By Asif Rasool

1st Batch, TCN

1. NURSING PROCESS
Introduced by Lydia Hall in 1955
In 1960 it was 4 steps process

Nursing process = dynamic & modified form of scientific method, for assessing client
needs, creating course of action to solve problems

“organized sequence of problem-solving steps used to identify and to manage the health
problems”

Made by American nurses’ association ANA

PURPOSE:
identify problems, establish plans, fulfill needs

Client care should be:

 Individualized
 Holistic
 Effective
 Efficient

5 COMPONENTS OF NURSING PROCESS:

1. Assessment (data collection),
2. Nursing diagnosis,
3. Planning,
4. Implementation
5. Evaluation.

(Discuss the requirements for effective use of the nursing process)

(Apply the functional health approach to the nursing process)

1. ASSESSMENT is the systematic and continuous collection, organization, validation, and

documentation of data (COVD)

Through Gordon functional health pattern: 11 health patterns

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1st Batch, TCN
By Asif Rasool
1st Batch, TCN

1. Health perception health management pattern

2. Nutrition and metabolic pattern
3. Elimination pattern
4. Activity exercise pattern
5. Cognitive perceptual pattern
6. Rest and sleep pattern
7. Self-perception /self-concept pattern
8. Role relationship pattern
9. Coping /stress pattern
10. Sexuality /reproductive pattern
11. Value belief pattern

four types of assessments are;

1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment

The ultimate Purpose of assessment is data collection

1. Initial nursing assessment:

Performed within specified time after admission.
To establish a complete database for problem identification.
E.g.: Nursing admission assessment

2. Problem-focused assessment:
To determine the status of a specific problem identified in an earlier assessment.
E.g.: hourly checking of vital signs of fever patient

3. Emergency assessment:
During emergency situation to identify any life-threatening situation.
E.g. Rapid assessment of an individual’s airway, breathing status, and circulation
during a cardiac arrest.

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1st Batch, TCN
 By Asif Rasool
1st Batch, TCN

4. Time-lapsed reassessment:
Several months after initial assessment. To compare the client’s current health status
with the data previously obtained

Collection of data: It includes the health history, physical examination, results of

laboratory and diagnostic tests, and material contributed by other health personnel.

Two types of data:

1. subjective(covert)
2. objective(overt)

2 sources of data:
1. primary (client itself)
2. secondary (other than client)

5 Methods of data collection:

1. Interview
2. Observation
3. Palpation
4. Percussion
5. Auscultation

 Organization of data
The nurse uses a format that organizes the assessment data systematically.
This is often referred to as nursing health history or nursing assessment form.

 Validation of data
Information is double checked

 Documentation of data

(Discuss nursing assessment using a functional health approach.)

(Differentiate the three major activities involved in nursing assessment.)

2. DIAGNOSIS

By Asif Rasool
1st Batch, TCN
By Asif Rasool
1st Batch, TCN

“A clinical judgment concerning a human response to health conditions/life processes, or

a vulnerability for that response, by an individual, family, group, or community.”
-NANDA
Nurses use critical thinking skills to interpret assessment data

3 Steps of Diagnosis:
1. Analyze data
2. Identify health problems, risks, and strengths
3. Formulate diagnostic statement

“Status refers to the actuality or potentiality of the diagnosis or the categorization of the
diagnosis” (NANDA-2009)
The kinds (6) of nursing diagnoses according to status are:
1. Actual
2. Health promotion
3. Risk
4. Wellness.
5. Possible Nursing Diagnosis
6. Syndrome Nursing diagnosis

1. Actual: a problem that is present at the time of nursing assessment; ineffective

breathing pattern, anxiety. (based on presence of sign and symptoms).

2. Health promotion: client’s preparedness to implement behaviors; enhanced diet

(begins with “readiness for enhanced”).

3. Risk: a problem might develop; isolation of immune compromised patient

4. Wellness: specific level of wellness to a higher level of wellness

E.g. Family coping: potential for growth related to unexpected birth of twins.

5. Possible: suspected problem, insuffiecient data to validate the problem.

eg: Possible social isolation related to unknown etiology.

6. Syndrome: a cluster of diagnosis, go together, present a clinical picture.

Disuse syndrome (long term bed ridden patients)

3 COMPONENTS OF NURSING DIAGNOSIS:

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1st Batch, TCN
 By Asif Rasool
1st Batch, TCN

1. The problem statement (Diagnostic Label): describes patient health status;

e.g. Activity intolerance or Constipation, Deficient Knowledge (Medications).
The purpose of the diagnostic label is to direct the formation of client goals and desired outcomes.
It may also suggest some nursing interventions.

2. The etiology (related factors & risk factors): cause of the health problem;
Activity intolerance related to generalized weakness or obesity or sedentary lifestyle.
Constipation related to inadequate fluid intake or inadequate fiber intake.

3. Signs & Symptoms: cluster of signs and symptoms that indicate the presence of a
particular diagnostic label or health problem.
Fluid volume deficit related to decreased oral intake manifested by dry skin and
mucus membranes.

FORMULATING DIAGNOSTIC STATEMENT:

Two or three parts.
Two parts: PE
(problem) related to (etiology)
Three parts: PES
(problem) related to (etiology) evidenced by (symptom)

NURSING DIAGNOSIS MEDICAL DIAGNOSIS

 Condition only nurse can treat  Only physician can treat
 Nursing judgment  Medical judgment
 physical, sociocultural, psychologic  Pathophysiologic
and spiritual  Mostly same for all
 individualized  Same as long as disease process is
 change according to client response present

3. PLANNING

Involves: decision making and problem solving

Three types of planning:

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1st Batch, TCN
 By Asif Rasool
1st Batch, TCN

1. Initial:
done after initial assessment

2. Ongoing:
occurs at the beginning of shift.
Its continuous.
Can individualize the initial care plan further.

3. Discharging:
anticipating and planning for needs after discharge. crucial part of a
comprehensive health care

Planning process:
1. Prioritize problems/ diagnosis: frequently use Maslow hierarchy
2. Formulate goals/desired outcomes: short term = less than a week, or long term =
month.
Client goals / desired outcomes: It is a specific and measurable behavior or response
that reflects a clients highest possible level of wellness and independence in function.
3. Select Nursing intervention
4. Write Nursing intervention

Goals types: 2
Short term: less than 6 weeks or less than a week
Long term: 3 months

3 Type of interventions:
1. Independent: activities that nurses are licensed for
2. Dependent: under physician
3. Collaborative: other team members

(Differentiate the three major activities involved in nursing assessment.)

4. IMPLEMENTATION / INTERVENTION

Intervenes, doing and documenting,

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1st Batch, TCN
 By Asif Rasool
1st Batch, TCN

Process of implementing:
1. Reassessing the client: just before intervention nurse re-assess if it’s still needed
2. Determining the nurse’s need for assistance: can’t do alone, reduce client anxiety,
lack of skill
3. Implementing the nursing interventions: explain to client
4. Supervising the delegated care: nurse validates and responds to any adverse findings
5. Documenting nursing activities: progress notes

5. EVALUATION

Evaluation is a planned, ongoing, purposeful activity

An activity that determines progress toward goals, effectiveness of NCP.

(List the principles of charting)

2. CONCEPT OF VALUE & BELIEF

• Values underpin all aspects of professional practice

Values are divided into three levels of expressions:

1. Beliefs
2. Values
3. Attitudes

Terminology:
 Value: belief or attitude about the worth of something.
 Belief: beliefs are assumptions… about how things are expected to be.
 Attitude: feelings towards something/someone (accept reject?????)
 Assumption: beliefs that are taken for granted. Rarely questioned or examined
 Code: a system of rules relating to one subject.
 Conduct: mode of action, behavior
 Moral: principles of right or wrong.

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 By Asif Rasool
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 Attitude: the way a person applies their beliefs.

e.g. I get really upset (expression) when I hear about cruelty (value) to children
and animals

1. Belief:
A state of mind about something being true.
Irrational and about unproven things.
No proof or evidence.
Belief is the most basic value and changes the least.
Based of faith rather than fact.
Main belief of nursing: patient will get better with care.

• Another belief may be that this, rather than other work, is ultimately satisfactory .

Belief Systems: An ideology or set of principles. often deal with issues which cannot be
explained by reason or logic – creation, the meaning of life, afterlife. E.g. religions

Values serve as broad guidelines in all situations for nurses

A belief system is an ideology or set of principles that helps us to interpret our everyday
reality.

Types of beliefs:
Commendatory: im a good writer
Existentialism: god
Mono, poly, atheism

2. Value:

“Beliefs about what is desirable or good and what is undesirable or bad”

Values like morals help us distinguish b/w right or wrong

Value = worth
e.g. I value freedom of speech
Value is a measure of the worth

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1st Batch, TCN
By Asif Rasool
1st Batch, TCN

• A coherent set of values adopted and/or evolved by a person, organization, or society

as a standard to guide its behavior in preferences in all situations

Types of values: 7
1- Religious Value – based on scriptures.
2- Personal Value – honesty, reliability, trust
3- Cultural Value – faiths, customs
4- Humanistic – everyone has intrinsic value
5- Optimistic – people are good
6- Democratic – sanctity (sacredness) of individual
7- Motivational Value: 5
a. Achievement – demonstrating competence
b. Hedonism – pursuit of pleasure, pleasure is of highest value
c. Stimulation - challenges
d. Self-direction – independent thought and action choosing, creating
exploring
e. Power – social status, control over the people and resources

Rituals:
Set of symbolic actions, recuring interval.
Puja, communion, prayer.

Values transmission:
Values are learned through observation and experience.
Through teachers, parents, religious leaders

Gaps b/w values and behaviors can be closed by a reward system.

Professional values for nurses:

Kindness, considerate, listening.

American association of colleges of nursing: (AACN, 1998)

Five essential values for nurse:
a. Altruism – concern for wellbeing of others

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By Asif Rasool
1st Batch, TCN

b. Autonomy – the right to self-determination (clients)

c. Human dignity
d. Integrity – following code of ethics and principles
e. Social justice – ensure equal treatment under the law

Professional behaviors: 8
1. understand culture, belief etc. of others.
2. Advocacy
3. Takes risk on client’ behalf
4. Mentors other professionals
5. Partners with patient
6. Right of patient and family
7. Preserves client’ confidentiality
8. Accountability for own actions

CONFLICTS:

Ethics:
The study of moral rules and principles that govern a person’ behavior.

Most values are derived from four main sources: Science, Culture, Religion and
Experience
people arrive at their own values through Choosing, Prizing and then acting on them.

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1st Batch, TCN
 By Asif Rasool
1st Batch, TCN

3. CONCEPT OF SELF AND SELF-PERCEPTION

Individual conceptualization, how one views themselves.
It is a subjective sense of unconscious and conscious thoughts, attitude and perceptions.
Self-concept provides a frame of reference that effects the management of all situations
and relationship with others.

“Self-concept is an individual’s identity about how one thinks about himself or herself. It
means how one thinks or how one feels about himself or herself – By Dougles “1966”
Self-concept is one’s mental image of oneself
Individual’s beliefs about their personal attributes.

Terms:
 Perception: the ability to perceive
 Self-perception: self-knowledge, self-evaluation
 Self-Concept: reflection of the reactions of others towards an individual

Capacity for self-reflection is necessary for self-understanding

The ABCs of self-concept:

 Affective /evaluative aspect – self-esteem – comparison between real self and
ideal self
 Behavioral aspect – self perception
 Cognitive aspect – self schema are “cognitive generalizations about the self,
derived from past experience, that organize and guide the processing of self-
related information”

Self-esteem = success/pretension - William James (1890)

Pretension (ideals against which individuals assess their actual self-image)
Pretension (claim, aspiration)

Darl Bem (1972) influential self-perception theory reflects:

By Asif Rasool
1st Batch, TCN
By Asif Rasool
1st Batch, TCN

We observe our behavior and the situation in which it took place, make attributions
about why the behavior occurred, and draw conclusions about our own characteristic
and disposition.

JOHARI WINDOW – by joseph luft and harington ingham 1955

Known by self Unknown by Self

OPEN ARENA BLIND SPOT

Known by
other

Unknown by FACADE UNKNOWN

other HIDDEN

Three mechanisms of self-concept

1. Ideal self
2. Real self
3. Public self

Characteristics of positive self-concept:

1. Self-confidence
2. Accept criticism
3. Set obtainable goals
4. Take risks

Components (4) of self-concept: (a nurse assesses these)

1. Self-Identity – what sets one person apart as a unique individual, begins to develop
during childhood

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By Asif Rasool
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Identity includes a person’s name, gender, ethnic identity, family status, occupation,
and roles.
2. Body Image – attitude about one’s physical attributes etc.
3. Role Performance – set of expected behaviors
Stressors Affecting Role Performance:
Role Overload
Role Conflict
Whenever a person is unable to fulfill role responsibilities, self-concept is impaired.

4. Self-esteem
Self-ideal serves as an internal regulator to support self-respect and self-esteem
Two sources for esteem are self and others.

Dimensions (4) of self-concept

1. Self-knowledge – who am i?
2. Self-expectation – realistic or unrealistic – who I want to be?
3. Social self – perceived by others?
4. Self-evaluation – how well do I like myself?

Global Self: is the term used to describe the composite of all basic facts, qualities,
traits, images, and feelings one holds about oneself.

Self-Ideal is the perception of behavior based on personal standards and self-

expectations.

Self-esteem is the evaluative and affective component of self-concept

DEVELOPMENT OF SELF-CONCEPT:
Self-concept evolves throughout life and depends to an extent on an individual’s
developmental level.

FORMATION OF SELF-CONCEPT
1. Infant learns physical-self different from environment.

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2. If basic needs are met, child has positive feelings of self.

3. Child internalizes others people’s attitudes toward self.
4. Child or adult internalizes standards of society.

STAGES IN DEVELOPMENT OF SELF:

 Self-awareness (Newborn (28-Days) infancy=1year)

 Self-recognition (18 months) Toddler and

 Self-definition (3 years) Preschooler

 Self-concept (6 to7years) School Age Adolescence Adulthood Stages

ERIKSON’S STAGES (8) OF PSYCHOSOCIAL DEVELOPMENT:

1. Infancy: Trust vs. mistrust
2. Toddlerhood: Autonomy vs. shame and doubt
3. Early childhood: Initiative vs. guilt
4. Early school years: Industry vs. inferiority
5. Adolescence: Identity vs. role confusion
6. Early adulthood: Intimacy vs. isolation
7. Middle-aged adults: Generativity vs. stagnation
8. Older adults: Integrity vs. despair

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 By Asif Rasool
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4. CONCEPT OF PAIN

Fifth vital sign

Symptom of underlying condition
Pain = response to noxious stimulus
Pain = warning mech.
Pain has both affective (effects emotions) and a sensory component

COLDERR formula – characteristics, onset, location, duration, exacerbation, relief,

radiation

Likert scale – 5 or 7 point scale

SMARTS formula –

“An unpleasant sensory and emotional experience that is associated with actual or
potential tissue damage” - International Association for the Study of Pain (IASP)

nociception, usually causes the perception of pain

spinal dorsal grey horn, release 2 substances: glutamine, P-substance

frontal cortex – perception
central gyrus – localization of pain

modulation: release of serotonin and opioids – gates for substance P are closed
segmental modulation: capsulated neurons – rubbing hands

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THERE ARE FOUR MAJOR PROCESSES:

1. Transduction: physical stimulus transformed into signal that can be carried
2. Transmission:
travel along efferent nerve fibers.
A-delta fiber (fast myelinated)
Send sharp localized and distinct sensation

C-fiber (Slow unmyelinated)

Slow impulses e.g needle stick

Beta fibers for segmental modulation

3. Perception: pain transmitted to cortex, become conscious of intensity, location,

and quality of pain

4. Modulation: activation of neural pathways that inhibit transmission of pain.

The periaqueductal gray (PAG), dorsolateral pontine tegmentum (DLPT), and
rostroventral medulla (RVM) are the key regions of the brain involved in this
descending pain modulation.

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GATE CONTROL THEORY (Ronald Melzack and Patrick Wall, 1965)

• The gate control theory of pain asserts that non-painful input closes the "gates" to
painful input, which prevents pain sensation from traveling to the central nervous
system.
• Therefore, stimulation by non-noxious input is able to suppress pain.

• Convert noxious stimulus to non-nxious

TYPES OF PAIN:
ACUTE – sudden and limited duration + anxiety and emotional distress
CHRONIC – resistant to medical treatment, osteoarthritis

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• Pain is often classified by the kind of damage that causes it.

Two main catigories:
• tissue damage, also called nociceptive pain,
• nerve damage, also called neuropathic pain.

• psychogenic pain, which is pain that is affected by psychological factors

• classification of pain based on origin:

• Somatic pain comes from the skin. muscles, and soft tissues,
• visceral pain comes from the internal organs.
• Cutaneous pain: is caused by stimulation of the cutaneous nerve endings in the skin.

NON-PHARMACOLOGICAL THERAPIES:
Physical (sensory) interventions:
inhibit nociceptive input and pain perception.
e.g. transcutaneous electrical nerve stimulation (TENS), acupuncture.
Psychological interventions:

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acceptance and commitment therapy (ACT), meditation, guided imagery and

biofeedback.

PHARMACOLOGICAL INTERVENTIONS:
WHO Analgesic Ladder Step 1-3:
Developed by WHO to improve cancer pain
used for providing stepwise pain relief

Non-opioid medications: Step 1 (Mild to Moderate pain)

NSAIDs
Paracetamol (acetaminophen)
Aspirin (acetylsalicylic acid – ASA)

Compound analgesics: Step 2 (mild to moderate pain)

Combination of drugs in a single tablet: codeine (a weak opiate) and aspirin or
paracetamol.
e.g. co-dydramol which contain codeine and paracetamol in various formulas
(8/500, 10/500, 15/500, 30/500)

Opioid medications: Step 3 (severe pain)

Derivatives of morphine, mimic natural analgesics, most potent yet.
e.g. oxycodone, codeine, tramadol, buprenorphine, fentanyl, and diamorphine
(heroin)

adjuvants:
for neuropathic pain prescribe additional medicine; tricyclic antidepressants, anti
epileptics

topical analgesics:
localized pain relief
e.g. rubefacients, topical NSAIDs and local anesthetics.

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Assignment:
1. Intensive Theory (Erb, 1874)
2. Strong's Theory (Strong, 1895)
3. Specificity Theory (Von Frey, 1895)
4. Pattern Theory (Gold Schneider (1920)
5. Central Summation Theory (Livingstone, 1943)
6. Sensory Interaction Theory (Noordenbos, 1959)

5. CONCEPT OF NUTRITION AND DIETARY PATTERN

NUTRITION: The science related to the food requirements of the body.
Nutrition is the intake of food, considered in relation to the body’s dietary needs.
Good nutrition is a cornerstone of good health.

• Poor nutrition can lead to reduced immunity, increased susceptibility to disease,

impaired physical and mental development, and reduced productivity - (WHO)

Nutrition: field of study

Nutrients: chemical Compounds

ESSENTIAL NUTRIENTS:
ESSENTIAL NUTRIENTS FOR BODY GROWTH ARE INCLUDE:
 Protein - 10% - 35% of calories.
Major constituent of hormones, enzymes, and antibodies.
Found in meat, fish, eggs, pulses etc.
 Fats - 20% - 35% of calories.
 Carbohydrates - 45% - 65% of calories USDA

DIGESTION OF CARBOHYDRATE:
galactose and fructose are metabolized further by the liver to produce glucose and
minimal amounts of other metabolites.

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DIGESTION OF PROTEIN:
Chymotrypsin (secreted by pancreas)

DIGESTION OF FAT:
fats into fatty acids and glycerol for absorption of fatty acids.
Only freely dissolved monoglycerides and fatty acids can be absorbed.

NUTRITIONAL CONSIDERATION ACROSS LIFE SPAN

birth to six months of age:
6 months breast feeding exclusive

six to 12 months of age:

Avoid cow’s milk as a drink in the first 12months.
can be used in cereals and custards.
Pasteurized
Nuts = choking
Give enough vitamin D

Food for young children:

 Fruit juices should be limited and soft drinks avoided.

Food for children entering their teenage years:

Calcium foods

Adolescent girls should be particularly encouraged to consume milk and milk

products.
nutrient-dense foods such as wholegrain breads and cereals, fruits, legumes, nuts,
vegetables, fish and lean meats.

Older teenagers and young adults:

Reduce fat and salt
 Be careful to include foods rich in iron and calcium.

Food for older people:

Activity; appetite, maintain muscle
Vitamin D

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Limit salt
eggs, lean meats, fish, low-fat dairy foods, nuts and seeds, legumes, fruit and
vegetables, wholegrain breads and cereals.

Nutrition Assessment:
 Trouble chewing
 Swallowing disorders
 Weight history
 Height and weight
 Measurement
 Skin integrity
 Edema
 Electrolyte abnormalities
 Hand-grip strength (have the patient squeeze your hand).

Purpose: to determine the client dietary habits and metabolic needs.

 conditions of hair, skin, nails, teeth and mucous membranes are assessed.

Subjective Data:

Guideline Questions:
Dietary and Fluid Intake:
1. What time, type and amount of food?
2. follow any certain type of diet?
3. Difficulties while eating?
4. Snack types, frequency?
5. Vitamin supplements?
6. Do you consider your diet high in fat? Sugar? Salt?
7. Intolerance?
8. Kinds of fluids, frequency?
9. When was your last dental exam? What were the result?
10.Do you ever experience sore throat, sore tongue, sore gums? Describe
11.Nausea or vomiting?
12.Abdominal pain?
13.Use antacids? Frequency and kinds

Condition of hair & nails:

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1. Excessively oily or dry?

2. Scalp itching or sores?
3. Hair and scalp products?
4. Nail color canges?
5. Cracking? Shape? Lines?

Condition of skin:
1. How quickly does it heal?
2. Lesions?
3. Oily dry?
4. Itching? What do you use for relief?

Metabolism:
1. Is your weight your ideal?
2. Recent weight gain/ loss? Used any measures for it?
3. Intolerance to heat or cold?
4. changes in your eating or drinking habits?

OBJECTIVE DATA:
temperature, pulse, respirations, and height and weight.

ACTUAL DIAGNOSIS:
 Ineffective Thermo regulation.

NUTRITION AND METABOLIC PATTERN

Number of meals per day. Break fast: _____________Lunch_________ Dinner__________
Snacks ______________________
Food Preference:(1) Like :_________________( 2) Dislikes__________________________
Amount of fluids per day: ________________Rout (I/V) _________Oral________________
Tube feeding __________________Any dietary restriction__________________________
Any fluid restriction________________________________________
Skin
Turgor _________________Color______________Texture______________Edema_______
Hair: Texture______________________Distribution__________________________
Oral mucus membrane: _______________Gums_____________No of teeth_____________
Alignment: ___________________Dentures:________ Height_________ Weight________

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Labs; HB____________ HCT_____________ WBC ______________ESR _________

RBC_____________Platelets____________PT_________ APTT _________INR ________
Albumin _____________ Na_____________ K __________Ca______
Mg___________ Others___________________
Nursing Diagnosis: __________________________________________________________
__________________________________________________________________________

NURSING INTERVENTION TO PROVIDE OPTIMAL DIETARY HEALTH:

“Modifiable risk factors such as unhealthy diet, physical inactivity, tobacco use and harmful
use of alcohol are major causes of CVDs.” (WHO)

Measure weight daily

Determine daily caloric need.
Give encouragement of individual to eat with others.
Give more protein and high fiber diet and avoid excessive carbohydrate and fats.

Exercise?
Discuss nutritional requirement for a patient with;
 Diarrhea
 Constipation
 Immobility
 Over weight

(List factors that can effect dietary pattern)

(Describe manifestations of altered nutrition)

6. CONCEPT OF ELIMINATION

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ELIMINATION PATTERNS describe the regulation, control, and removal of by-products

and wastes in the body.
Elimination = sweat, urine, feces

Bowel elimination:
defecation
Large intestine = 125-150 cm long.
Seven parts: (CAT-DSRA)
1. Cecum
2. Ascending
3. Transverse
4. Descending
5. Sigmoid colon
6. Rectum
7. Anus
The muscles are circular and longitudinal to facilitate peristaltic movements.
Defecation is initiated by two reflexes???
mesenteric plexus = initiate movement in rectum etc.

Characteristics of Feces:
Feces (Healthy People):
• Soft, brown, moist, and firmed.
• Distinct odor.

COMMON PROBLEMS?
Black: tarry stool may indicate of bleeding from upper gastrointestinal tract or drug.
Red: may indicate of bleeding from lower gastrointestinal tract.
Pale: may indicated to mal absorption.
Dry hard: dehydration decreased intestinal motility.
Green: may indicate intestinal infection.
Pus: bacterial infection.

Factors promoting elimination:

Stress free
High fiber
Squatting position

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Factors impairing elimination:

Anxiety
High carb / fat diet
Overuse of cathartics, narcotic analgesic

Fecal Impaction: Mass of hardened feces in rectum…recognized by seepage

NCP:
Assessment: inspection, auscultation, percussion (sound based, dull), palpation

Diagnosis: Bowl incontinence related to fecal impaction.

Nursing Interventions: nutrition, privacy, exercise

Flatulence = glycerin suppository

Interventions:
Cathartics/Laxatives: induce emptying of the interest.
Toilet pt 30 – 60 min before usual time of incontinence.
Enemas: removing feces
Suppositories: bullet shaped substance inserted into the rectum beyond the anal
sphincter where it melts to aid in elimination.

URINARY ELIMINATION:
Renal system composed of: (6)
 2 kidneys,
 2 ureters,
 1 bladder,
 1 urethra

Kidney:
 11cm long,6 cm wide, 3 cm thick

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 150G,
 posterior abdominal wall,
 situated at T12-L3.

500ml of urine, maximum = bladder

Formation of urine:
3 processes:
1. filtration,
2. reabsorption,
3. tubular secretion.

 Urine consists of 95% water and 5% solid substances.

 need to urinate is usually felt at 300-350ml
 1000-1500 mL is voided daily.
 Adult: 250-450mL of urine –
 Children: 50-200mL of urine – Stretch receptors stimulated

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COMMON URINARY ELIMINATION PROBLEMS

1. Urinary retention
2. Urinary tract infections
3. Urinary incontinence.

ALTERED URINARY ELIMINATION:

 Frequent
 Nocturia – 2,3 times
 Urgency
 Enuresis: involuntary urination – related to disease (bed wetting)
 Dysuria: means voiding that is either painful or difficulty.
 Urine retention: accumulation of urine in the bladder and become over distended

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 Hypospadias is a birth (congenital) defect in which the opening of the urethra is on

the underside of the penis

NURSING PROCESS OF URINARY ELIMINATION:

Assessment:
voiding pattern & frequency,
Presence of an ostomy,
Presence of urinary diversion.

Urine: 40-60 ml/hr or 1500-2000 ml/day

Ostomy: shortcut hole in abdomen for regular removal of waste

Nursing Diagnosis:
Risk for infection related to urinary retention.

Managing Urinary Incontinence (UI):

Bladder training:
resist urgency,
void according to timetable,
lengthen intervals

Habit training:
void according to schedule,
must void

Prompt voiding:
encourage and remind client to void

Pelvic Muscle Exercises (PME)

Kegel’s exercises
pubococcygeal muscles - female’s ability to start and stop the stream of urine

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retention = catheterization

(Describe factors that can alter urinary function)

7. CONCEPT OF SLEEP & REST

Sleep is a basic human need

Humans spend about one third of their lives asleep
sleep-wake pattern, is a biological rhythm that guides the body as to when it should
sleep and when it should wake.
The term circadian comes from Latin words that literally mean "around the day."

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the stages of sleep were determined in 1936 by Harvey and Loomis,

the first descriptions of delta and theta waves were made by Walter and Dovey,
REM sleep was discovered in 1953

Adults: 7 hours of sleep

REST:
decreased state of activity
Rest is without altered level of consciousness.
OR
In medical care, rest is defined as behavior aimed at increasing physical and mental
well-being, which usually involves stopping activity.

SLEEP:
An altered state of consciousness
OR
Sleep is a partial detachment from the world, where most external stimuli are blocked
from the senses.

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SLEEP REST
1. Sleep is a body-mind state in which we 1. decreased state of activity
experience sensory detachment from
our surroundings.
2. typical posture, such as lying down 2. No typical posture required for rest
with eyes closed
3. Sleep results in a decreased 3. In other resting conditions we are in
responsiveness to external stimuli contact with external stimuli
4. It’s a narrow term. 4. It’s a broader term.
5. Sleep is physical 5. Rest is spiritual
6. We need 7.5 hours of sleep per day 6. We need 2 hours to 2-25 min rest per
day

CHARACTERISTICS OF SLEEP:
• changes in brain wave activity, breathing, heart rate, body temperature
• Depending on the sleep stage, different physiological functions may be
• more active and variable, for example, during REM sleep,
• less active and more stable for example, during NREM sleep.

• SLEEP CONSISTS OF TWO MAIN PHASES THAT ARE

1. Non-Rapid Movement (NREM)
2. Rapid Eye Movement (REM)

Stages of Sleep:
1. Non-Rapid Movement (NREM)
About 75% to 80% of sleep.
divided into four stages, each associated with distinct brain activity and physiology.
NREM –Non rapid eye moment:
Stage -I
Stage -II
Stage -III
Stage-IV

Characteristics of NREM:

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Stage I:
very light sleep
lasts only a few minutes.
the person feels drowsy and relaxed, the eyes roll from side to side, and the heart
and respiratory rates drop slightly.
The sleeper can be readily awakened and may deny that he or she was sleeping.
• Profound and restfullness
• Floating sensation

Stage II:
light sleep
The eyes are generally still,
the heart and respiratory rates decrease slightly, and body temperature falls.
Stage II lasts only about 10 to 15 minutes
constitutes 44% to 55% of total sleep
(Choudhary & Choudhary, 2009).
An individual in stage II requires more intense stimuli than in stage I to awaken such
as touching or shaking.
• Easily aroused?

Stage -III:
medium-depth sleep where vital signs and metabolic processes slow further because
of the PARASYMPATHETIC nervous system influence.
• Stage lasts 15 to 30 minutes.
• It involves initial stages of deep sleep.
• Muscles are completely relaxed.
• Large slow waves in EEG
• Vital signs decline but remain regular.
• Sleeper is difficult to arouse and rarely moves

STAGE 4:
deepest sleep or delta sleep.
It is the stage where the heart rate and respiratory rate drop 20-30% below those
exhibited during waking hours.

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This stage is thought to restore the body physically.

Some dreaming may occur here.
This stage may be absent in the elderly.
• Stage lasts approximately 15 to 30 minutes.
• If sleep loss has occurred, sleeper spends considerable portion of night in this
stage. (Stage 4)
• Further slowing of EEG
• Sleep walking and enuresis (bed-wetting) sometimes occur.
• is very difficult to arouse sleeper

Stages III & stage IV:

the deepest stages of sleep, differing only in the percentage of delta waves recorded
during a 30-second period.
The person is not disturbed by sensory stimuli, the skeletal muscles are very relaxed,
reflexes are diminished, and snoring is most likely to occur. Even swallowing and
saliva production are reduced during delta sleep (Choudhary & Choudhary, 2009).
These stages are essential for restoring energy and releasing important growth
hormones

1. Characteristics of REM:
 recurs about every 90 minutes and lasts 5 to 30 minutes.
 Other name: PARADOXICAL Sleep. The EEG pattern resembles that of the “awake” state.
This is not as restful as NREM sleep.
 Most dreams take place during this period and the dreams are usually remembered or
consolidated to memory.
 The brain is highly active with metabolic rate increasing as much as 20%
 The sleeper may be very difficult to arouse.
 There are rapid conjugate eye movements, muscle tone is depressed, but gastric
secretions increase, HR and RR are increased and IRREGULAR.

 This sleep period becomes longer as the night progresses

NREM REM

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• Slow eye movement • Rapid eye movement

• Restful sleep • Not restful
• Decrease metabolism • Increased metabolism
• Vital sign low • Vital signs irregular
• Muscle tone maintained • Muscle tone depressed
• No vivid dreams • Dreams occur

Sleep Cycles:
During a sleep cycle, people typically pass through NREM and REM sleep, the complete
cycle usually lasting about 90 to 110 minutes in adults.

 In the first sleep cycle, a sleeper usually passes through all of the first 3 NREM stages
in a total of about 20 to 30 minutes.
 Then, stage IV may last about 30 minutes.
 After stage IV, the sleep passes back through stages III and II over about 20 minutes.
Thereafter, the first REM stage occurs, lasting about 10 minutes, completing the first
sleep cycle.

It is not unusual for the first REM period to be very brief or even skipped entirely.
Avg. four to six cycles of sleep during 7 to 8 hours.

The sleeper who is awakened during any stage must begin a new at stage I NREM sleep
and proceed through all stages to REM sleep.

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FUNCTIONS OF SLEEP:
The effects of sleep on the body are not completely understood.

Sleep exerts physiological effects on the nervous system and other body structures.
The role of sleep in psychological well-being is best noticed by the deterioration in
mental functioning related to sleep loss.
inadequate sleep: emotionally irritable, have poor concentration, difficulty making
decisions. (Regulation of emotion)

• Restore biological processes (NREM)

• Preserve cardiac functions?
• HGH released
• Proteins synthesis and cell division
• Body conserve energy during sleep
• Thermoregulation
• REM: brain tissue restoration and cognitive functions
• Loss of REM sleep leads to feeling of confusion and suspicion

Prolong sleep loss leads to alterations in mood, memory, and motor performance
Disturb REM sleep may affect body such as,
• Risk for obesity
• Memory problem

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• Easily gets depression

• Disturb metabolism

Age:
 Newborn: 16-18 hours /day
 Infants: 12-14 hours (some 22 hours)
 Toddlers: 10-12 hours
 Preschool: 11-12 hours
 School-Age: 8- 12 hours
 Adolescents: 8-10 hours
 Adult: 6-8 hours
 Elders: 6 hours

FACTORS AFFECTING SLEEP:

• Hyperthyrodism lengthens pre-sleep time making it difficult for a client to fall asleep.
• Hypothyroidism, conversely, decreases stage IV sleep.
• Elevated body temperatures can cause some reduction in delta sleep and REM sleep.

Environment:
The absence of usual stimuli or the presence of unfamiliar stimuli can prevent people
from sleeping.
some hospitals have instituted “quiet times” in the afternoon on nursing units where
the lights are lowered and activity and noise are purposefully decreased

Lifestyle:
Moderate exercise in the morning or early afternoon usually is conducive to sleep, but
exercise late in the day can delay sleep.
It is best to avoid doing homework or office work before or after getting into bed.

Wearing dark wrap-around sunglasses during the drive home and light-blocking shades
can minimize the alerting effects of exposure to daylight, thus making it easier to fall
asleep when body temperature is rising.

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Emotional Stress:
Stress = number one cause of short-term sleeping difficulties
(National Sleep Foundation)
Anxiety increases the norepinephrine blood levels through stimulation of the
sympathetic nervous system = less deep sleep and REM sleep and more stage changes
and awakenings.

Stimulants and Alcohol:

Alcohol disrupts REM sleep.
The alcohol-tolerant person may be unable to sleep well and become irritable as a
result.

Diet:
Obesity –reduced total sleep time, broken sleep, and earlier awakening.
Dietary L-tryptophan—found in cheese and milk—may induce sleep

Smoking:
Smokers are light sleepers.

Motivation:
Motivation can increase alertness in some situations.
Mere motivation is unable to cause sleeplessness
Mere boredom is unable to cause sleepiness

Medications:
Most hypnotics can interfere with deep sleep and suppress REM sleep.
• Beta-blockers cause insomnia and nightmares.
• Narcotics – morphine suppress REM sleep and to cause frequent awakenings and
drowsiness.
• Tranquilizers interfere with REM sleep.
• Although antidepressants suppress REM sleep, this effect is considered a therapeutic
action – HOW?

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COMMON SLEEP DISORDERS:

typically categorized for the purpose of research as
• Dysomnias,
• Parasomnias,
• Disorders associated with medical or psychiatric illness,

Primary disorders can be divided into parasomnias and dyssomnias.

 Parasomnia sleep disorders cause abnormal activities during sleep, such as sleep
terrors or sleep walking.
 Dyssomnia sleep disorders cause trouble falling asleep or staying asleep.

COMMON SLEEP DISORDERS:

DYSOMNIAS
1. Insomnia
the inability to fall asleep or remain asleep, wake up not well rested

Acute insomnia lasts one to several nights and is often caused by personal stressors or
worry.

Chronic insomnia: longer than a month

More often, people experience chronic-intermittent insomnia, which means difficulty

sleeping for a few nights, followed by a few nights of adequate sleep

The two main risk factors of insomnia

1) Older age - (caused by some other medical condition.)
2) Female gender - hormonal changes (e.g., menstruation, pregnancy, and
menopause).
(National Sleep Foundation).

Treatment: New behavior patterns that induce sleep and maintain sleep.
Examples of behavioral treatments:

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• Stimulus control: creating a sleep environment that promotes sleep

• Cognitive therapy: learning to develop positive thoughts and beliefs about sleep
(???)
• Sleep restriction: following a program that limits time in bed in order to get to
sleep and stay asleep throughout the night.

Similarly, the long-term efficacy of hypnotic medications is questionable.

Don’t treat the cause
their prolonged use can create drug dependencies.

2. Excessive Daytime Sleepiness

excessive day time sleepiness due to:
hypersomnia, narcolepsy, sleep apnea, and insufficient sleep.

A. Hypersomnia
sufficient sleep at night yet cannot stay awake during the day.
Caused by medical conditions, for example, CNS damage and certain kidney, liver, or
metabolic disorders, such as diabetic acidosis and hypothyroidism.
Rarely does hypersomnia have a psychological origin

B. Narcolepsy (Sleeping at the wrong time) or falling asleep uncontrollably, sleep attacks.
excessive daytime sleepiness caused by the lack of the chemical hypocretin in the area of
the CNS that regulates sleep.
their sleep at night begins with a sleep-onset REM period (dreaming sleep occurs within
the first 15 minutes of falling asleep).
• Sleep intrudes into wakefulness,
• Sleep is brief but refreshing
• May also have:
• sleep paralysis,
• sudden loss of strength,
• hallucinations as fall asleep or awaken.

C. Sleep Apnea

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 frequent short breathing pauses during sleep.

 all individuals have occasional periods of apnea during sleep,
 more than five apneic episodes or five breathing pauses longer than 10
seconds/hour is considered abnormal

Symptoms:
loud snoring, frequent nocturnal awakenings, excessive daytime sleepiness,
difficulties falling asleep at night, morning headaches, memory and cognitive
problems, and irritability.

frequently diagnosed in men and postmenopausal women, it may occur during

childhood.
Three common types of sleep apnea are
i.Obstructive Apnea,
ii.Central Apnea,
iii.Mixed Apnea.

i. Obstructive apnea
the structures of the pharynx or oral cavity block the flow of air.
abdominal muscles move.
The movements of the diaphragm become stronger and stronger until the
obstruction is removed.
Enlarged tonsils and adenoids, a deviated nasal septum, nasal polyps, and obesity
predispose the client to obstructive apnea.
An episode of obstructive sleep apnea:
1. begins with snoring
2. breathing ceases
3. snoring as breathing resumes.
4. increased carbon dioxide levels in the blood cause the client to wake.

ii. Central apnea

a defect in the respiratory center of the brain.
All actions involved in breathing cease.

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Clients who have brainstem injuries and muscular dystrophy often have central
sleep apnea.
There is no available treatment.

iii. Mixed apnea is a combination of central apnea and obstructive apnea.

D. Insufficient Sleep (Disturbed Sleep or Sleep Deprivation)

Depending on the severity and chronicity of this voluntary, unintentional sleep
deprivation, individuals may develop attention and concentration deficits, reduced
vigilance, distractibility, reduced motivation, fatigue, malaise, and occasionally diplopia
(double seeing things /vision) and dry mouth.

Parasomnia
behavior that may interfere with sleep and may even occur during sleep.
The International Classification of Sleep Disorders subdivides parasomnias into:
i. Arousal disorders (e.g., sleepwalking, sleep terrors),
ii. Seep /wake transition disorders (e.g., sleep talking),
iii. Parasomnias associated with REM sleep (e.g., nightmares), and others (e.g., bruxism).

Bruxism:
Occurring during stage II NREM sleep,
Clenching and grinding of the teeth can eventually erode dental crowns, cause teeth
to come loose, and lead to deterioration of the temporomandibular (TMJ) joint,
called TMJ syndrome.

Enuresis:
Bed-wetting during sleep can occur in children over 3 years old.
More males than females are affected.
It often occurs 1 to 2 hours after falling asleep, when rousing from NREM stages III
and IV.

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Periodic limb movement disorder (PLMD).

the legs jerk twice or three times per minute during sleep.
common among older adults.
This kicking motion can wake the client

Sleep talking:
occurs during NREM sleep before REM sleep.
It rarely presents a problem to the person unless it becomes troublesome to others.

Sleep walking:
(somnambulism) occurs during stages III and IV of NREM sleep.
It is episodic and usually occurs 1 to 2 hours after falling asleep.
Can’t notice dangers (e.g., stairs)

Disorders due to other medical conditions:

Associated with Medical or Psychiatric or other illness.
Usually the disorders that cause sleep disturbance includes:
• Depression
• Alcoholism
• Thyroid dysfunction
• Peptic ulcer
• COPD

PROMOTING SLEEP:
Sleep Pattern
• regular bedtime and wake-up time
• nap (e.g., 15 to 30 minutes) among older adults, can be restorative and not interfere
with nighttime sleep.
A younger person with insomnia should not nap.
• Avoid dealing with office work or family problems before bedtime.
• Get adequate exercise during the day to reduce stress.

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• When you are unable to sleep, get out of bed, go into another room, and pursue
some relaxing activity until you feel drowsy

ENVIRONMENT
• sleep-conducive: dark, quiet, comfortable, and cool.
• Keep noise to a minimum; block out extraneous noise as necessary with noise from a
fan, air conditioner, or noise machine.
• Music is not recommended; music will promote wakefulness (it is interesting and
people will pay attention to it).

DIET
• Avoid heavy meals 2 to 3 hours before bedtime.
• Avoid alcohol and caffeine at least 4 hours before bedtime.
Both caffeine and alcohol act as diuretics, creating the need to void during sleep time.
• Bedtime; consume only light carbohydrates or a milk drink.
Heavy or spicy foods can cause gastrointestinal upsets that disturb sleep

MEDICATIONS
• Use sleeping medications only as a last resort.
• Use OTC medications sparingly because many contain antihistamines that cause
daytime drowsiness.
• Take analgesics before bedtime to relieve aches and pains.

NURSING PROCESS FOR A PATIENT TO PROMOTE SLEEP:

Assessment of Sleep:
Assessment of a client’s sleep includes:
• Sleep history
• Physical examination
• Sleep diary

Sleep Rest Pattern:

• No. of hour’s sleep/24 hours: Home______________ Hospital __________ Naps
• Any problem to fall/stay a sleep___________

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• Use of tranquillizers___________
• Any home remedy to induce sleep___________
• Evidence of lack of sleep_____
• Quality of sleep______

• Nursing diagnosis (?)

Sleep History:
• When does client usually go to sleep?
• Bedtime rituals?
• Can client stay awake during day?
• Taking any prescribed medications?

What is the usual sleeping pattern, specifically?

• sleeping and waking times
• hours of undisturbed sleep, etc.
• Bedtime rituals
• Use of sleep medications
• Sleep environment
• Changes in sleep pattern

Physical Examination:
• facial appearance, behaviour, and energy level.
• Darkened areas around the eyes, puffy eyelids, reddened conjunctiva, dull appearing
eyes.
• Irritability, yawning, slumped posture, hand tremor, rubbing of eyes, confusion,
fatigued, lethargic, etc.

Nursing Diagnosis:
• Impaired sleep related to obstructive sleep apnea
• Impaired gas exchange related to central or obstructive sleep apnea
• At risk for disturbed sleep secondary to alcohol use
• Insomnia related to unrelenting pain and the lack of comfort

Intervention:

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• The promotion of sleep and adequate rest depends on correcting any underlying
problems, including pain and alcohol use.

Interventions:
• The promotion of comfort using techniques such as white noise, dim lighting, pain
management, stress reduction techniques, massage.
• Reduce or eliminate overhead lighting: provide night light at the bedside or in the
bathroom
• Perform only essential noisy activities during sleeping hours

Reducing environmental distractions in Hospitals:

• Close window curtains
• Reduce or eliminate overhead lighting
• Close the door of the client’s room
• Perform only essential noisy activities during sleeping hours
• Ensure that all cart wheels are well oiled
• Wear rubber soled shoes
• Keep required staff conversations at low levels

Teaching to promote rest & sleep:

• Exercise just not 2 hrs before bedtime
• Decrease fluid intake 2-4 hrs before bed
• Avoid heavy meals 3 hrs before bedtime
• Avoid alcohol & caffeine at least 4 hrs before bedtime

8. HUMAN RESPONSES TO ILLNESS

Health:
It is a complete state of physical, mental, and social well-being, and not merely the
absence of disease or infirmity. (WHO,1948)

Second definition:
“Dynamic state, in which the individual adapts to changes in internal and external
environments to maintain a state of well-being” – Potter & Perry (2014)

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Wellness:
It is the state in which attitudes and behaviors enhance the quality of life and maximizing
personal potentials.
OR
Wellness is an active state, oriented toward maximizing the potential of the individual.
OR
Wellness is a status in which individual is capable of meeting the minimum physical,
psychological, and social requirement of appropriate functioning.

Dimensions of Wellness: 7

1. Physical Potential:
Able to carry out daily tasks, achieve fitness, maintain adequate nutrition, body fat, avoid
alcohol/Drug abuse or tobacco products, practice healthy lifestyle habits.

2. Social Potential:
Able to interact successfully with people in one’s environment, to develop and maintain
intimacy with others, to develop respect and tolerance about different opinions and
believes.

3. Emotional Potential:
Ability to manage stress, expresses emotions appropriately and accepts limitations.

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4. Intellectual Potential:
Ability to learn and use information effectively for personal development and meeting
new challenges.

5. Environmental Potential:
Ability to promote health measures to enhance standard of living and quality of life in
community

6. Spiritual potential:
Belief in some forces or higher power, meaning and purpose of life (morals, values,
ethics)

7. Occupational Potential:
The ability to achieve a balance between work and leisure time, A person's beliefs about
education, employment, and home influence personal satisfaction and relationships with
others.

8. Economic
(PSEI ESO)

CONCEPTS OF ILLNESS AND DISEASE:

DISEASE
An alteration in body functions resulting in a reduction of capacities or shortening of the
normal life span.
OR
A disease is a pathological condition that impairs normal body structure and functions

Illness is a broad term that is used to describe a person who is in a poor state of health.
Illness is not always due to disease.

ILLNESS:
the unique response of a person to a disease

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“Illness is a condition characterized by a deviation from a normal health state which is

manifested by physical & psychological symptoms.” – Kozier

“Illness is a state in which a person’s physical, intellectual, emotional, social or spiritual

functioning is diminished or impaired in comparison with the previous experience.”
Potter & Perry

Variables Affecting Illness Behavior:

1. Internal Variables.
2. External Variables.

1. INTERNAL VARIABLES:
1. Perception of symptoms.
2. Nature of illness.
3. Characteristics of person

2. EXTERNAL VARIABLES:
1. Visibility of symptoms.
2. Social group.
3. Culture & values.
4. Economic variable.
5. Accessibility of health care system.

TYPES OF ILLNESSES:
ACUTE ILLNESS: rapid onset of symptoms
– Short duration
– Mostly severe
– Starts abruptly and subsides in relatively short period (less than 6 months)
Examples: Appendicitis, Pneumonia, Diarrhea, Common Cold

CHRONIC ILLNESS:
A broad term that encompasses many different physical and mental alterations.
• It is a permanent change
• It causes/is caused by irreversible alterations in normal A & P

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• It requires special patient education for rehabilitation

• It requires a long period of care or support
• Persist for more than six months
• May affect functioning of body in any dimension
• Up to the level of disability
• Major health problem
Examples: Diabetes Mellitus, COPD, Arthritis, CRF (chronic renal failure) etc.

ILLNESS BEHAVIOR:
“the way in which symptoms are perceived, evaluated, and acted upon by a person who
recognizes some pain, discomfort or other signs of organic malfunction”
OR
A coping mechanism, involves ways individual describes, monitor, interpret their
symptoms, take remedial actions, and the use of health care system.
OR
The way the sick person acts is called illness behaviour

Stages of Illness Behavior:

Edward Suchman (1972) identified 5 stages of illness behavior.
When a person experience illness, he/she generally passes through five stages of illness
behavior.
This pattern involves how a person seeks, finds & completes the health care.
1. Stage I: Symptom experience.
2. Stage II: Assumption of sick role.
3. Stage III: Medical care contact.
4. Stage IV: Dependent client care.
5. Stage V: Recovery & rehabilitation.

STAGE I – SYMPTOM EXPERIENCE (manifestation /Signs)

• feels something is wrong but is not able to diagnose the problem.
• awareness of physical change like pain, rashes, lump.
• At the end of this stage, he is able to make the decision that it is a symptom of an
illness.

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• Awareness of physical changes.

• Pain, rashes and lump etc

STAGE II –ASSUMPTION OF SICK ROLE

(Disruption of normal social roles, rights, obligation)
emotional changes such as withdrawal, depression, physical changes.
The person may deny & delay the contact with health care system.
• Accept sick role and seek confirmation
• Self-treatment
• Excuses
• Emotional responses
• Illness persist seek professional help

STAGE III –MEDICAL CARE CONTACT

the client acknowledges the illness & seeks explanation of causes, duration of illness &
it’s complications.
• Seek professional advice
• Accept or deny diagnosis
• Follow the treatment plan

STAGE IV – DEPENDENT STAGE

(Increased attention and escape for work responsibilities)
After accepting the diagnosis.
the client accepts the care, sympathy, protection from the demands & stress of life.
• Dependent for professional help.
• Accept their dependence on the primary care provider.

STAGE V – RECOVERY & REHABILITATION

symptoms of illness get subsiding.
regaining original health status.
In case of chronic illness, final stage involves an adjustment to a prolonged reduction in
health & functioning.
 Relinquish the dependent role
 Resume former roles and responsibilities.

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Acute illness (short term) – recovery fast

Chronic illness (Long term) – recovery difficult

EMOTIONAL RESPONSES TO ILLNESS:

1. Fear.
2. Over dependence & feeling of helplessness.
3. Anxiety.
4. Hope.
5. Anger & hostility.

Impact Of Illness:
1. on client.
2. on client & family.

Support During Illness:

• Family Support
• Health Care Givers Support
• Complementary and Alternative Medicine
• Faith Healing
• Homeopathy

Models of Health and Illness:

1. The Agent-Host-Environment Model (Leavell and Clark)
2. The Health–Illness Continuum (Betty Neuman)
3. The High-Level Wellness Model (Dunn)
4. The Health Belief model (Rosenstock)
5. The Health Promotion Model (Pender)

1. Agent-Host-Environment Model (Leavell and Clark)

 Agent: environmental factor or stressor, bacteria, virus, chemical substance
 Host: living organism cable of being affected by the agent

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 Environment: factors that are external to host that make illness more likely
i.e: Lack of Sleep. Cold Temperature
3 levels of prevention - Leavell and Clark

2. The Health–Illness Continuum (Betty Neuman)

 Measures a person’s level of health
 Views health as a constantly changing state with high-level wellness and death on
opposite sides of a continuum

3. The High-Level Wellness Model (Dunn)

• care for the total person
• functioning maximum potential, maintaining balance and a purposeful direction
• wellness = active state
• Incorporates the processes of being, belonging, becoming, and befitting

Active State: wellness (passive) maximizes the person’s potential. More total person
focus encompasses all of the dimensions
Being: Recognizing self as separate and individual
Belonging: Being part of a whole
becoming: Growing and Developing
Befitting: Making personal choices to befit the self of the future

Dunn (1959) described a health grid in which a health axis and an environmental axis
intersect.

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The Health axis = wellness to death,

the environmental axis = very favourable to very unfavourable.
The intersection of two axis forms four quadrants of health and wellness;
1. High level wellness in a favourable environment
2. Emergent high-level wellness in an unfavorable environment
3. Protected Poor Health in a favorable environment
4. Poor health in an unfavorable environment

4. The Health Belief Model (Rosenstock)

• “What people perceive to be true about themselves in relation to their health”
• Modifying factors for health include demographic, sociopsychological, and structural
variables
• Based on three components of individual perceptions of threat of a disease
1. Perceived susceptibility to a disease
2. Perceived seriousness of a disease
3. Perceived benefits of action

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5. Health Promotion Model (Pender)

Illustrates the “multidimensional nature of persons interacting with their environment as
they pursue health”
Incorporates individual characteristics and experiences and behavior-specific knowledge
and beliefs, to motivate health-promoting behavior
Personal, biologic, psychological, and sociocultural factors are predicative of a certain
health-related habit
Health-related behavior is the outcome of the model and is directed toward attaining
positive health outcomes and experiences throughout the lifespan

Example: Used to predict how a person is likely to incorporate health promotion

behaviors into their lifestyle.
Smoking: If parents smoke children more likely to smoke

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Primary prevention—e.g., Diet, Exercise

Level of prevention:
• Primary prevention—e.g., Diet, Exercise, Immunizations
• Secondary prevention—e.g., Screenings, Mammograms, Family Counseling
• Tertiary prevention—e.g., Medications, Surgical Treatment, Rehabilitation

Leavell and Clark (1965) defined three levels of prevention: primary, secondary,
and tertiary.
Five steps describe these levels:
1. Primary prevention:
focuses on:
(a) health promotion
(b) protection against specific health problems (e.g., immunization against
hepatitis B).
Purpose: decrease the risk / exposure of the individual or community to disease.
Examples:

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Health education

2. Secondary prevention:
Focuses on:
(a) early identification of health problems
(b) prompt intervention to alleviate health problems.
Its goal is to identify individuals in an early stage of a disease process and to limit
future disability.
Examples:
 Screening surveys
 Regular checkups
 Teaching self-assessment

3. Tertiary prevention:
focuses on restoration and rehabilitation with the goal of returning the individual to
an optimal level of functioning.
Examples:
 Rehab
 Coping

*The three levels of prevention may overlap in practice.

For example, a client may have experienced a heart attack, and a goal of secondary
prevention is to limit disability. The teaching (e.g., lifestyle changes) for the client’s
rehabilitation will be similar to the health education activities used for primary
prevention teaching. *

9. CONCEPT OF SEXUALITY
MALE REPRODUCTIVE SYSTEM:
• An adult male manufacture over 100 million sperm cells each day.

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• Testosterone, is a hormone that is responsible for the development of the secondary

sex characteristics of men such as the beard, deep voice, and masculine body shape.

FEMALE REPRODUCTIVE SYSTEM:

• Estrogen is responsible for the development of the secondary sexual characteristics
of a mature woman.
• Estrogen continues to be secreted throughout the reproductive age of the female,
regulates menstrual period in female, eggs production occurs prior to birth.

Sexuality pattern:
• Sexuality is a state or quality of being sexual including the collective characteristics
that distinguish male and female.
It comprises of: (four components of sexuality)
1. Sexual identity – male or female
2. Sex role – masculine or feminine
3. Sexual performance – hetero, bi, homo.
4. Social norms – premarital sex, consent age

1. Sexual or Gender identity:

• Anatomical state of being male and female, results from genetic and hormonal
influence
• It is sense of one's self as male or female
• Characteristic develop 8 months to 3 years of life

2. Sex role:
• This is expression of one's own gender through behavior, feeling, attitude.
• Culturally defined as feminine and masculine role.

3. Sexual orientation:
Sexual attraction towards sexual partner
• Heterosexual: "opposite sex”
• Bisexual: both

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• Homosexual:

4. Social Norms:
• Each society has their own and different norms regarding premarital sex, sexual
consent, and many other sexual behaviors
• Mostly influenced by Religion & Culture

Sexual Reproductive pattern:

• Sexual reproduction is a union that results in increasing genetic diversity of the
offspring.
• Reproduction is only one component of sexuality

NORMAL SEXUAL PATTERN:

Four stages of sexual responsiveness

1. Excitement Phase: is the first stage of the human sexual response cycle. It occurs as
the result of any physical or mental stimulation that leads to sexual arousal

2. Platuae Phase: is the period of sexual excitement prior to orgasm.

3. Orgasm Phase: is the conclusion of the plateau phase of the sexual response cycle. It
is accompanied by quick cycles of muscle contraction in the lower pelvic muscles,
which surround both the anus and the primary sexual organs.

4. Resolution Phase: occurs after orgasm and allows the muscles to relax, blood
pressure to drop and the body to slow down from its excited state.

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Abnormal Sexuality:
• Sexual behavior that is destructive to oneself or others, that is markedly constricted,
that cannot be directed toward a partner, that excludes stimulation of the primary
sex organs, and that is inappropriately associated with guilt or anxiety.

Stages of Sexuality:
• Growth and development are continuous processes, which bring a change in an
individual, every moment.
• Development of sexuality starts as early as in intrauterine life following conception
and continues through infancy, childhood, adolescence, adulthood till death
• During infancy, there is no awareness of gender.
• The child acknowledges its gender in early childhood as early as by 3 years.
• Self-awareness about sexuality (gender role, gender identity) evolves during the
childhood.

SEXUALITY TO ALL STAGES OF LIFE CYCLE:

• Adolescence is a phase of transition during which major developments of sexuality
takes place. Puberty is reached during adolescence, which is a major landmark in the
development of sexuality.
• Adolescent sexuality development can be better explained with the bio-psycho-social
model.
• Biological factors, psychological factors, as well as social factors have equal
importance in determining, the development of sexuality in adolescents.
• Other than the biological, psychological, and social factors, many more factors such
as political, legal, philosophical, spiritual, ethical, and moral values significantly
influence the sexuality development.

• Sigmund Freud had proposed his theory of psychosexual development, where he

described about – oral phase, anal phase, phallic phase, latency phase, and genital
phase as the landmark steps of psycho-sexual development.

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• During these phases, different body parts behave as most erotogenic and the
individual attempts to explore or stimulate these erotogenic zones in order to get
gratification
• He emphasized that a child's personality is formed by the ways which his parents
managed his sexual and aggressive drives.
FREUD’S PSYCHOSEXUAL STAGES:

• Stage: Focus:

• Oral (0-18 months) Pleasure centers on the mouth-sucking,

chewing, biting

• Anal (18-36 months) Pleasure focuses on bowel and bladder

elimination; coping with demands for
control

• Phallic (3-6 years) Pleasure zone is the genitals; coping with

incestuous sexual feelings

• Latency (6 to puberty) Dormant sexual feeling

• Genital (puberty on) Maturation of sexual interest.

• Sexuality is a normative and physiological component of adolescent development and

usually this group engage in risky sexual practices such as early sexual intercourse,
multiple sexual partners, unprotected sexual intercourse, and casual sex
• Adulthood, is a time of exploration, experimentation, and instability.
• Adolescents and youth are one of the populations most impacted by sexually
transmitted infections (STIs), including human immunodeficiency virus (HIV) and
papillomavirus (HPV)
• Sociocultural differences are determinant of sexual behaviors, influencing the age of
first intercourse, number of partners, coercive sexual culture and it can affect the
probability of being engaged in risky sex

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• Sexuality in older age concerns the sexual drive, sexual activity, interests,
orientation, intimacy, self-esteem, behaviors, and the social perceptions concerning
sexuality in older age.
• Older people engage in a variety of sexual acts from time to time for a variety of
reasons.
• Desire for intimacy does not disappear with age.
• Sexuality in older age is often considered a taboo yet it is considered to be quite a
healthy practice; however, this stigma can affect how older individuals experience
their sexuality.
• While the human body has some limits on the maximum age for reproduction, sexual
activity can be performed or experienced well into the later years of life

FACTORS AFFECTING SEXUALITY:

• Quality of relationship
• Cognition and perception
• Culture, value and believe
• Self-concept
• Previous experience
• Environment
• Pregnancy
• Illness and diseases
• life circumstances
• Personality traits
• Biological makeup

RISKS AND ALTERATION IN SEXUALITY:

• General health status (Chronic diseases)
• Sexual abuse
• Sexual dysfunction
• Impotence and ejaculatory dysfunction
• Dyspareunia – painful genitals before /during sex

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NURSING CARE PROCESS:

Assessment:
• History; About existent sexual problem
• Type and quality of relation among partners
• Level of knowledge
• Drug and other illness
• PLISSIT model

PLISSIT model:
• The model was created in 1976 by Jack S. Annon
• The PLISSIT Model offers nurses or case managers a concise framework for
intervention to address patients' concerns at the earliest stages of their distress, and
helps assure informed feedback to the healthcare team regarding the patients' sexual
issues.

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Nursing Diagnosis:
• Ineffective sexuality pattern.
• Sexual dysfunction
• Rape trauma syndrome

Goal:
• The person will resume previous sexual activity
• The person will have alternative sexual activity

Nursing Interventions:
• Establish trusting relationship
• Maintain privacy
• Active listening
• Clarify the patient that sexuality does not mean only intercourse
• Discuss alternative methods

10. CONCEPT OF LOSS, DEATH, AND GRIEVING

Death is defined as “The irreversible cessation of all vital functions especially as indicated by
permanent stoppage of the heart, respiration, and higher brain function”

Dying means “approaching death”

PHYSIOLOGIC SIGNS OF DEATH:

The four main characteristic changes are;
• Loss of muscle tone
• Slowing of the circulation
• Changes in the vital signs
• Sensory impairment

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The following guidelines for physicians as indications of death.

1. Total lack of response to external stimuli
2. No muscular movement (esp. breathing)
3. No reflexes
4. Flat encephalogram.

BELIEFS AND ATTITUDES ABOUT DEATH IN RELATION TO AGE:

• Infancy to 5 years; Does not understand concept of death, believes death is
reversible, temporary departure or sleep.

• 5 to 9 years; Understand death is final, believes own death can be avoided, believes
wishes and unreleased actions can be responsible for death.

• 9 to 12 years; Begin to understand own mortality, expressed in after life and fear of
death.

• 12 to 18 years; May still hold concept from previous developmental stages, may
seem to reach “adult’’ perception of death but be emotionally unable to accept it.

• 18 to 45 years; Has attitude towards death influenced by religious and cultural

beliefs.

• 45 to 65 years; Accepts own mortality. encounters death of parents and some peers
experiences.

• 65 years +; Fears prolonged illness, sees death as having multiple meanings, (eg,
freedom from pain, reunion with already deceased family)

DYING PATIENTS:
We may help the dying patient meet his/her
1. Physiological Needs
2. Spiritual Needs
3. Emotional Needs

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1. PHYSIOLOGIC NEEDS:
• Providing personal hygiene measures
• Controlling pain
• Relieving respiratory difficulties
• Assisting with movement, nutrition, hydration, and elimination.
• Providing comfort to the patient

2. SPIRITUAL SUPPORT:
• Identify patient spiritual needs
• Respect the beliefs of patients
• Be willing to listen and discuss issues of spirituality
• Demonstrate empathy
• Provide a supportive presence
• Refer to community resources or spiritual leaders
• Acknowledge and provide for the rituals

3. EMOTIONAL SUPPORT:
• Compassion (desire to help)
• Responsiveness to emotional needs
• Maintain a positive attitude
• Expressing empathy
• Attending wishes
• Being present.

PHYSICAL CHANGES AFTER DEATH:

– Pupils - Fixed and dilated
– Algor Mortis- Rapid cooling of the body
– Rigor Mortis- Stiffening of the body, develops 2-4 hours after death
– Livor Mortis- Purple discoloration of skin in dependent areas

CARE AFTER DEATH:

• Death certificate by physician.

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• Autopsy (written permission)

• Customs & principles are kept in mind.
• Positioning- body straitened & arms laid at the side.
• Eyes are closed as in sleep.
• Dentures are removed & prop chin in position with bandaging.
• Remove all the appliances used for patient care. (e.g. Catheter, tubing's, I,V.sets, etc)
• Remove ornaments and list them to relatives.
• All orifices are to be plugged with cotton to prevent escape of body discharges.
• Prevention of spread of diseases (i.e sealing body)
• Send body clean and neatly dressed.
• An identification tag.
• If relatives are present then body is handed over them with proper written legal
authority permission.
• Maintain record of death and inform to authority for register of deaths. for body.

LEGAL ASPECTS OF DEATH:

Federal and state law require that institutions develop policies and procedures for
certain events that occur after death.

1. Requesting organ or tissue donation

2. Autopsy
3. Certifying and documenting the occurrence of a death.
4. Providing safe and appropriate post mortem care.

In unusual death, an autopsy (postmortem examination) may be required.

Request family member consent and signature for autopsy.

Several reasons for a death becoming a case for the coroner:

– Death by suspicious means or not under a doctor’s care
– Death resulting from an accident
– Client has been hospitalized for less than 24 hours

• Dying Persons’ Bill of Rights -

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• Passive euthanasia -
• California Law (1976)- “Right to Die” bill -
• California Natural Death Act -

LOSS:
Loss occurs when a valued person, object, or situation is changed.
OR
Loss can be defined as the undesired change or removal of a valued object ,person or
situation
Loss is a universal experience that occurs throughout the lifespan.

Types of loss:
1. Actual Loss
can be recognized by others including the person sustaining the loss,
ex: a person losing a limb, spouse, valued object, job etc.

2. Perceived loss
felt by the person but is intangible to others
e.g. loss of your youth, financial dependence, loss of confidence or prestige.

3. Anticipated loss
the person displays loss and grief behaviors for loss that has yet to take place.
EX: families with terminally ill patients and serves to lessen the impact of actual loss

GRIEF:
Grief is an emotional response to a loss.
Grief is a form of sorrow involving feelings, thoughts and behaviors caused by
bereavement (state of deprived).
Grief is the physical, psychological, and spiritual responses to loss.
Grief is a “set of cognitive, emotional, and social difficulties that follow the death of a
loved one.”

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The grief process involves a sequence of affective, cognitive and psychological states
as a person responds to and finally accepts a loss.
It is a normal, natural, necessary, and adaptive response to a loss.

Loss & Grieving:

• LOSS Something of value is gone
• GRIEF Total response to emotional experience related to loss
• BEREAVEMENT Subjective response to by loved ones
• MOURNING Behavioral response

Functions of Grief:
• To make the outer reality of the loss in to an internally accepted reality
• To lessen the emotional attachment to the lost person or object
• To make it possible for the bereaved person to become attached to other people or
objects (moving on)

Types Of Grief: 4
1. Anticipatory grief
2. Normal or common grief
3. Complicated grief (when your grieving process does not move all the way through the steps of
grief. It can be prolonged and much more intense)
4. Disenfranchised grief /Ambiguous gried (you feel that your loss isn’t validated by others, a
culture or society doesn’t recognize your loss. Death of an addict, suicide.)

Common Grief Reactions: 4

A grief reaction is a set of psychological and somatic (body) symptoms that results from
extreme sorrow or loss.
These reactions fall into four different categories:
I. Thought Patterns
II. Physical Sensations
III. Emotions
IV. Behaviors.

COMMON CLINICAL MANIFESTATIONS OF GRIEF:

• Shock and disbelief

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• Sadness
• Guilt
• Anger
• Fear
• Disorganized behavior
• Physical symptom:
Anorexia , GI issues, SOB etc.

STAGES OF GRIEF: 5
Kubler-Ross, in extensive research with terminally ill patients, identified five stages of
feelings and behaviours that individuals experience in response to a real, perceived or
anticipated loss.

KUBLER-ROSS STAGES OF GRIEVING (1969)

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

1. Denial and Isolation

• Denial is a conscious or unconscious refusal to accept facts, information, reality, etc.,
relating to the situation concerned.
• It's a defense mechanism and perfectly natural.

2.Anger
• Anger can manifest in different ways.
• People dealing with emotional upset can be angry with themselves, and/or with
others, especially those close to them.
• “Why me?” and It’s not fair!” are comments often expressed during anger stage.

3. Bargaining
 Traditionally the bargaining stage for people facing death can involve attempting to
bargain with whatever God the person believes in.

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 For example "Can we still be friends?" when facing a break-up.

 Bargaining rarely provides a sustainable solution, especially if it's a matter of life or
death.

4. Depression
• full impact of the loss is experienced.
• This is a time of quiet desperation and disengagement from all association with the
lost entity.

5. Acceptance
 The final stage brings a feeling of peace regarding the loss that has occurred.
 It is a time of quiet expectation and resignation.
 The focus is on the reality of the loss and its meaning for the individuals affected by
it.
 Reaching this stage of mourning is a gift not afforded to everyone.

NURSING IMPLICATIONS:
• providing comfort, maintaining safety, addressing physical and emotional needs, and
teaching coping strategies to terminally ill patients and their families.
• the nurse must explain what is happening to the patient and the family and be a
confident who listens to them talk about dying.
• Hospice care (palliative care)
• The nurse must also be concerned with ethical considerations and quality-of-life
issues that affect dying people
• Of utmost importance to the patient is assistance with the transition from living to
dying, maintaining, and sustaining relationships, finishing well with the family, and
accomplishing what needs to be said and done.
• In the hospital, in long-term care facilities, and in home settings, the nurse explores
choices and end-of-life decisions with the patient and family.

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• Referrals to home care and hospice services, as well as specific referrals appropriate
for the management of the situation, are initiated.
• Advocate for the dying person. The use of living wills and advance directives allows
the patient to exercise the right to have a "good death or to die with dignity.

(Discuss the effects of multiple losses on the grief process)

11. CONCEPT OF STRESS AND COPING

Stress is a person response to stressor such as an environmental condition or a stimulus.
OR
Mind and body response or reaction to a real or imagined threat, event, or change.
OR
Stress is condition in which the person experience changes in the normal balance state.

 Stressor----- event or stimulus

 Coping strategies, coping response, coping mechanism-----person response to stress

Stress can result from both positive and negative experiences........

Examples;
• A bride preparing for her wedding
• A graduate preparing to start new job
• A husband concern about caring of his wife and family
• Diagnosis of cancer
• Losing of special object, person

STRESS COPING:
"The cognitive and behavioral efforts to manage specific internal demands (infection,
feeling of depression) or external demands (move to another city, death in family) that are
appraised as exceeding the resources of a person".
Folkman and Lazarus (1991)

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GENERAL ADAPTATION SYNDROME (GAS) AS BIOCHEMICAL MODEL OF STRESS

(HANS SELYE)

GAS occurs in three stages,

Alarm Reaction Stage

During this stage, your body sends a distress signal to your brain.
Your brain responds by sending a message to the body releasing hormones called
glucocorticoids and adrenaline.
elevated blood pressure and heart rate levels.

Resistance Stage
During this stage, your body tries to thwart the changes that occurred during the reaction stage
employing the parasympathetic nervous system.
occurs when stressor has stopped.

If you remain stressed, the reaction stage will persist.

In the resistance stage, your body begins to lower your blood pressure and heart rate.
It also reduces the amount of adrenaline and cortisol being produced.

Your body remains on alert in this stage and can easily switch back to the reaction stage if the
stressor persists.
At this stage, your body is simply trying to recover from the shock of the alarm reaction stage.

Exhaustion Stage
Stress puts your body through a toll, and the exhaustion stage occurs after prolonged stress.
Here, even if the stressor persists, your body is too depleted to continue to combat it.

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This is the riskiest stage of general adaptation syndrome, as you are most prone to developing
health conditions here.

Indicators of stress:
1. Physiological indicators
2. Psychological indicators

1. PHYSIOLOGICAL INDICATORS
• Result from the activation of sympathetic and neuroendocrine systems
• Clinical manifestations lists physiological indicators of stress:
• Pupils dilates
• Sweat production
• Heart rate increase
• Cardiac output increase
• Skin is paled (because of constriction of peripheral blood vessels)
• Sodium and water retention increase which increase blood volume
• Rate and depth of respiration increase (because of dilation of bronchioles)
• Urinary output decrease
• Mouth may be dry
• Peristalsis of intestine decrease
• Muscles tension increase

2. PSYCHOLOGICAL INDICATORS:
1. Anxiety
2. Fear
3. Anger
4. Depression
5. Unconscious Ego Mechanism

1. Anxiety: Common reaction to stress

• A state of mental uneasiness, apprehension, or a feeling of helplessness related to an
impending or anticipated unidentified threat to self or significant relationships.

Four levels of anxiety

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1. Mild Anxiety
2. Moderate Anxiety
3. Severe Anxiety
4. Panic

2. FEAR
An emotion or feeling of apprehension aroused by impending or seeming danger,
pain, or another perceived threat

Anxiety and Fear differ in four ways

1. The source of anxiety may not be identified

2. Anxiety is related to mainly future, to an anticipated event,

fear is related to past, present, and future

3. Anxiety is Vague, whereas fear is definite

4. Anxiety results from psychological or emotional conflicts,

fear results from a specific physical or psychological entity.

3. Anger
An emotional state consisting of a subjective feeling of animosity or strong displeasure

4. Depression
• A common reaction to events that seem overwhelming or negative
• An extreme feeling of sadness , despair , dejection , lack of worth , or emptiness

5. Unconscious Ego Mechanisms

Unconscious psychological adaptive mechanism or mental mechanisms that develop
as the personality attempts to defend itself , establish compromises among
conflicting impulses and calm inner tensions

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COPING PATTERN:
• The cognitive and behavioral efforts to manage specific external or internal demands
that are appraised as exceeding the resources of the person - Folkman and Lazarus (1991)
OR
• A natural or learned way of responding to a changing environment or specific
problem or situation

TYPES OF COPING: 7
1. Problem- focused coping
2. Emotion-Focused coping
3. Long term coping strategies
4. Short term coping strategies
5. Adoptive coping
6. Maladaptive coping
7. Care-giver burden

1. Problem- focused coping

Refers to efforts to improve a situation by making changes or talking actions (Lazarus 2006)

2. Emotion-focused coping
• Include thoughts and actions that relieve emotional destress
• Doesn't improve the situation but the person often feels better (Lazarus 2006)

3. Long term coping strategies

• Can be constructive and practical
• In certain situations talking with others and trying to find out more about the
situation are long term strategies

Other long term Coping strategies include

• Lifestyle pattern
e.g.

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 Eating a healthy diet

 Exercising regularly
 Decision making

4. Short term coping strategies

• Can reduce stress to a tolerable limit temporarily but are ineffective ways to
permanently deal with reality.
• These may even have destructive or detrimental effect on the person
• Examples;
• Using Alcohol
• Using drugs

5. Adaptive coping
• Helps the person to deal effectively with stressful events and minimizes distress
associated with them
• Effective coping result in adaptations

6. Maladaptive coping
• Can cause unnecessary distress for the person and others associated with the person
or stressful events
• Ineffective coping result in maladaptation

7. care giver Burden

• Reaction to a long-term stress is seen in family members who undertake the Care of a
person in the home for long time period
• Produces responses such as chronic fatigue, sleeping difficulties and high blood
pressure

FACTORS AFFECTING COPING PATTERN DURING HOSPITALIZATION:

Anxiety:
feelings of tension, worried thoughts, and physical changes like increased blood pressure.

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 Anxiety in hospital: Depression and anxiety are common in hospitalized patients

especially those waiting for surgery and with chronic or hard-to-treat conditions.
Hospitalization exacerbates patients' emotions, and increases feelings of depression
and anxiety.

Fear:
More prosaic issues might result in the fear of hospitals, such as smells, sick roommates,
and a complete lack of privacy. Media reports surrounding medical mishaps often result in
fear among patients.

• Referral to a reliable support system and programs increase the chances of

successfully managing, treating, and overcoming phobias and other fears.

• Possibility of fear for nurse: the possibility of harming a patient is their biggest fear.
“We are the gatekeepers of health.

Sleep:
Less quality sleep, then the patient cannot manage such stress.
• Sleep loss: cardio-metabolic derangements and increased risk of delirium (Sudden
and serious change in metal health)

Isolation from parents

Change in nutrition
teeth that are in poor condition, or unfit dentures

Economic:
Cannot afford and sustain their cost that way the copping pattern is affected.

Social culture:
• They affect decisions about a patient's treatment and who makes the decisions.
• Cultural differences create problems in communication, rapport, physical
examination, and treatment compliance and follow through.

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• The special meaning of medicines and diet requires particular attention.

NURSING MANAGEMENT OF STRESS:

Assessing
History:
Client perceived stressors or stressful incidents
Manifestations of stress
Past coping strategies
Present coping strategies

Physical examination:
• Verbal and cognitive manifestations
• Indicators of stress such as, Nail biting, Nervousness, Weight changes
• Stress related health problems such as:
• Hypertension
• Hyperthyroidism
• Dyspnea

Nursing diagnosis
• Anxiety related to unconscious conflict's about essential goals and values of life
• threat to self-concept
• positive or negative self-talk
• physiological factors (E.g hyperthyroidism , dysrhythmias ,dyspnea )

Planning
• Decrease or resolve anxiety
• Increase ability to manage or cope with stressful events or circumstances
• Improve role performance

Implementation
• stress is highly individualized
• Physical exercise (relief mention, feeling of wellbeing, relaxation)
• Optimal Nutrition (balanced diet)

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• Adequate rest and sleep (sleep restore bodies energy levels and is essential aspect of
stress management)
• Time management (people who manage their time effectively usually experience less
stress because they feel more in control of their circumstances)

Evaluation
• How does the client perceive the problems?
• Is there an underlying problem not identified?
• Have new stressors occur that interfere with successful Coping?
• Were existing coping strategies sufficient to meet intended outcomes?
• How does the client perceive the effectiveness of new coping strategies?
• Did the client implement new coping strategies properly?
• Did the client access and use available resources?
• Have family members and significant others provided effective support?

Stress Management for Nurses:

Stressors:
• Increasing severity of client illness
• Adjusting to various work shifts
• Inadequate support from supervisors
• Caring for dying client etc.
some Nurses become overwhelmed and develop Burnout

BURNOUT
• A complex syndrome of behavior
• The Nurses with Burnout manifests physical and emotional depletion
• A negative attitude and self-concept
• Feeling of helplessness and hopelessness

STEPS TO REDUCE STRESS FOR NURSES

• Plan daily relaxation programs to reduce tension (I.e. read novels, listen to music or
other favorite activities)
• Establish regular exercise program

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• Learn to accept failure's

• Seek counseling if indicated
• Support each other as a team
• Take time to relax
• Eat properly
• Learn something New

12. Medication (parenteral)

Para: outside
Enteron: intestine (i.e. beside the intestine)
Other than oral routes.
injection or infusion: needle or catheter

Parenteral are sterile solutions or suspension of drug in aqueous or oily vehicle.

Parenteral drugs are administered directly in to the veins, muscles or under the skin , or
more specialized tissues such as spinal cord.

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PARENTERAL ROUTES:
four major sites of injection:
1. Intradermal (ID): Injection into the dermis just under the epidermis.
2. Subcutaneous (SC): Injection into tissues just below the dermis of the skin.
3. Intramuscular (IM): Injection into a muscle.
4. Intravenous (IV): Injection into a vein.

Some medications are administered into body cavities.

5. Intra-arterial
6. Intracardiac
7. Intrathecal – spinal theca
8. Intracisternal -
9. Peridural -
10. Intraarticular – between joints
11. Intracerebral
12. Intrapleural
13. Intraosseous
14. Intraperitoneal

INTRADERMAL INJECTIONS (ID):

0.1ml
frequently used for allergy testing and tuberculosis (TB) screening.
• Use a tuberculin or small hypodermic syringe for skin testing.
• The angle of insertion for an intradermal injection is 5 to 15 degrees
• Needle used is a short (3/8 inch) length, gauge (25-27G).

– Local Anesthesia
– Diagnostic Tests
– Immunizations (BCG vaccine)
After injecting the medication, a small bleb resembling a mosquito bite appears on the
surface of the skin

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Check the 5 Right then:

1. Wash hand and Take equipment to the patient's side.
2. Explain procedure to patient.
3. Locate the site of injection, and cleanse the skin with a spirit swab, allow the area to
dry.
4. Remove needle cap and holds syringe at 10˚-15˚ angle from skin with bevel up and
Inject the solution.
5. Remove the needle quickly but gently at the same angle used for injection.
6. Wipe with dry cotton ball but do not press or massage the injection site.
7. Chart the data and time of the administration of the drug.
8. Take care of the equipment & return to their places.

SUBCUTANEOUS INJECTIONS (SC):

Absorption of the drug is rapid. E.g. insulin
Injection sites:
• The outer posterior aspect of the upper arms
• The abdomen
• The anterior aspects of the thighs
• The scapular areas of the upper back
• The upper ventral or dorsal gluteal areas.

Subcutaneous (SC; SQ; Sub Q):

• The injection is given under the skin
• Need to be isotonic
• Up to 2 ml is given
• Using ½ to 1 inch
• 23-gauge needle or smaller needle
• angle: 90 or 45 degrees.

Kinds of drugs commonly administered:

1. Vaccines
2. Preoperative medications

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3. Narcotics
4. Insulin
5. Heparin – prevent blood clots /blood thinner /anticoagulant
6. Scopolamine - to prevent nausea and vomiting caused by motion sickness or
medications used during surgery (antimuscarinics)
7. Epinephrine

• Only small volumes (0.5 to 1.5 mL)

Subcutaneous Injection Procedure:

Check the 5 Right then:
1. Wash hand and Take equipment to the patient's side.
2. Explain procedure to patient.
3. Locate the site of injection, and Cleanse the skin with a spirit swab, allow the area to
dry.
4. Remove needle cap and holds syringe at 45˚angle, then inject the needle.
5. Draw back the plunger to check you are or aren't in the blood vessel (Blood return
should not be seen) then inject the solution.
6. Remove the needle quickly but gently at the same angle used for injection and
massage the area with alcohol swab.
7. Chart the data and time of the administration of the drug.
8. Take care of the equipment & return to their places.

INTRAMUSCULAR INJECTION (IM):

drug aqueous = absorption rapid
if the drug is in an oily liquid or in the form of a suspension, it can prolong the release of
the drug.

Used to administer:
Some antibiotics
Vitamins or iron
Some Vaccines (DTP) (Diphtheria-Tetanus-Pertussis)
Given:

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• Solutions
• Emulsions
• Oils
• Suspension

– Needle used is (1-1.5 inch) length, gauge(19-22G).

– Volume usually 2-5 ml are injected.
– Inject the needle at an angle of 90˚.

• Striated muscle fibre

• 0.5 to 2 ml sometimes up to 4 ml
• Preferably isotonic

Principle sites: 4
• Gluteal (buttocks) (Ventrogluteal , Dorsogluteal)
• Deltoid (upper arms)
• Vastus lateralis (lateral thigh)
• Rectus Femoris

Intramuscular Injection Procedure:

Check the 5 Right then:
1. Wash hand and Take equipment to the patient's side.
2. Explain procedure to patient.
3. Locate the site of injection, and Cleanse the skin with a spirit swab, allow the area to
dry.
4. Remove needle cap and holds syringe at 90˚ angle then Inject the needle .
5. Draw back the plunger to check you are or aren't in the blood vessel (Blood return
should not be seen) then inject the solution.
6. Remove the needle quickly but gently at the same angle used for injection and
massage the area with alcohol swab.
7. Chart the data and time of the administration of the drug.
8. Take care of the equipment & return to their places.

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By Asif Rasool
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INTRAVENOUS INJECTIONS (IV):

• Fast-acting route
• Often used in the emergency department and in critical care areas

Commonly used
– For fluid and electrolyte replacement
– To provide necessary nutrition to the patient who is critically ill
• Needle used is (1-1.5 inch) length, gauge (16-20 G).
• Intravenous (IV) injections are administered at an angle of 15˚-20˚

For adults, the veins on the arm are:

– Basilic vein
– Median cubital vein
– Dorsal veins
– Median vein
– Radial vein
– Cephalic vein

On the foot, the veins are;

– Great saphenous vein
– Dorsal plexus

Given:
• Aqueous solutions
• Hydro alcoholic solutions
• Emulsions
• Liposome

Intravenous Injection Procedure:

Check the 5 Right then:
1. Wash hand and Take equipment to the patient's side.
2. Explain procedure to patient. Expose the arm and apply tourniquet
3. Ask pt. To open and close his fist.

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4. Palpate the vein and clean with alcohol swab the site of the injection
5. Remove needle cap and holds syringe at 15˚-20˚ angle.
6. Puncture the vein and draw back (Blood return should be seen (.
7. Once you know that you are in the vein, release the tourniquet and gently lower the
angle of the needle then inject the solution very slowly.
8. Remove the needle quickly but gently at the same angle used for injection and apply
pressure over the area to prevent bleeding.
9. Chart the data and time of the administration of the drug.
10. Take care of the equipment & return to their places

COMPLICATIONS DURING IV THERAPY:

• Infiltration:
escape of fluid into subcutaneous tissue due to dislodgement of the needle causing
swelling and pain.
Gross infiltration may result in nerve compression injury which can result in
permanent loss of function of extremity or in case of irritating medications (vesicant),
significant tissue loss, permanent disfigurement or loss of function may result.

• Phlebitis:
the inflammation of the vein.
This may result from mechanical trauma due to the insertion too big a needle (for
small vein) or leaving a device in place for a long time.
Chemical trauma results from irritation from solutions or infusing too rapidly.
This manifests as pain or burning sensation along the vein. On observation, there may
be redness, increased temperature over the course of the vein. The site should be
changed and warm compress should be applied.

• Circulatory Overload:
the intravascular fluid compartment contains more fluid than normal.
This occurs when infusion is too rapid or excess volume is infused.
This manifests as dyspnea, cough, frothy sputum, and gurgling sounds on aspiration.

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• Embolism:
obstruction of the blood vessels by travelling air emboli or clot of the blood.
It is fatal

General requirements of parenteral preparations:

• Stability
• Sterility
• Free from Pyrogens
• Free from foreign particles
• Isotonicity
• Specific gravity
• Chemical purity

Equipment:
Needles:
the smaller the number, the larger the gauge (inside diameter)
Length – long enough to penetrate the appropriate layers of tissue

Syringes
• Barrel
• Plunger
• With or without needle
• Calibrated in milliliters or units

Needles:

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Most needles are made of stainless steel, and all are disposable.
A needle has three parts:
1. The hub, which fits onto the tip of a syringe
2. The shaft, which connects to the hub
3. The bevel, the tip of the needle
The hollow bore of the needle shaft is known as the lumen.

Needle Size-is Designated by Length and Gauge:

length: in inches from the juncture of the hub and the shaft to the tip of the point.
lengths range from 3/8 inch to 3 1/2 inches; some special use needles are even
longer.
gauge of a needle ranges from 27 (the finest) to 13 (the largest).
(The gauge varies from 18 to 30) – WTF?

Long needles for IM

Short for SC

Preventing needle stick injuries:

• One of the most potentially hazardous procedures.
• hepatitis B virus, human immunodeficiency virus (HIV).
• puncture-proof disposal containers
• Never throw sharps in wastebaskets.
• Never recap used needles
• When recapping a needle, Use a one-handed “scoop” method:
• a) Placing the needle cap and syringe with needle horizontally on a flat
surface.

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• b) Inserting the needle into the cap, using one hand.

• c) Then using your other hand to pick up the cap and tighten it to the needle
hub.

SYRINGES:
Syringes have three parts:
1. The tip, which connects with the needle
2. The barrel, or outside part, on which the scales are printed
3. The plunger, which fits inside the barrel

Types Of Syringes: 6
sizes from 1 to 60 mL.
from 1 to 3 mL in size for injections (e.g. subcutaneous or intramuscular).

1. Standard- comes in 3ml, 5 and 10ml

2. Insulin
3. Tuberculin-narrow syringe, use to administer small or precise doses such as
pediatric dosages.
4. Should be used for doses of 0.5ml or less
5. Pre-filled Single dose Syringe
6. Autoinjectors

Cannula:
flexible tube
intravenous fluids, blood samples and for administering medicines.

Types Of Cannulas:
1. IV cannula pen-like model.
2. IV cannula with wings model.

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3. IV cannula with injection part model.

4. IV cannula y-type model.
5. Butterfly Canula

Pen like Model Canula:

Canula with Injection Portal Model:

Y-Type Model of IV Canula:

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Butterfly cannula:

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Parenteral Drug Packaging:

Ampule – glass or plastic
Vial

Advantages of the Parenteral Route:

• The IV route is the fastest method for delivering systemic drugs
• Preferred administration in an emergency situation
• It can provide fluids, electrolytes, and nutrition.
• Patients who cannot take food or have serious problems with the GI tract
• It provides higher concentration of drug to bloodstream or tissues
• Advantageous in serious bacterial infection.
• IV infusion provides a continuous amount of needed medication
• Infusion rate can be adjusted.
• To provide more or less medication as the situation dictates
• Drug action can be prolonged by modifying the formulation

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Disadvantages of the Parenteral Route:

• Traumatic injury from the insertion of needle
• Potential for introducing:
– Toxic agents
– Microbes
– Pyrogens
• Impossible to retrieve if adverse reaction occurs
• Injected directly into the body
• Correct syringe, needle, and technique must be used
• Rotation of injection sites with long-term use
• Sensitivity or allergic reaction at the site of injection
• Prevents scarring and other skin changes
• Can influence drug absorption
• More expensive and costly to produce
• Trained person is required.
• Require specialized equipment, devices, and techniques to prepare and administer
drugs
• Requires strict control of sterility & non pyrogenicity than other formulation

Pyrogen: fever causing agent, LPS lipopolysaccharide, endotoxin

(Define medication, drug, prescription orders and other related terms)

(Learn timings and basic formulas to calculate dosages of oral and parenteral medication)
(Discuss the rights and legal aspects of medication administration)
(Explain the factors affecting the medication action and Administration)
(Discuss different effects of medications)

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 By Asif Rasool
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Chapter: CRITICAL THINKING

CRITICAL THINKING:
Careful and goal-directed thinking that is used to assess more complicated situations,
identify actual and potential problems, and make decisions about an action plan.
• Critical thinking is the ability to think clearly and rationally about what to do or
what to believe.
• It includes the ability to engage in reflective and independent thinking.

Critical thinking and clinical Reasoning:

The practice of nursing requires critical thinking and clinical reasoning.

CRITICAL THINKING
Is the process of intentional higher-level thinking of defining a clients’ problem,
examining, the evidence – based practice in caring for the client, and make choices in the
delivery of care.

Clinical reasoning:
Is the cognitive process that uses thinking strategies to gather and analyze client’s
information, evaluate the relevance of the information, and decide on possible nursing to
improve the clients physiological and psychosocial outcomes.
Clinical reasoning requires the integration of critical thinking in the identification of the
most appropriate interventions that will improve the clients’ condition.

Components of Critical Thinking:

1. Ask questions to determine the reason why certain developments have occurred and
to see whether more information is needed to understand the situation accurately.
2. Gather as much relevant information as possible to consider as many factors as
possible
3. Validate the information presented to make sure that it is accurate (not just
supposition or opinion), that it makes sense, and that it is based on fact and evidence
4. Analyze the information to determine what it means and to see whether it forms
clusters or patterns that point to certain conclusions.

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5. Draw on past clinical experience and knowledge to explain what is happening and to
anticipate what might happen next, acknowledging personal bias and cultural
influences.
6. Maintain a flexible attitude that allows the facts to guide thinking and takes into
account all possibilities.
7. Consider available options and examine each in terms of its advantages and
disadvantages.
8. Formulate decisions that reflect creativity and independent decision making.

CRITICAL THINKING IN NURSING PRACTICE:

Nurses must use critical thinking skills in all practice settings—acute care, ambulatory care,
extended care, and in the home and community.
• Regardless of the setting, each patient situation is viewed as unique and dynamic.
• The unique factors that the patient and nurse bring to the health care situation are
considered, studied, analyzed, and interpreted.
• Interpretation of the information presented then allows the nurse to focus on those
factors that are most relevant and most significant to the clinical situation.
• Decisions about what to do and how to do it are then developed into a plan of action.

APPLYING CRITICAL THINKING TO NURSING PRACTICE:

Implementation of the nursing process provides nurses with a creative approach to
thinking and doing to obtain, categorize, and analyze client data and plan actions that will
meet the client’s needs.

Problem Solving
Process used when a gap is perceived between an existing state (what is occurring) & a
desired state of what should be occurring.
Throughout the problem-solving process the implementation of critical thought may or
may not be required in working toward a solution (Wilkinson, 2012). The nurse carefully
evaluates the possible solutions and chooses the best one to implement.
Commonly used approaches to problem solving include:
trial and error, intuition, and the research process

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1. Trial and Error:

• In trial and error, a number of approaches are tried until a solution is found.
• The use of trial- and-error methods in nursing care can be dangerous because the
client might suffer harm if an approach is inappropriate.
• However, nurses often use trial and error in the home setting due to logistics,
equipment, and client lifestyle.

2. Intuition
• Is a problem-solving approach that relies on a nurse’s inner sense.
• It is a legitimate aspect of a nursing judgment in the implementation of care.
• Intuition is the understanding or learning of things without the conscious use of the
reasoning.
• It I also known as sixth sense, feeling, or suspicion.

3. Clinical judgment:
• In nursing is a decision-making process to ascertain the right nursing action to be
implemented at the appropriate time in the client’s care.
• The nurse must first have the knowledge base necessary to practice in the clinical
area and then use that knowledge in clinical practice.
• Clinical experience allows the nurse to recognize cues and patterns and begin to
reach correct conclusions.

4. Research Process:
 Is a formalized, logical, systematic approach to problem solving.
 The classic quantitative research process is most useful when the researcher is
working in a controlled situation. Health professionals, often working with people.
 For example, unlike many experiments with animals in which the environment can be
strictly regulated, the effects of diet on health in humans are complicated by a
person’s genetic variations, lifestyle, and personal preferences. However, it is
becoming increasingly important for nurses to identify evidence that supports
effective nursing care. One critical source of this evidence is research.

WAYS TO ENHANCE CRITICAL THINKING IN NURSING: 5

1. Recognition

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2. Questioning
3. Information gathering
4. Evaluation
5. Communication

CHARACTERISTICS OF CRITICAL THINKERS:

1. Strive for understanding
2. Are honest with themselves
3. Base judgment on evidence
4. Are interested in other people’s ideas
5. Control their feeling/emotions
6. Keep an open mind
7. They are very observant
8. Identify key issues and raise questions
9. Obtain relevant facts
10. Evaluate the findings from judgments

SKILLS USED IN CRITICAL THINKING: 6

1. Analytical skills
2. Communication
3. Creativity
4. Open Minded
5. Problem solving
6. Identifying Biases

1. Analytical Skills:
People with analytical skills can examine information, and then understand what it
means, and what it represents.
• Asking thoughtful questions
• Data analysis
• Information seeking
• Interpretation
• Judgment
• Questioning evidence

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• Recognizing differences and similarities

2. Communication:
Often, you will need to share your conclusions with your employers or with a group
of colleagues.
You need to be able to communicate with others to share your ideas effectively.
• Assessment
• Collaboration
• Explanation
• Expressing opinions and ideas
• Presentation
• Teamwork
• Verbal communication
• Written communication

3. Creativity:
Critical thinking often involves some level of creativity.
You might need to spot patterns in the information you are looking at or come up
with a solution that no one else has thought of before.
All of this involves a creative eye.
• Cognitive flexibility
• Conceptualization
• Curiosity (interest)
• Imagination
• Making abstract connections
• Predicting
• Synthesizing (produce)
• Visionary (idealistic)

4. Open Minded:
Put aside any assumptions or judgments and merely(simply) analyze the information
you receive.
You need to be objective, evaluating ideas without bias.
• Embracing different cultural perspectives

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• Fair
• Humble
• Inclusive (wide range)
• Objective (neutral)
• Observation

5. Problem Solving:
Problem solving is another important critical thinking skill that involves analyzing a
problem, generating, and implementing a solution, and assessing the success of the
plan.
• Applying standards
• Attention to detail
• Clarification
• Collaboration (team work)
• Decision making
• Evaluation
• Innovative (advanced)
• Logical reasoning

6. Identifying Biases
This skill can be exceedingly difficult, as even the smartest among us can fail to
recognize biases.
• Strong critical thinkers do their best to evaluate information objectively.
• Think of yourself as a judge in that you want to evaluate the claims of both sides
of an argument, but you’ll also need to keep in mind the biases each side may
possess.

FACTORS THAT AFFECT THINKING:

1. Attitude
2. Common Sense
3. Nature
4. Intelligence
5. Mindset

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6. Wisdom
7. Environment
8. Stage of health
9. Companions
10. Lack of knowledge
11. Lack of skills
12. Lack of awareness
13. Lack of confidence
14. Dependency thinking
15. Cognitive style

(Classify the three major factors that affect thinking)

(Plan personal goals for developing critical thinking skills.)

EXACT DEFINITIONS:

“Status refers to the actuality or potentiality of the diagnosis or the categorization of the
diagnosis” (NANDA-2009).

“Self-concept is an individual’s identity about how one thinks about himself or herself. It
means how one thinks or how one feels about himself or herself – By Dougles “1966”

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By Asif Rasool
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Darl Bem (1972) influential self-perception theory reflects “we observe our behavior and
the situation in which it took place, make attributions about why the behavior occurred,
and draw conclusions about our own characteristic and disposition.”

It is a complete state of physical, mental, and social well-being, and not merely the
absence of disease or infirmity. (WHO,1948)

“Dynamic state, in which the individual adapts to changes in internal and external
environments to maintain a state of well-being” – Potter & Perry (2014) – health

Wellness is a status in which individual is capable of meeting the minimum physical,

psychological, and social requirement of appropriate functioning.

“Illness is a condition characterized by a deviation from a normal health state which is

manifested by physical & psychological symptoms.” – Kozier

“Illness is a state in which a person’s physical, intellectual, emotional, social or spiritual

functioning is diminished or impaired in comparison with the previous experience.”
Potter & Perry

Illness Behavior:
“the way in which symptoms are perceived, evaluated, and acted upon by a person who
recognizes some pain, discomfort or other signs of organic malfunction”

Stress Coping:
"The cognitive and behavioral efforts to manage specific internal demands (infection,
feeling of depression) or external demands (move to another city, death in family) that are
appraised as exceeding the resources of a person".
Folkman and Lazarus (1991)

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