by 2
hours
Alcohol
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Decreases arousals
during the first half
of the night, and
increases the number
of arousals during
the second half
Decreases REM sleep
and makes it more
fragmented
Diet
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A person gaining
weight may sleep
longer and deeper
than normal
A person losing
weight may sleep for
shorter periods of
time and may have
more fragmented
sleep
Environment
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Noise is the most disruptive
Occasional loud noise is more
disruptive than a constant noise
Episodic noise disrupts sleep and
increases the amount of Stage 1 sleep
When temperature rises above 75°F
individuals have reduced REM and
Stage 3 and 4 Sleep, wake more
often, move more frequently, and
sometimes have a greater dream
recall
Environment
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Cool temperatures below 54°F,
can produce unpleasant and
emotional dreams
Sleep improves in quiet
surroundings, in a comfortable
bed, and without light and noise
Familiar surroundings also
facilitate sleep
Emotional Factors
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Mood and
expectations
strongly influence
sleep patterns
Acute and chronic
stress can
increase arousal
and inhibit sleep
Physical Illness
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Any illness that
cause pain,
physical
discomfort, or
mood problems,
such as anxiety
or depression
can result in
sleep problems.
Examples:
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Respiratory disease
Coronary heart disease
Hypertension
Nocturia
Restless leg syndrome
Peptic ulcer disease
Drugs and Substances
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Many drugs
and substances
have an affect
on the amount
and quality of
sleep patient’s
receive.
Sleep Disorders
Narcolepsy
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Characterized by abnormal sleep
tendencies and pathologic
manifestations of REM sleep
Brief attacks of sleep occur many
times a day, during times of
physical inactivity or when least
expected
Sleep Apnea
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Characterized by transient failure
to breathe during sleep
Three types: 1) central; 2)
obstructive; and 3) mixed;
Clients with any type of sleep
apnea that is untreated are at
risk for sudden cardiac arrest
Central Sleep Apnea
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Occurs when the client experiences
inadequate airflow through the nose
and mouth from an absence of
inspiratory effort
Ventilatory drive disappears, and
nerve impulses to the respiratory
muscles cease
Breathing recurs when nerve output
resumes
Obstructive Sleep Apnea
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Occurs when the client’s diaphragm
and chest wall move with changes
in intrathoracic pressure, but no air
flows through the mouth or nose
The upper airway collapses,
obstructing movement, and blood
oxygenation decreases
Episode terminates when arousal
restores muscle tone or when
increasing respiratory efforts
reopen the airway
Mixed Sleep Apnea
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Takes place when central and
obstructive sleep apneas occur in
a single episode of airflow
ccessation.
Insomnia
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Inability to sleep
May be transient or chronic
Subjective phenomenon
Most often affects female,
elderly, neurotic patients, thin,
smokers or people who drink
alcohol
Transient Insomnia
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Refers to insomnia of less than 3
weeks in duration
Usually occurs with a brief
illness, life crisis, new baby,
bereavement, hypnotic
withdrawal, travel or temporary
sleep deprivation.
Rapid recovery usually occurs
after a sleep disruption of 2 – 3
weeks
Chronic Insomnia
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May continue through life
Advanced age, medical,
behavioral, and psychiatric
problems frequently cause
prolonged difficulties in
obtaining restful sleep
May accompany another sleep
disorder, such as sleep apnea
Bruxism
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Teeth grinding during sleep
Can cause Temporomandibular
Joint Disorder which can cause
joint pain, clicking or popping of
joint, headaches, chronic ear
pain
Enuresis
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Chronic bedwetting
Involuntary urination during
sleep in an individual with
normal bladder control
Most children gain bladder
control by 3-4 years old; not
considered abnormal until they
are 5 and over.
Night Terrors
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Cause a sudden fearful partial
arousal from sleep during Stage
3 and 4
Upon awakening in the morning,
the client has no memory of the
episode
Affect children more often than
adults
Somnambulism
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Sleepwalking
Occurs at least once in
approximately 15% of all
children between ages 5 and 12
Most children outgrow this
behavior within 1 to 3 years
Adults rarely sleepwalk
Assessment
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Assessment is aimed at
understanding the characteristics
of any sleep problem and the
client’s usual sleep habits so that
ways for promoting sleep can be
incorporated into nursing care.
Visual Analog Scale
Sleep History
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Description of patient’s sleep
problem
Prior or usual sleep pattern
Bedtime routines and sleeping
environment
Use of sleep and other
prescription medications and
OTC drugs
Sleep History
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Pattern of dietary intake and
amount of substance(s) that
influence sleep
Symptoms experienced during
waking hours
Concurrent physical illness
Recent life events
Current emotional and mental
status.
Description of Sleeping
Problems
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Nature of the Problem
Signs and Symptoms
Onset and Duration
Severity
Predisposing Factors
Effect on Client
Planning
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Formulate diagnosis or nursing
diagnosis to determine plan of
care for patient.
Sleep pattern disturbance,
difficulty falling asleep related
to:
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Noisy environment
Arthritis pain
Sleep pattern disturbance,
frequent awakening related to:
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Concern over loss of job
Barbituate dependency
Risk for injury related:
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to acts of sleepwalking 2°
Somnambulism
Ineffective family coping:
compromised related to:
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Spouse’s/family’s poor
understanding of narcolepsy
Self-Esteem disturbance
related to:
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Incidents of bed wetting
Altered thought processes
related to:
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Sleep deprivation
Impaired gas exchange during
sleep related to:
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Altered oxygen supply
Ineffective breathing pattern
related to:
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Tracheobronchial obstruction
Goals of care plan:
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Client obtains sense of restfulness
and renewed energy following sleep.
Client establishes a healthy sleep
pattern.
Client understands factors that
promote or disrupt sleep
Client assumes self-care behaviors to
eliminate factors contributing to the
sleep disturbance.
Implementation
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Environmental controls
Home
Hospital
Promoting bedtime routines
Promoting comfort
Establishing periods of rest and sleep
Controlling physiologic disturbances
Stress reduction
Bedtime snacks
Pharmacological Approaches
Health Promotion Through
Health Education
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Instruct client to try to exercise
daily and avoid vigorous exercise
2h prior to bedtime
Caution clients against sleeping
long hours during weekends or
holidays to prevent disturbance
of normal sleep-wake cycle
The bedroom should only be for
sleeping
Health Promotion Through
Health Education
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Instruct the client to avoid worrisome
thinking and to use relaxation
techniques if necessary
If client has trouble going to sleep
instruct them to do a quiet activity
until they feel sleepy enough to go
back to bed
Instruct client to make sure
environment is conducive to sleep
Instruct client to avoid heavy meals
for 3h prior to bedtime; a light snack
is okay
Evaluation

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Determine if patient achieved
goals according to evaluation
criteria
If goals were not achieved what
needs to be adjusted in the
implementation to help patient
achieve goals.
Pharmacology
Instructions:


Complete the information
requested for the following
drugs.
Document where you found your
information in APA format.
What is a
Benzodiazepine?
Temazepam (Generic Name)
Restoril (Brand Name)
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Drug Description –
Classification –
Indications for use –
Dosage administration –
Mechanism of action –
Side Effects/Adverse Reactions –
Drug Abuse and Dependence –
Drug Interaction(s) -
Temazepam (Generic Name)
Restoril (Brand Name)
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Warnings/Precautions –
Laboratory Test(s) –
Contraindications –
Overdose treatment –
Drug Route –
Availability –
What is a
Barbiturate?
Zolpidem tartrate (Generic Name)
Ambien (Brand Name)
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Drug Description –
Classification –
Indications for use –
Dosage administration –
Mechanism of action –
Side Effects/Adverse Reactions –
Drug Abuse and Dependence –
Drug Interaction(s) -
Zolpidem tartrate (Generic Name)
Ambien (Brand Name)
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Warnings/Precautions –
Laboratory Test(s) –
Contraindications –
Overdose treatment –
Drug Route –
Availability –
Medical Terminology
Instructions:
Look through the power point and
identify the key terms that are
important for you to know.
Write them down in your
notebook.
Medical Abbreviations
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ac = before meals
ad lib = as desired, at liberty
alt h = alternate hours
aq = water
bid = twice a day
bin = twice a night
C = celsius
cap or caps = capsule
cc = cubic centimeter
comp. = compound
cm = centimeter
VIP of the Week
Nathaniel Kleitman
Instructions: Research this person and
write the following in your interactive
notebook.
 Who is he? Describe him as a person.
 What significance did he have to
medicine, science, or health care?
 How can you utilize his contribution
in your profession?
 How did his contribution affect the
world?
Critical Thinking
Answer the following questions:
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What factors would need to be
included in an education plan for a
patient taking benzodiazepines?
What nonpharmacologic measures
should accompany the adminstration
of sleep medication?
If a patient has symptoms of
insomnia, what type of sleep hygiene
habits might you recommend?
Case Study:
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Mrs. Wills visits the community
health clinic for a routine visit.
She is 78yo. During the health
history she tells you that she
normally spends about 7 hours in
bed at night. She states that
frequently it takes her ½ hour or
longer to fall asleep. Mrs. Wills is
concerned.
Question:
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What would you as the
healthcare provider assess
regarding her sleep-wake
patterns?
What counseling might be
appropriate?
Case Study:
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Mr. John is a 55yo sheet metal
worker who works the evening
shift. He typically drinks three to
four beers before going to bed.
He normally sleeps about 6 hours
a nigh after he goes to bed
around 1am. It is common for
him to arise during the night to
urinate. His favorite way to relax
is watching TV in bed.
Question:
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As the healthcare provider what
would you assess regarding Mr.
John’s sleep history?