This chapter provides a comprehensive description of sleep-related breathing disorders, which include includes obstructive sleep apnea (OSA), central sleep apnea (CSA), and Cheyne-Stokes breathing (CSB). It also describes sleep-related hypoventilation/hypoxemic syndromes and sleep-related hypoventilation/hypoxemia due to other medical conditions. CSB and CSA are characterized by instability of the respiratory control system that leads to apneic periods without respiratory effort. Sleep-related breathing disorders are characterized by partial or complete cessation of respiration during sleep, oxyhemoglobin desaturation and sleep fragmentation. Sleep-disordered breathing is a chronic condition that has major implications for morbidity, mortality, and quality of life throughout the world. Nurses, in collaboration with other health care providers, have important roles to play in assessment, treatment, and supporting long-term management and evaluation of this chronic condition. The chapter addresses the characteristics, epidemiology, related factors and consequences, pathophysiology, assessment, diagnosis, and treatment of these disorders, and discusses implications for nursing.

Sleep loss has tremendous societal implications associated with lost productivity, injuries, accidents, and excessive financial costs. This chapter discusses the nature of sleep loss and sleep disorders and their implications for human health and well-being. It reviews the epidemiological and societal consequences of sleep disorders and discusses diagnostic classification systems and their implications for nursing. Sleep loss results from obtaining less sleep than needed and/or fragmented sleep that leads to deprivation of specific sleep stages even in the presence of adequate total sleep. However, chronic sleep deprivation is endemic and contributes to pathophysiology, daytime dysfunction, fatigue, sleepiness, morbidity, injury, mortality, and poor quality of life. Sleep loss, its consequences, and strategies to prevent and/or treat it are important thematic underpinnings in these narratives. Proficiency in the use of relevant sleep diagnostic classification systems is necessary to interdisciplinary collaboration and sleep diagnosis and treatment.

This chapter reviews normal physiological and anatomical changes that occur during pregnancy and discusses common sleep disorders that can occur during pregnancy as well as postpartum. It also discusses the adverse effects of poor sleep on labor and delivery outcomes and reviews postpartum sleep patterns within the context of risk for postpartum depression. The chapter examines the nurses’ role in sleep promotion in relation to sleep hygiene behaviors that can be adapted for pregnant women and new mothers and their families during the first 6 months postpartum. It describes alternative strategies nurses can use to safely promote sleep during perinatal period. Restless legs syndrome (RLS) and sleep-disordered breathing (SDB) or obstructive sleep apnea (OSA) the most critical causes of disturbed sleep during pregnancy and require urgent assessment and referral for effective and non-pharmacologic interventions. The chapter explores sleep during the postpartum period, when women’s experience with sleep deprivation is expected.

This chapter discusses the characteristics of sleep, factors associated with sleep, and evidence-based strategies to promote sleep in acute and critical care settings. It discusses implications for nursing practice and research. Disordered sleep is common in patients hospitalized in demographical and clinically diverse acute and critical care settings. Careful assessment for factors that increase the risk for sleep disturbance and its consequences during hospitalization is needed. Although randomized clinical trials are sparse, the available evidence suggests the promise of multimodal interventions that reduce environmental stimuli or their impact. Given the high prevalence of obstructive sleep apnea (OSA) in the general population and its underdiagnosis, there is a compelling need for assessment and preventative interventions for this condition. Research is needed on the short- and longer-term outcomes of sleep-promoting interventions on patients’ function, quality of life, and morbidity.

This chapter provides practical strategies for nursing care related to sleep promotion and prevention and treatment of sleep disorders in pediatric primary care settings, acute care settings, and schools. In children with sleep disorders, inadequate sleep does not often result in excessive daytime sleepiness, but in behavioral difficulties such as inattention, hyperactivity, cognitive dysfunction, and/or scholastic problems. Nurses who see children in the primary care setting can take an active role in the evaluation and assessment of all children’s sleep health and provide follow-up care and ongoing treatment monitoring for children who have sleep disorders. In the acute care setting, nurses can incorporate regular treatment plans for a child’s sleep disorder during hospitalization and should be aware of potential for obstructive sleep apnea (OSA)-related perioperative complications for children undergoing adenotonsillectomy. School nurses have the opportunity to promote healthy sleep and improve behavior and school performance in children at risk.

This chapter discusses the roles, qualifications, and educational opportunities for advanced practice nurses (APRNs) in specialized sleep practice. It provides exemplars of practice models to illustrate available opportunities. APRNs are well-positioned to develop specialized sleep practices, based on their strong preparation in health assessment, health promotion, and management of episodic and chronic health care conditions in a wide variety of populations and the pressing societal need for an increase in sleep specialists. Their expertise in promoting lifestyle change is a particular strength. Possible roles for APRNS are multidimensional and encompass clinical practice, education, advocacy, and research. Creative models of practice are needed and continue to emerge. While there is a growing cadre of APRNs with specialized sleep practices in a variety of settings, there is a need for more systematic opportunities for education in sleep, chronobiology, and sleep disorders in basic nursing education, graduate school, and continuing education (CE).

Insomnia is a highly prevalent condition that is known to be associated with important pathophysiological, cognitive, and functional consequences. Adults of all ages and all states of health frequently suffer from insomnia. Therefore, nurses are likely to encounter patients with insomnia in many health care and home settings, including primary care, and acute and long-term care settings. Assessment for insomnia should routinely be incorporated into nursing practice in these settings. Although hypnotics are of some use, cognitive behavioral therapy for insomnia (CBT-I) offers the best long-term results in improving sleep and the daytime sequela resulting from poor sleep. Nurse at all levels play an important role in assessment of insomnia, education about the importance of insomnia, and offering strategies for prevention of chronic insomnia. Effective diagnosis, prevention, and treatment of insomnia are likely to have important effects on reducing its deleterious effects on pathophysiology, functional performance, and quality of life.

Narcolepsy is a potentially disabling hypersomnia of central origin that is associated with dysregulation of sleep and waking states. Although less prevalent than some other sleep disorders, such as sleep apnea and insomnia, narcolepsy is very important because studies of this condition have provided scientists with insight into basic mechanisms of sleep-wake regulation. Although the exact cause of narcolepsy is unknown, causes appear to be multifactorial, for example, genetics, infection, stress, and low levels of the brain neurochemical hypocretin. Effective treatments are available and can improve this chronic condition, as well as its negative consequences. This chapter describes the characteristics and consequences of narcolepsy and strategies for assessment and treatment of this sleep disorder, and discusses implications for nursing practice. Nurses and advanced practice nurses, as members of an interdisciplinary team, play important roles in assessment, diagnosis, treatment, and follow-up care.

Disturbed sleep is associated with increased health care utilization and costs, risks to public safety, reduced quality of life, and morbidity and mortality in the general population. This chapter reviews data related to racial and ethnic health disparities in sleep disorders and discusses the implications for nursing. It focuses on American populations for whom there is available data on sleep. Latino, African, and Asian-Americans may be at greater risk to have or to develop sleep disorders, including sleep-disordered breathing, insomnia, and short sleep duration than their Caucasian counterparts. Risk for developing sleep-related comorbidities may be compounded by cultural barriers, language, acculturation, stress, low income, low education, and lack of health insurance. Well-designed studies are needed to adequately and appropriately evaluate the prevalence of sleep disorders and their associations with morbidity, mortality, function, quality of life and to evaluate sleep disorders treatment outcome.

This chapter provides an overview of information related to some of the most prevalent medical disorders associated with sleep problems including the prevalence, consequences, pathophysiology, and treatment. Unfortunately, sleep problems in patients with cardiovascular disease often go unrecognized and untreated. Clinician factors for this problem include lack of awareness of classic symptoms, lack of mechanistic research, and the need for multicenter random clinical trials. Conversely, diabetes is often associated with a variety of symptoms, which may trigger the development of sleep problems. These include anxiety, depression, painful neuropathy, nocturia, and restless legs. Reducing the severity and impact of symptoms has long been an important priority in the management of individuals with cancer. The chapter describes the impact that sleep problems have on the clinical outcomes of human immunodeficiency virus (HIV) /AIDS patients. It discusses a summary of information related to assessment, diagnosis, and follow-up care.

This chapter describes the characteristics, epidemiology, pathophysiology, and treatment of movement disorders: periodic limb movement disorder (PLMD) and restless legs syndrome (RLS) and suggests implications for nursing practice. Parasomnias and movement disorders are associated with many behaviors that occur in proximity to the sleep period during sleep stage transitions, or during REM or NREM sleep. Movement disorders, in particular, are associated with significant impairment in quality of life and possibly negative cardiovascular consequences. Both groups of conditions occur in adults and children. Although some conditions are occasional, benign, and self-limiting, others are persistent and associated with significant sleep loss and/or the risk of injury to self and others. Nursing care for movement disorders and parasomnias is focused on patient education, providing appropriate reassurance regarding benign and self-limiting behaviors, a safe environment, and symptom control where necessary. Sleep hygiene, avoiding caffeine, and regularly scheduled sleep-wake cycle often reduces negative consequences.

Circadian rhythm disorders (CRD) result from a complex interplay of developmental and pathophysiological circadian processes, comorbid psychiatric and medical conditions, and environmental factors. The etiology ranges from internal and genetic to psychological to psychosocial and environmental. Treatments are likewise variable and include pharmacologic, environmental, behavioral, occupational, and public health interventions. Nurses’ roles in working with people who experience these disorders are multifaceted and focus on anticipatory guidance, assessment, patient and family teaching, and assisting patients to adopt behavioral strategies and environmental changes that support the regularization of circadian rhythms. It is important for nurses to have an integrative perspective that recognizes important contributions of circadian physiology and environmental factors to sleep disorders. Clinical supervision is a critical element in developing skill and expertise with the clinical management of these disorders and should be used to broaden the nurse’s comfort and competence in a new area of practice for the novice.

Sleep is a multidimensional, biobehavioral process that is essential to human health and function. This chapter explains the behavioral and physiological aspects of normal sleep and strategies used to measure them. This information is foundational to the understanding of sleep disorders and their pathological consequences and providing nursing care that focuses on sleep promotion and sleep disorders treatment. Behaviorally, sleep is defined as a temporary perceptual disengagement from and unresponsiveness to environmental surroundings. The chapter describes sleep stages and cycles, physiological changes associated with sleep stages, and the neurobiology of wake and sleep onset and maintenance. Sleep is divided into two distinct stages such as non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. The chapter also describes a homeostatic and circadian rhythm model of sleep and wake regulation and methods to measure sleep in humans across the lifespan.

This chapter describes nursing care for sleep disorders in the primary care setting. The most prevalent sleep disorders in adults and older adults, and those most commonly seen in primary care settings are insomnia, sleep-disordered breathing, and restless legs syndrome. There is a compelling need for widespread access to sleep assessment and treatment among the large population of primary care clients who have sleep disorders-many of which are currently undetected. Primary care providers, especially nurses, are in an ideal position to assess, implement, and evaluate sleep promotion and sleep disorders treatment in primary care clients. The reach, adoption, implementation, and long-term maintenance of sleep promotion and sleep disorders treatment is most likely to be successful if implemented at the practice/organizational level. Nurses, especially advanced practice nurses play a pivotal role in implementing and evaluating policies and procedures to assure the translation and uptake of these important services.

Sex and gender differences occur during normal sleep and at sleep-wake transitions and may influence the prevalence and presentation of sleep disorders across the lifespan. This chapter describes sex and gender differences in normal sleep throughout the lifespan and hormonal changes that affect sleep in women and men that may underlie risk for the development of sleep disorders. Gender refers to gender identity within the context of relationships to the society and culture that may evolve over time. Research on gender and sleep has revealed physiologically based sex differences in sleep and important information on sleep as a behavior embedded in the social environment. Although over the course of the human lifespan gender differences are modest, differences in presentation and prevalence of sleep disorders and their potential impact suggest the importance of sex- and gender-related factors in sleep promotion and assessment and management of sleep disorders.

Sleep disorders are common in both children and adults. Untreated sleep disturbances pose significant, adverse daytime consequences and place individuals at considerable risk for adverse health outcomes. Nurses are well positioned to assess and intervene with sleep disorders because they care for people across all cultures, age groups, and health conditions in community and clinical settings. There is widespread agreement among clinical and research experts that sleep assessment should be an integral component of all health assessment, with the specific focus and scope dependent on the situation. This chapter familiarizes nurses with evidence-based approaches to the assessment of sleep. It addresses the basic components of sleep assessment for children and adults, including obtaining sleep-related history, detailed sleep evaluation, and physical examination. The chapter includes information on self-report and objective sleep measurement and resources on sleep assessment for nurses, patients, and their families.

This chapter provides an overview of common sleep disorders that affect children and specific information on sleep assessment in pediatric patients. Sleep disorders are common among children and adolescence, with the prevalence varying according to developmental stage. The chapter examines that children often exhibit symptoms of sleep disorders in ways that differ from the presentation of similar disorders in adults. Snoring, the most common symptom of obstructive sleep apnea (OSA) in children from infancy through adolescence, results from turbulence in airflow through the narrowed oronasopharynx. The importance of incorporating a developmental approach to sleep assessment and treatment into nursing care is underscored by the profound effects of sleep and sleep disorders on children’s behavior, learning, and daily function. Many sleep disorders can be addressed by the nurse and members of the interdisciplinary team with behavioral treatments.

This chapter discusses the work-related impediments to sleep and interventions to improve sleep, with implications for health promotion and occupational health programs in the workplace. The work relatedness of sleep is clear, and responsibility to improve duration and quality of sleep must be shared by the worker, the employer, and clinicians who are informed about sleep. Workers themselves must make time for sleep, select a schedule that permits adequate sleep, seek treatment for sleep disorders, and adhere to treatment recommendations. Occupational health providers are in a prime position to improve health of a large swath of the population by employing population-based principles to ensure that work-related sleep deprivation is reduced or eliminated. For occupational health nurses, this will add a new emphasis area to their practice, and allow them to use their current skills in an area that will reap great reward towards improving the health of their worker population.

This chapter familiarizes the reader with interactions between sleep and sleep disorders and psychiatric disorders. It discusses implications for nurses who work with patients who have psychiatric disorders. Patients with psychiatric disorders are treated across many practice settings. The chapter also discusses some of the most clinically salient and well-documented linkages between sleep and psychiatric illness and includes common mood disorders, anxiety disorders, schizophrenia, alcoholism, and attention deficit hyperactivity disorder (ADHD). It discusses pharmacologic and behavioral interventions related to treatment of the particular disorder as it relates to sleep. The chapter focuses on care of adults and addresses childhood issues in the content related to ADHD. Finally, it highlights information on the diagnostic features of the disorders; changes seen in the polysomnographic changes in sleep across these illnesses; and the impact of pharmacologic treatment on sleep.

Developmental aspects of sleep are manifested in physiological, perceptual, and behavioral aspects of sleep across the human lifespan from birth to old-age. Healthy sleep is also a marker of neurological development, health, and well-being. Nurses can play a supportive-educative role with individual clients and their families in helping them to understand their sleep and in promoting normal sleep patterns in the community and across health care settings. Sleep promotion has an important place in health care settings, as well as schools and the workplace. A key nursing role is clarification of misconceptions about sleep and supporting families and individuals to engage in behaviors that facilitate healthy sleep behaviors. Although many of the observed developmental changes in sleep are physiological in origin, sociocultural factors play an important role and should be incorporated into nursing care. Therefore, incorporating knowledge of cultural variations is an important component of promoting normal sleep.

In psychiatric nursing practice, recognition of sleep dysregulation associated with the various mental illnesses has implications that transect all levels of the systems involved in the general health of the individual receiving treatment. Across all specialties and levels of nursing practice, nurses deal directly with patients who live with psychiatric illness. Sleep disorders are common within this population of patients and are a source of significant morbidity and mortality. Accurate symptom identification, thorough assessment, and evidence-based intervention strategies related to sleep in those with psychiatric illness will have a powerful impact on public health. In order to facilitate increasing awareness of sleep in psychiatric nursing practice, a multifaceted approach needs to be developed that involves professional nursing education as well as health care and community organizations. Broad-based education is an essential key to facilitating the culture shift within these groups to embrace sleep-related science to the benefit of public health.

There is abundant evidence of the importance of sleep and sleep disorders in nursing practice. This chapter provides a perspective on future directions in nursing research, practice, and education relative to sleep promotion and prevention and treatment of sleep disorders. It also provides an opportunity to examine some of the exciting possibilities and challenges for advancing sleep science and the implementation of this evidence in the discipline of nursing. While the contributions of nurses to sleep science are growing, the application of science to practice and pedagogy lags behind scientific progress. The chapter presents an overview of opportunities and possible directions for nursing scholarship related to sleep, and also presents an overview of current trends that intersect with the need for evidence-based practice in sleep promotion, and suggest implications for nursing curricula. The effort will require creativity, dedication, strategic planning and successful interdisciplinary collaboration, as well as collaborations within nursing.

This chapter reviews the evidence for the effects of complementary and alternative medicine (CAM) therapy for promoting sleep, and discusses implications for nursing practice. The term “complementary” refers to the use of therapies that are outside of the realm of conventional western medicine, while the term “alternative” refers to use of modalities in place of conventional western medicine. The chapter also reviews research on the effects of CAM modalities on sleep is organized according to four CAM domains: mind-body, biological based, manipulative and body-based, and energy. CAM whole medical systems cut across all domains. The chapter provides an overview of CAM domains, examples of modalities in each category, and the specific modalities selected because of their potential relevance to sleep and sleep disorders. Resources and products are available to support nurses and other health care providers in providing CAM treatments.

Older adults living in long-term care (LTC) settings suffer from extremely disturbed sleep associated with many negative consequences including agitation, excessive daytime sleepiness, and accelerated cognitive and functional decline. This chapter describes the nature of sleep disturbances in LTC, the scope of concerns relative to sleep disturbances, the consequences of sleep disturbances, sleep-promoting interventions, and implications for research and nursing practice. Sleep is critically important in LTC residents. Nurses play a key role in identifying and assessing for sleep disorders, devising interventions to improve sleep, and determining when referrals to sleep specialists are required. Because the nurse’s personal beliefs about the importance of sleep influence practice, educational programs about the importance of sleep, the consequences of poor sleep, and evidence-based practice to promote sleep in the LTC environment are critical in supporting the implementation and continuance of practice patterns to address sleep problems and promote positive sleep outcomes.

Wilhelm Einthoven contributed significantly to the study of the heart by inventing the electrocardiogram (EKG). Einthoven attached wires or electrodes to the right arm, left arm, and left leg forming a theoretical triangle. When the electrodes were connected to a galvanometer, they measured the electrical activity generated within the heart. The EKG is recorded on special standardized paper that scrolls out of the machine at a specific and controlled speed. The baseline on a 12-lead EKG is an imaginary-line that connects T wave and P wave. A waves that goes upward and downward from the baseline are said to be positive and negative respectively. The 12 leads are consistently arranged in a standard pattern. The first six leads represent the frontal plane of the heart and are called the limb leads. The next six leads represent the horizontal plane of the heart and are called precordial leads.

The heart has an intricate electrical system, made up of highly specialized cells, that is responsible for generating each heart beat. The heart’s electrical system consists of five structures: the sinoatrial (SA node), the atrioventricular (AV node), the bundle of His, the right and left bundle branches, and the Purkinje fibers. The electrical activation of the atria is represented on the EKG as a “P” wave. The atrioventricular node is located in the lower part of the right atrium. The AV node receives the impulse from the SA node and continues transmitting it to the bundle of His. Ventricular depolarization is represented on the EKG as the QRS complex. The QRS complex consists of a Q wave, an R wave, and/or an S wave, occurring either singly or in any combination. The T wave represents ventricular repolarization. The ventricles must repolarize or recharge themselves before next cardiac cycle can begin.

This chapter defines the pathophysiology of Right Bundle Branch Block (RBBB) and the two electrocardiogram (EKG) criteria for RBBB. The right and left bundles form an exquisitely capable communication system. They carefully navigate the impulse and depolarize every single one of the hundreds of millions of ventricular cells. This depolarization of the right and left ventricles forms the normal QRS with a normal interval of 0.08. The normal QRS complex represents combined depolarization of all the right and left ventricular cells. Both ventricles normally depolarize at the same time, and so the left ventricular component of the total electrical force overshadows the much smaller right ventricular force. The ventricles are not depolarized at the same time, but in sequence—first the left ventricle, then the right ventricle. The chapter presents case examples of RBBB with associated hemiblock and anterior infarction.

This chapter explains different types of hemiblock such as left anterior hemiblock and left posterior hemiblock. Hemiblock is the loss of function in one of the two parts of the left bundle. Left anterior hemiblock (LAHB) occurs when there is a loss of function in the anterior branch or fascicle of the left bundle branch. Left anterior hemiblock shifts the mean QRS axis upward and leftward. Left posterior hemiblock (LPHB) occurs when there is a loss of function in the posterior part or fascicle of the left bundle branch. Like LAHB, it is diagnosed by evaluating the mean QRS axis or direction in the frontal plane. Left posterior hemiblock shifts the mean QSR axis to the patient’s right side. hemiblock does not significantly increase the duration of the QRS interval because each side of the heart has one functioning fascicle.

This chapter presents the ways in which PR, QRS, and QT intervals are measured. They are measured only in the limb leads. The limb leads: I, II, III, AVR, AVL, and AVF, are also called the frontal plane leads. The PR interval measures the duration of time from the very beginning of atrial activation to the very beginning of ventricular depolarization. The next step after measuring and analyzing the PR interval is to evaluate the QRS interval. The QRS interval measures the time from the beginning of ventricular activation to the end of ventricular activation. The last interval to be measured on the EKG is the QT interval. The QT measures the distance from the beginning of the QRS to the end of the T wave. The normal QT interval depends on the heart rate. The faster the heart rate, the shorter the QT interval and vice-versa.

Child abuse is more than a visible injury and can present in many forms: neglect, physical abuse, emotional abuse, and sexual abuse. The nurse who knows the common signs of abuse is in a position to intervene and make a difference in the life of a child. Child Protective Service Laws have been enacted to provide a system of reporting suspected child abuse. Licensees of the Board of Nursing are charged with the responsibility to report suspected child abuse. All reasonable cause to suspect that a child is an abused child must be reported. This chapter explores the definition of abuse according to the Federal Child Abuse Prevention and Treatment Act and explains when to report abuses, how to report abuse, and also discusses cultural issues and perceptions of abuse. Reporting requires a phone call to the state child abuse reporting.

Well child care is a continuous process, as is the growth and development of the child. The nurse needs to understand that there are three components to well child care: immunizations, preventive care, and counseling with anticipatory guidance for safety. This chapter reviews recommended immunization schedule for children of all ages, catch-up schedule for children from birth to age 18 years, and considerations on immunization for high-risk children. The widespread use of immunizations has been one of the most significant advances in pediatrics and is responsible for the marked decline of preventable diseases. Well child care should include a discussion of childhood immunizations for diphtheria, tetanus, pertussis, poliovirus, measles, mumps, rubella, Haemophilus influenzae type b, hepatitis A and B viruses, influenza, rotavirus, chickenpox, and vaccines that protect against meningo-coccal and pneumococcal infections.

Patients may have a history of cardiac disease and are on nurse unit for treatment. Other patients may be admitted with a noncardiac-related issue and develop a cardiac emergency. Nurses need to be able to see the “whole picture” of the patient and understand that signs and symptoms of cardiac disease may mimic other causes. On encountering any patient that nurses’ suspect may be experiencing a cardiac issue, they should immediately perform a focused assessment. Included in this assessment should be a set of vital signs, including blood glucose and pulse oximetry. The most common cardiovascular disorders and emergencies seen on the medical-surgical unit include the following: chest pain, heart failure, angina pectoris, myocardial infarction (MI), and venous thrombosis. Chest pain is a patient complaint for which the causes range from postgastric-procedure “gas” pain to angina pectoris and MI.

There are distinct differences between the child and adult in regard to the gastrointestinal (GI) system. The newborn has a decreased resistance to bacterial and viral infections due to incomplete development of the GI system. Due to greater percentage of total body water, children will experience dehydration more quickly than adults if nausea, vomiting, and/or diarrhea occur. The hepatic efficiency of the newborn is immature and can cause jaundice. Early recognition and treatment of GI disorders can prevent the child from falling behind in expected growth and development. This chapter reviews common GI dysfunctions, congenital structural defects, and common obstructive disorders in children. GI dysfunctions are often caused by infectious agents in the GI tract. Structural defects are a result of interruption or failure of cellular processes during embryonic development.

One of the most basic yet important pieces of information the EKG provides is the heart rate (HR). The most accurate way to measure heart rate is by measuring the R-R interval. The R-R interval is the distance from one R wave to the next R wave. The sinus node normally sets and controls the heart at a rate of 60 to 100 beats per minute. This is called sinus rhythm or normal sinus rhythm. The sinus node normally sets and controls the rate of depolarization and contraction of the rest of the heart. In this sense, the sinus node is the master of the heart. Sinus tachycardia represents a relative imbalance in the normal sympathetic/parasympathetic balance of the heart. Commonly used drugs that cause increased sympathetic activity include bronchodilators, inotropic infusions, and pressors. From the EKG, diagnose sinus tachycardia, and then evaluate the patient to determine its cause.

The chapter explores how to measure the electrical direction for the P wave, the QRS complex, and the T wave, as well as for other forces. It provides a method for determining the direction of the electrical force for any of these waves, or complexes, on the electrocardiograph (EKG). The heart produces electrical and mechanical energy on a continuous basis. Both forms of energy come from specialized cardiac muscle fibers. These fibers provide electrical signals and mechanical energy that physically pumps the blood. Although the EKG does not show that mechanical energy, it can be used to measure a variety of electrical events. When a force is abnormal in size or direction, it may indicate that the specific part of the heart producing the force is abnormal. Therefore, learning the normal electrical direction of forces in the heart provides a simple and scientific way of understanding and interpreting an EKG.

Incidence and type of kidney and urinary tract dysfunctions change with age and the presenting complaints can vary with maturation of the child. This chapter reviews common genitourinary tract disorders and defects, glomerular disease in children, and Wilm’s tumor description and management. Genitourinary dysfunction is a category associated with either infection along the urinary tract or an external congenital defect. This group of disorders presents as the most common conditions found in childhood. Glomerular disease is a large group of diseases that are caused by systemic disease or infection, or that can be associated with hereditary disorders. Wilms’ Tumor/Nephroblastoma is most common malignant renal and intraabdominal tumor of childhood. Care is taken in the bathing and handling of the child to prevent trauma to the tumor site and/or disseminate cancer cells to adjacent tissues.

This chapter defines and explains how to identify the associated electrocardiogram (EKG) changes for: pneumothorax, pleural effusion, dextrocardia pericardial, effusion infiltrative, cardiomyopathy, and pericarditis dilated cardiomyopathy hypertrophic, cardiomyopathy chronic, obstructive lung disease (COPD) and athlete’s heart. It describes possible EKG changes associated with: postoperative patients and cancer patients. Drug effects and toxicities, electrolyte imbalances, trauma, pericardial diseases, lung disease, cancer, cardiomyopathies, and systemic diseases are conditions that can cause specific changes on the EKG. A pneumothorax occurs when air seeps into the pleural space. The air interferes with the negative pressure in the pleural space and causes the lung to collapse. The air in the pleural space pushes the heart away from the chest wall and, since air is a poor conductor of electricity, it makes the waveforms on the EKG smaller. A pleural effusion is another condition that causes smaller waveforms on the EKG.

This chapter talks about sinus rhythm, sinus tachycardia, sinus arrhythmia, sinus bradycardia, atrial tachycardia, atrial flutter, premature atrial contraction, sinus pause and atrial fibrillation. Sinus arrhythmia is a rhythm characterized by a gradually increasing, then decreasing heart rate, over a period of seconds. Sinus bradycardia (SB) is a regular rhythm, with a rate of less than 60 bpm. The class of medications called beta blockers commonly cause sinus bradycardia. Atrial tachycardia (AT) or supraventricular tachycardia (SVT) is a regular rhythm at a rate of 160 to 260. Atrial tachycardia is usually associated with increased sympathetic activity. It can be seen in normal and abnormal hearts. Atrial flutter usually is a regular rhythm at a rate of 240 to 340 with flutter waves, but not every flutter wave produces a QRS. Atrial flutter frequently is associated with underlying heart or lung disease.

This chapter describes the pathophysiology of right ventricular hypertrophy (RVH) and explains two criteria for diagnosing RVH on the electrocardiogram (EKG). It also describes the EKG findings of RVH in pulmonary embolism. The normal QRS complex represents simultaneous depolarization of the right and left ventricles. The diagnostic hallmark of right ventricular hypertrophy is an overall QRS direction that points either to the patient’s right, anterior, or both. The chapter presents the case examples of Chronic obstructive lung disease (COPD), commonly caused by smoking, increases the pulmonary resistance to blood flow from the pulmonary artery, and pulmonary embolism usually a part of a disease process termed venous thromboembolism (VTE). The embolus in the pulmonary artery obstructs blood flow to part of the lungs and increases the pressure behind the clot. The right ventricle typically dilates rapidly in response to this.

This chapter explains different types of ventricular arrhythmias such as premature ventricular contraction (PVC), ventricular bigeminy, ventricular trigeminy, paired PVC, ventricular tachycardia and ventricular fibrillation. A premature ventricular contraction (PVC) is a single abnormal beat that comes earlier than the expected next beat and is abnormally wide. It originates in the ventricle. PVCs can occur in a pattern that pairs them with a normal beat. This is called ventricular bigeminy. This can occur in normal and abnormal hearts. PVCs can occur in a pattern that pairs them with two normal beats. Paired PVCs have a more unstable rhythm than single PVC and are more likely to be associated with underlying heart disease than single PVC. Ventricular tachycardia (VT) is a regular rhythm originating in the ventricles at a rate of greater than 100 bpm. VT is associated with underlying heart disease, such as coronary disease, cardiomyopathy, and congestive heart failure.

This chapter provides examples of inferior Q Wave infarction, septal and anterior wall infarction, and septal infarction with right bundle branch block (RBBB) and left anterior hemiblock (LAHB) and septal infarction causing left bundle branch block (LBBB). The initial part of the QRS normally distributes itself evenly and equally through all parts of the left ventricle. The criterion for an abnormal beginning to the QRS is that the first 0.04 seconds is on average negative. Timing of the infarction can be suggested but not proven on a single electrocardiogram (EKG). The presence of ST segment elevation always suggests acuteness of the event. Rarely, untreated ST segment elevation persists indefinitely, and indicates formation of a left ventricular aneurysm. The changes that take place during when inferior Q wave infarction occurs are the beginning of the QRS is pointing to the left and superiorly away from the inferior wall.

This chapter presents the anatomy review of the human heart. The human heart is a hollow four-chambered muscle that is responsible for pumping blood throughout the body. The heart lies in the mediastinum in the thorax, pointing toward the left of the midline. The heart consists of four main layers: the pericardium, epicardium, myocardium, and endocardium. The epicardium is the outermost layer of the heart muscle. The middle layer of the heart is called the myocardium. The innermost layer of the heart is the endocardium. The heart is divided into right and the left side. The right side of the heart contains the right atrium and right ventricle. The left side of the heart contains the left atrium and left ventricle. The heart has four valves: tricuspid valve, mitral valve, aortic valve, pulmonary valve; acting as tiny doors that keep the blood moving in one direction.

This chapter explains infarction such as inferior Ischemia, lateral wall ischemia, apical ischemia and septal and anterior ischemia based on T wave changes. The T wave is normally the last complex in the cardiac cycle. It represents electrical activity produced during rapid ventricular repolarization. One can visualize the direction of the normal T wave axis as pointing inferiorly and to the patient’s left, which is toward the apex of the left ventricle, much as the QRS does. Ischemic areas cannot generate energy to repolarize as readily as nonischemic cells, so the direction of repolarization changes. On the electrocardiogram (EKG), this appears as a T wave direction pointing away from an area of ischemia. Ischemia occurs when there is an imbalance between the supply of oxygen to the myocardium and the demand for oxygen by the myocardial.

The endocrine or ductless glands work with the nervous system to regulate the body’s metabolic processes. Hormones interact with specific target organs to create an effect on the body. This chapter reviews the pathophysiology behind the metabolic system in pediatric clients. It describes nursing care required for pediatric clients with various metabolic conditions. The chapter explores instruction necessary for families of clients with metabolic conditions. Most of the glands and structures of the endocrine system develop during the first trimester of fetal development. Hormonal control is immature until approximately 18 months of age, leaving the infant prone to dysfunction of the endocrine system. Hundreds of hereditary biochemical disorders affect the metabolism. As the infant adjusts to life, symptoms can rapidly emerge that are life-threatening. The most common endocrine dis.

This chapter explains the concept of normal QRS interval, normal QRS direction and two electrocardiogram (EKG) criteria for left bundle branch block (LBBB). The right and left bundles form an exquisitely capable communication system. They carefully navigate the impulse and depolarize every single one of the hundreds of millions of ventricular cells. The normal QRS complex represents combined depolarization of all the right and left ventricular cells. The message to depolarize is conducted to both the ventricles. Both ventricles normally depolarize at the same time, and so the left ventricular component of the total electrical force overshadows the much smaller right ventricular force. The chapter describes resynchronization therapy that is used in situations where both severe left ventricular systolic function and bundle branch block are present. Less than total loss of function in either the right or left bundle is called intraventricular conduction delay (IVCD) or incomplete LBBB.

Urinary tract issues are common in the hospitalized patient-common, but they should not become a normal event for the patient. Focused nursing assessments and interventions can assist the patient in preventing infection. Health care-associated urinary tract infections (UTIs) can be deadly to the hospitalized patient, so every effort must be taken to prevent this complication. The chapter lists the symptoms of a UTI, and describes how to prevent a catheter-associated UTI (CAUTI). It also explores risk factors for a urinary tract disorder and factors to prevent transient incontinence in the hospitalized patient. Prior medical conditions can place a patient at risk of developing renal and urologic disorders. Some of the most common genitourinary issues that develop on a medical-surgical unit include: UTI, CAUTI, and urinary incontinence. In the elderly, symptoms of a UTI may include altered mentation, lethargy, new-onset incontinence, or lowgrade fever without any signs of UTI.

The prevention and monitoring of wounds have always been one of the main responsibilities of the nurse. Technique for infection prevention in wound care cannot be forgotten, nor can techniques in preventing pressure ulcers. Unfortunately, health care institutions still have a high rate of acquired pressure ulcers and surgical site infections, so much so that the Institute for Healthcare Improvement (IHI) has developed guidelines for their prevention. A focused skin assessment should be completed any time an alteration in skin integrity is found. Signs of infection in a surgical wound include swelling, drainage, and bright red inflammation. The most common integumentary issues seen on a medical-surgical unit include the following: pressure ulcers, surgical wounds, and wounds. The most common sites of pressure ulcers are the sacrum and heels. Facilities with a wound-care nurse or team allow them to stage pressure ulcers.

The neurological assessment for the medical surgical nurse is less in depth than that of a nurse working in critical care. Any patient, regardless of diagnosis, can experience a neurological deficit. Evaluation of level of consciousness (LOC) and mentation are the most important parts of the neurological exam. The most common neurological issues that develop on a medical-surgical unit include the following: altered mental status (AMS), headaches, stroke, and seizure. AMS is the most common neurologic emergency. It can occur in hospitalized patients due to hypoxia, hypoglycemia, head injury, an infection in the brain, brain tumor, psychological condition, or a metabolic alteration or as an adverse effect of medications. Headaches are the most common neurological complaint. A stroke occurs when there is a disruption of blood flow to the brain resulting in a loss of brain function. There are two types of stroke: ischemic stroke, and hemorrhagic stroke.

The nurse must consider the developmental level of the pediatric patient when planning physical assessment sites and techniques. All physical assessments begin with an inspection of the general appearance. The interaction between the child, family, and the nurse can provide data on the status of the child. Notable characteristics include physical appearance, posture, eye contact, speech/lust of cry, motor skills, and growth. This chapter reviews techniques for pediatric physical assessment, describes unique physical assessment findings related to the pediatric population, and explores methods to gain cooperation by the pediatric patient at various ages. It is important that the pediatric nurse has an understanding of normal vital signs so that abnormal vital signs are quickly addressed. Pain assessment involving children has many obstacles, including age and a lack of understanding and interpretation of pain levels. Many believe that children, especially infants, do not feel pain in the same intensity as adults.

This chapter lists common resources needed by the medical-surgical nurse. This includes guides for proper syringe selection, pain scales and how to use them, intravenous (IV) solutions, common parameters for documentation purposes, fall prevention and restraint reduction, the “art” of intake and output, and weighing of patients and common calculations. The chapter demonstrates measurement of edema, demonstrates Z-track method of intramuscular (IM) injection, and also demonstrates the use of transmission-based precautions. The use of electronic IV pumps is widespread in all institution. In order to maintain patient safety, however, IV drip rates should be rechecked by the nurse prior to starting the IV fluid. The Z-track method is used in IM injections in order to minimize skin irritation, decrease the occurrence of lesions, decrease pain at the site, and to prevent the injected medication from leaking from the injection site.

Respiratory disorders are the most common causes of illness and hospitalization in children. Respiratory disorders range from mild and self-limiting to life-threatening. Pediatric respiratory health is promoted through prevention, early detection, treatment of disorders, and education efforts. This chapter reviews common pediatric respiratory disorders, explores etiology of pediatric respiratory disorders, and discusses specific care of pediatric clients with respiratory disorders. Newborns have less mucous production, making them more susceptible to infection. Throughout childhood, infants/preschoolers have larger tongues, tonsils, and adenoids, which can cause airway obstruction even in the absence of disease. The common cold is the most common upper respiratory infection (URI) or nasopharyngitis. The causes of a URI include rhinoviruses, parainfluenza, and the respiratory syncytial virus (RSV). Pediatric disorders that affect the lower respiratory tract can be short- or long-term conditions depending upon the cause.

Pediatric nursing is a specialized branch of nursing that is filled with challenges, surprises, and rewards. This chapter reviews strategies on how to relate to pediatric clients, methods that invoke cooperation with pediatric procedures, and provides tips to reduce anxiety in the client and family. The approach by a nurse when entering a pediatric client’s room and the communication that follows depend on the age of the client. The role of the pediatric nurse is threefold: a teacher, a child advocate, a preventive health provider. Infants between 6 and 30 months exhibit separation anxiety, which is normal. An infant’s cry is important to note. The parents often experience quilt feelings, blaming themselves for child’s illness. The parent and child may also have fears such as the unknown, improper care, financial burden, siblings contracting the disease, and/or the child’s potential s.

In an ideal situation, a complete head-to-toe assessment would be conducted for each patient by each nurse that cares for the patient. Time constraints and patient acuity, however, often exclude this type of assessment. Nurses will be completing shorter, more focused assessments throughout the admission of the patient based on chief complaint or current abnormality of the patient. This chapter reviews skills that include communication between health care professionals. A focused assessment collects relevant information pertaining to the current condition of the patient after a change or new symptom develops. Nurses use the “PQRST” system to guide their data collection and to determine what questions to address to the patient. In 2004 a study by the Agency for Healthcare Research and Quality found that 70” to 80” of medical errors are related to communication issues. One method used to reduce the incidents of missed communication is the SBAR technique.

This chapter explains various types of heart blocks such as premature atrial contraction, sinus arrest and asystole. It explains various types of pacemakers such as ventricular pacemaker and artrial pacemakers. Junctional rhythm is a regular rhythm. A P wave is frequently not seen because the rhythm originates in the AV junctional node. Junctional rhythm may be a manifestation of digitalis toxicity, sick sinus syndrome, and acute inferior wall infarction. Pauses are most commonly caused by premature atrial contractions (PACs) that do not conduct down to the ventricle and generate a QRS complex. These are called nonconducted PACs (NCPACs). Asystole is a prolonged period of no electrical activity. Cessation of function of the sinus node is called sinus arrest. Normally, when sinus arrest occurs, another pacemaker must take over, such as the junction or the ventricles. Ventricular pacemaker rhythm demonstrates a vertical electrical artifact (EA) at the beginning of the QRS.

The neurologic system is composed of the body’s nervous system. Neurologic disorders are classified according to primary location affected, type of dysfunction, or cause. Nervous system is also essential in memory and learning. Many neurologic abnormalities are a result of congenital malformations and/or chromosomal errors. This chapter helps a reader to gain a basic understanding of the most common neurological or chromosomal disorders found in children. It reviews pathophysiology of the neurologic system in pediatric clients and discusses nursing care required for pediatric clients with various neurologic conditions. The chapter explores instruction necessary for families of clients with neurologic conditions. Central Nervous System (CNS) dysfunction may be detected by a neurologic check. An intracranial hemorrhage is the most common type of birth injury resulting most commonly from trauma during the birth process or anoxia.

Parents and children experience stress when a child is ill. Nursing communication is essential to update the child and family as information becomes available. This chapter reviews reasons for hospitalization and also children’s reactions and behaviors related to hospitalization. It discusses family considerations when a child is hospitalized. When the opportunity presents, it is most beneficial for the child to be prepared for hospitalization to reduce anxiety and to help the child cope with the treatment regimen. The nurse has the ability to make the hospital experience a positive one. Caring for the parent and family members strengthens their ability to care for their child. The nurse must utilize keen assessment skills to determine objective data in the infant. School-age children have the cognitive ability to understand and describe their illness.

Growth and development are often referred to as a single unit, as the processes are interrelated throughout infancy to childhood and adolescence. The periods of the most rapid cellular growth occur in utero, during infancy, and in adolescence. This chapter reviews the trends in growth and development, developmental stages and milestones, and developmental warning signs. There are definite and predictable patterns of growth and development that allow the nurse to interpret age-appropriate norms. Although there are several factors that influence growth and development, one of the most important is nutrition. Adequate nutrition is closely related to good health throughout life. Parental care, love, and attention also affect growth and development. Good posture, appropriate amounts of exercise, and an adequate nutritional intake are essential for growth. Sexual characteristics develop as the adolescent reaches sexual maturity.

As with many body systems, rapid assessment of patients with gastrointestinal (GI) issues is very important in order to avoid morbidity and death. Nasogastric tubes (NGTs) are common patient care equipment on a medical-surgical unit, but correctly caring for the patient using an NGT and the equipment itself is often overlooked. This chapter provides information to assist nurses with effective care and monitoring of patients with GI conditions. Assessment of the GI system uses all four assessment techniques, including inspection, auscultation, palpation, and percussion. The most common symptom of a GI disorder is a complaint of indigestion. The common gastrointestinal conditions seen on the medical-surgical unit include: GI bleed, small bowel obstruction, large bowel obstruction, and GI intubation. GI bleeds can be caused by a variety of issues, including bleeding duodenal ulcer, gastric ulcers, gastritis, severe bouts of vomiting, and stress ulcers.

Well child care is a continuous process, as is the growth and development of the child. The nurse needs to understand there are three components to well child care: immunizations, preventive care, and counseling of anticipatory guidance for safety. This chapter reviews ongoing health screenings and physical exams for children of all ages. It describes general preventive well child care including nutrition, dental health, and sleep. The chapter explores anticipatory guidance and safety needs specific to each age group during childhood. Children of all ages should receive ongoing health screenings and preventive care checkups. Screening tests for: PKU, sickle-cell disease, thalassemia, galactosemia, hypothyroidism, maple syrup urine disease, homocystinuria, and cystic fibrosis as recommended by the Centers for Disease Control and Prevention (CDC). Due to our changing society, parents may look to the nurse for professional guidance. Injuries are a major cause of death during infancy, safety promotion and injury prevention.

The blood and blood-forming organs make up the hematological system. The components of blood include plasma and the formed elements known as red blood cells, platelets, and white blood cells. The lymphatic system is a subsystem of the circulatory system. The lymphatic system includes lymphocytes, lymphatic vessels, lymph nodes, the spleen, tonsils, adenoids, and thymus gland. This chapter reviews common lymphatic disorders of childhood, and common blood disorders found in children. It describes leukemia, which is associated with both lymphatic and blood systems. It explores the formula to calculate absolute neutrophil count. A risk factor that should be discussed prior to treatment with radiation and chemotherapy is the high risk of sterility from treatment. Anemia is a common blood disorder of childhood. Iron-deficiency anemia is specific to insufficient amounts of iron in the body.

Patient safety is a key responsibility of the nurse. Patients are exposed to a variety of dangers throughout the hospital admission and the nurse is the last line of defense in preventing harm. This chapter reviews the partnership for patient’s initiative that will assist nurse in preventing injury, prolonged hospital stay, and death caused by medication errors, infection, falls, and preventable wounds. It discusses how adverse drug events (ADEs) occur, explains the rights of medication administration, and describes how “high-alert” medications can cause harm and how to prevent harm when administering “high-alert” medications. Medicare and Medicaid pay for the care that adverse patients receive due to injury and prolonged hospital stays. The Department of Health and Human Services (DHHS) leads the effort in developing systems to improve the quality of health care that Americans receive. Effective communication among the patient and family, physician, and nurse, is important in preventing ADEs.

Musculoskeletal disorders are some of the most common causes of illness and hospitalization in children due to their active nature. This chapter reviews common pediatric musculoskeletal disorders, etiology of pediatric musculoskeletal disorders, and pediatric-specific care of musculoskeletal disorders. The musculoskeletal system supports the body structure and provides for client movement. Skeletal growth is most rapid during infancy and adolescence. Injury to the epiphysis can affect bone growth. The most common pediatric musculoskeletal disorders involve pediatric trauma. Torticollis is a symptom that causes a child’s chin to be rotated to one side and the head to the other side. The two most common disorders that can cause torticollis include: Congenital muscular torticollis, and Acquired torticollis. Osteomyelitis is an infection of the bone that occurs most often in infancy or between the ages of 5 and 14 years.

Orientation and preceptorship to a new unit or specialty can be a scary event to any nurse, seasoned or new. This chapter is intended to be a welcome to the profession as well as to provide basic tips for orientation. This includes understanding when medical-surgical nurse have a great preceptor, how to find a mentor, and how to take responsibility for a successful orientation. All specialty areas of nursing have their roots in medical-surgical nursing. Goals of medical-surgical nursing include assisting the patient, resident, or group in regaining or maintaining optimal health. Medical-surgical nurses are educators who help to prevent disease through patient education. Many areas of nursing, particularly subacute and rehabilitation, may expect patients to bring their own thermometers, blood pressure cuffs, and pulse oximeters. Mentors actually embrace change rather than shying away from it, and see change as a way to improve patient care rather than impede it.