Medical surgical

1. COLLEGE OF HEALTH SCIENCE
DEPARTMENT OF NURSING
MEDICAL SURGICAL NURSING
By: Haile W. (BSc N, MSc AHN)
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2. UNIT ONE
Introduction to medical surgical nursing
Objectives
At the end of this chapter students will be able to:-
Define medical surgical nursing
Explain concept of health and illness
Discuss the nursing process
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3. What does medical-surgical mean?
Medical nursing-nursing care for patients whose condition or
disorders are treated pharmacologically.
Surgical nursing-nursing care for patients whose conditions
or disorders are treated surgically.
Medical surgical nursing
- nursing care of adult patients whose conditions or
disorders are treated medically or surgically.
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4. Goal of medical surgical nursing is:
- to assist the individual or group in promoting, restoring
or maintaining optimal health.
Medical surgical nurse is skilled in:
- assessing, diagnosing, and treating actual or potential
alterations in functional ability and life style.
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5. Concepts of health & illness
Health
How health is perceived depends on how health is defined.
The health of the public is measured more globally by
morbidity, and mortality
Health is dynamic through time from wellness to death
Generally, there are two models concerning the definition
of health: Negative Vs Positive
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6. I. Negative (narrow) model- views health as:
Absence of diseases or disability or infirmity
II. Positive (broad) model- Sees health as a broader and more
holistic concept.
 Most widely known of such models is WHO Health
definition which defines health, as:
“A state of complete physical, mental, and social well-
being not merely the absence of disease or infirmity”
 It was criticized as being vague, excessively broad and was
not construed as measurable 6
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7. Wellness has been equivalent to health.
- It is the condition in which an individual functions at
optimal levels.
- It involves being proactive & being involved in self-
care activities aimed toward a state of physical,
psychological, and spiritual well-being.
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8. Illness
- A disease or period of sickness affecting the body part or
mind.
- Is the response of the person to a disease;
- An abnormal process in which the person’s level of
functioning is changed when compared with a previous level.
- Examples of Common Illnesses
• Diarrhea
• Headaches
• Stomach Aches 10
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9. Diseases
- a pathologic condition of body part , an organ or a system
resulting from various causes, such as infection, genetic
defect or environmental stress
- characterized by an identifiable group of sign or symptoms.
- Examples of Diseases
• Pneumonia
• Measles
• Hypertension
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10. Impairment, Disability and Handicap
Impairment
- loss or abnormality of psychological, physiologic, or
anatomic structure or function at the organ level (e.g.
hemiparesis);
- an abnormality of body structure, appearance,& organ
or system function resulting from any cause
- the specific problem with the person`s body.
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11. Disability
any restriction or lack (resulting from an impairment) of
ability to perform an activity in the manner or within the
range considered normal for a human being.
a functional limitation in a person’s abilities (eg, mobility,
personal care, communication, behavior)
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12. Handicap:
 a disadvantage for a given individual that limits or
prevents the fulfillment of a role that is normal
 a disadvantage experienced by a person in his or her
environment (eg. workplace)
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13. Classifications of Illness
Acute Illness
- usually has a rapid onset of symptoms & lasts short time.
Chronic illness
- is a broad term that encompasses many different physical
& mental alterations in health, with one or more of the
following characteristics:
it is a permanent change.
it causes, or is caused by, irreversible alterations in
normal anatomy & physiology.
it requires special patient education for rehabilitation.
it requires a long period of care or support.
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14. Both (e.g. adult with diabetes (a chronic illness) may
also have appendicitis (an acute illness)
Risk Factors for Illness or Injury
- is something that increases a person’s chances for
illness or injury.
Modifiable:- able to be changed, such as quitting
smoking
Non-modifiable: unable to be changed, such as a
family history of cancer.
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15.  Six general types of risk factors are:
o Age: elderly people are risk for HTN
o Genetic factors: family hx of cancer or diabetes
o Physiologic factors: obesity, pregnancy
o Health habits: smoking, poor nutrition
o Lifestyle: multiple sexual relationships
o Environment: working & living environments
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16. Health promotion & illness prevention
Health promotion
- behavior of an individual that is motivated by a
personal desire to increase well-being & health
potential.
Illness/disease prevention
- behavior motivated by a desire to avoid or detect
disease, or to maintain functioning within the
constraints of illness or disability.
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17. Level of health promotion & preventive care
Primary health promotion & illness prevention
- Directed toward promoting health & preventing the
development of disease processes or injury. e.g
Vaccinations/immunization
Counseling to change high-risk behaviors
Family planning services
Accident-prevention education
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18. Secondary health promotion & illness prevention
- Screening for early detection of disease with prompt
diagnosis & treatment of those found
- Disease is detected and treated early, often before
symptoms are present, thereby minimizing serious
consequences
 Example
- Assessing children for normal growth & development
- Encouraging regular medical, dental, & vision
examination. 18
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19. Tertiary health promotion & illness prevention
- Begins after an illness is diagnosed & treated to reduce
disability & to help rehabilitate patients to a maximum
level of functioning.
 Example
- Medical therapy, surgical treatment, rehabilitation
- Cardiac or stroke rehabilitation programs, chronic disease
management programs (e.G. For DM)
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20. What is Nursing Process
 It is a deliberate problem-solving approach for
meeting people’s health care and nursing needs
 It is a systematic, patient centered, goal oriented
methods of caring that provides frame work for
nursing practice.
 It directs nursing activities for health promotion,
health protection, and disease prevention and is used
by nurses in every practice setting and specialty.
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21. What is Nursing Process…
 It provides the basis for critical thinking in nursing
 Nursing is independent scientifically based and creative
required knowledgeable component and independent
profession.
 Nurses use the nursing process as a problem solving
method in all settings with clients of all ages to identify &
treat human responses to potential or actual health
problems.
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22. Purpose of Nursing Process:
1. Identify a client health status and actual or
potential health care problems and needs.
2. Establish plans to meet the identifying needs.
3. Deliver specific nursing intervention to meet
needs.
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23. Characteristics of Nursing Process
1. Systematic- each nursing activity is a part of an
ordered sequence of activities.
 Each activity depends on the accuracy of the activity
that precedes it & influences the action that follows it.
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24. 2. Dynamic- no one step in nursing process is a onetime
phenomenon.
 There is Overlapping and interaction among steps in
some nursing situations, all five stages occur almost
simultaneously.
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Characteristics …
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25. 3. Cyclic and interrelated
 The process as a whole is cyclical, the steps being
interrelated, interdependent, and recurrent.
 The steps of the nursing process build upon each
other, but they are not linear.
 There is overlap of each step with the previous and
subsequent steps
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Characteristics …
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26. 4. Interpersonal & collaborative
 nursing process insures that nurses are patient
centered rather than task centered.
 Always at the heart of nurse is human being.
 The nursing process encourages nurses to work
together to help patient use their strengths to meet all
their human needs
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Characteristics…
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27. 5. Goal oriented- nursing process offers a means for
nurses & patients to work together to identify specific
goals to determine which goals are the most important to
the patient and to match them with appropriate nursing
action.
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Characteristics …
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28. 6. Universally applicable- the nursing process offers
direction for all the activities carried out by the nurse
when caring for well or ill, any age at any practice
setting.
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Characteristics …
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29. Provides an orderly & systematic method for planning &
providing care
Enhances nursing efficiency by standardizing nursing practice
Facilitates documentation of care
Provides a unity of language for the nursing profession
Is economical
Stresses the independent function of nurses
Increases care quality through the use of deliberate actions
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Benefits of Nursing Process
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30. Benefits of …
When used well, the nursing process achieves for the patient
scientifically based holistic individualized care
provides opportunity to work collaboratively with
other nurses
provides continuity of the patient’s care
nurses who use nursing process achieves a clear and
efficient plan of action by which they process can achieve
the best results for the patients.
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31. 31
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32. Steps of nursing process
1. Assessment
2. Nursing diagnosis
3. Planning
4. Implementation
5. Evaluation
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33. Steps of nursing process
1. ASSESSMENT
 It is the systematic & continuous
collection, organization, validation,
& documentation of patient data.
 Nursing assessments focuses on the
patient’s response to health
problems
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34. Types of Assessment
Initial compressive assessment: - admission assessment
operformed at the time the pt. enters the health facility.
oprovides an in-depth, comprehensive database, which is
critical for evaluating changes in the client’s health status
in subsequent assessments.
overy broad & leads us to a center of our diagnosis
ocollection of data concerning actual or potential
dysfunction.
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35. Focus Assessment
ocollects data about a problem that has already been
identified.
ohave a narrower scope & a shorter time frame.
onurses determine whether the problems still exists or has
changed (i.e. improved, worsened, or resolved).
oincludes the appraisal of any new, overlooked, or
misdiagnosed problems.
oin ICU may perform focus assessment every few minute.
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36. Time-lapsed or ongoing assessment
oit is the final assessment done after a period of time
oassessment is focused type.
otakes place after the initial assessment to evaluate any
changes in the client’s functional health.
ocomparing the patient’s current status to baseline
obtained previously after an extended period of time.
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37. Emergency assessment
oassessment done on the life treating situation in which
the preservation of life is the top priority.
ooften the client’s difficulties involve airway, breathing
& circulatory problems (ABCs).
oemergency assessment focuses on few essential health
patterns & is not comprehensive
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38. Types of data-
There are two types of data based.
I. Subjective (covert data) or symptoms;
 Data that are not verified by other person
 It can be described or verified only by the patients
E.g. pain, nausea, headache, abdominal pain.
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39. II. Objective data (overt data or sign)
 It is observable & measurable data.
 It Can be verified by Health professionals.
 It can be seen heard, felt, or smelled, by observation and
physical examination.
 It is collected by Physical Examination
e.g discoloration, vital organ, lungs sounds, vomited 100ml
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40. • Identify the following data as subjective or objective?
Headache
Bp =170/110 mmHg
Nausea
Abdominal pain
Skin lesion
Pain, fear , mood
Fever
Temperature =38 oC
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41. Health History
- It’s a systematic collection of subjective data used to
determine the client’s health status.
- The nurse collects physiological, psychological, socio-
cultural, developmental,& spiritual client data.
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42. Components of a Health History (HHx)
1. Socio- demographic data
- Date, name, address, age, sex, marital status,
occupational status, religious, health care financing
& usual source of medical care.
2. Chief complaint (C/C)
- Client’s specific reason for seeking medical
attention.
- C/C should be recorded in the client’s own words.
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43. - C/C is the answer given to the question “what is
troubling you?” or “what brought you to the hospital
or clinic?”
- Ask the patient to clarify if they uses vague terms such
as bowel trouble or not feeling well.
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44. 3. History of present Illness
- Encourage the client to provide a factual account of
the illness.
Ask the client how he/she would describe his/her health
until this time
oWhen the symptoms started
oWhether the onset of symptoms was sudden/gradual
oHow often the problem occurs
oExact location of the problem
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45. Character of the complaint
- E.g. intensity of pain or quality of sputum emesis
Activity in which the client was involved when the
problem occurred or,
The precipitating factors & circumstances under which
the symptom occurs
- E.g. certain GIT complaints might occur after a meal,
a tension headache might follow an argument.
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46. Factors that aggravate or alleviate the problem; what, if
anything, causes the complaint to become better/worse
- aggravating factors- e.g. physical exertion, position,
ingestion of spicy food, cold weather, loud noises.
- alleviating factors-such as-home remedies, medical
treatment
Associated manifestations- related manifestations
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47. - E.g. swelling of the ankles and feet, ask questions
related to both cardiac and renal function.
- Medications:- all currently used prescription
4. Past health History
concerned with previous experience with illness
childhood immunizations & illnesses, such as
measles, streptococcal infections etc.
allergies to drugs, insects or other environmental
agents.
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48. accidents & injuries how, when, & where it occurred
type of injury treatment received
hospitalization for serious illness.
reason for hospitalization, dates surgery performed,
course of recovery, and any complications
5. Family History of illness
Used to identify whether the disease is hereditary or
communicable
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49. the ages of siblings, parents, grandparents & their
current status, and if they are deceased, the cause of
death should be stated,
attention should be given to disorders such as a
hereditary disease diabetes, hypertension, allergies,
asthma ,hemophilia, heart disease, mental &neurologic
health problems (epilepsy ,migraine headache) etc.
also some other communicable disease like Tb.
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50. 6. Life Style
Personal habits:- the amount, frequency, & duration of
substance use ( tobacco, alcohol, coffee, tea etc.)
Diet description-special diet, normal, number of meals
Sleep/ rest patterns:- usual daily sleep/ wake time,
Activities of daily living (ADL)- any difficulties
experienced in the basic activities (dressing).
Recreation / hobbies- exercise activity & tolerance,
hobbies & interests, vacations.
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51. 7. Social data
Family/ friend relationships
Ethnic affiliation, & beliefs, traditional practices that
may affect health care
Educational history:- about highest client’s level of
education & problems with learning in the past.
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52. Occupational
- Current employment status
- Number of days missed b/c of illness
- History of accidents on the job
- Any occupational hazards with a potential for
future disease or currently.
- Economic status.
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53. 8. Review of Systems
General health
‾ Currently/lately experienced any fever, chills, weight
loss, weakness.
‾ Mood changes, night sweats, profuse perspiration
(diaphoresis), intolerance to heat or cold,
‾ Excessive thirst (polydipsia), increased appetite
(polyphagia), or increased urination (polyuria).
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54. Skin, hair, and nails
- History of skin diseases, changes in skin color
(pigmentation), jaundice, excessive dryness or moisture,
rashes, itching (pruritus), frequent loss of hair.
- Head- frequent or severe headache, pain, dizziness
(vertigo), fainting (syncope), head injury
- Eye- history of infection, discharge, injury, visual changes,
eye pain, double vision (diplopia), blurring, excessive
tearing (lacrimation), photophobia, itching.
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55. Ears -history of infection, loss of hearing, pain,
discharge, ringing in the ears (tinnitus).
Nose, nasopharynx, & paranasal sinuses- discharge,
frequent colds, sneezing, nose bleeds (epistaxis), injury,
loss or poor sense of smell.
Mouth and throat- bleeding gums, frequent sore throat,
lesion of the mouth, lips or tongue, difficulty with taste,
chewing, dysphagia, voice changes; tooth aches,
cavities/dental caries
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56. Neck- pain, stiffness, swelling, limitation of movement
Breasts- nipple discharge, cracks (fissures) around nipples,
pain (mastodynia), skin discoloration or lesions, does the
client practice self breast examination
Respiratory- persistent cough, sputum (amount, color,
consistency), shortness of breath (dyspnea), chest pain,
wheezing, coughing up blood (hemoptysis)
Cardiovascular- chest pain, palpitation, high blood
pressure, fatigue, weakness, edema
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57. Gastrointestinal- nausea, vomiting, loss of a petite
(anorexia), indigestion ( dyspepsia), heart burn, bright blood
in stools, tarry black stool (melena).
Genitourinary
- frequency or urgency, urination at night (nocturia)
- difficulty in starting stream, blood in urine (hematuria) ,
dribbling(drip), unable to control bladder (incontinent),
- flank pain, burning sensation, & polyuria.
- color of the urine, urine odor, penile discharge, pain
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58. Gynecologic and obstetric
- Onset of menstruation (menarche), last menstrual
period, regularity of cycle,
- Durations of menstrual flow, vaginal discharge,
vaginal pruritus, number of pregnancy, number of
births.
Musculoskeletal
- Muscular pain, stiffness, swelling, weakness, soreness
in joints, limitation of movement, cramps.
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59. Neurology
- has the client-experienced unconsciousness, seizure,
difficulty of walking, nervousness, convulsions,
paralysis, numbness, tingling.
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60. Physical examination (P/E)
- It involves the use of one's senses to obtain
information (objective data) about the structure
and function of an area being observed or
manipulated.
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61. Purpose
- serve as a screening device for detecting abnormalities
that are unknown to the client and
- for identifying signs that may suggest illness or
deformity.
- support to validate problems suspected from the
client's history.
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62. Steps in physical examination
oObserving general appearance (G/A) - any signs of
distress, appear chronically ill, acutely ill or no
apparent distress.
oRecording vital signs(V/S)
- Temperature (T0), Pulse rate (P/R); Respiratory rate
(R/R), blood pressure(BP)
- Anthropometric measurement- Weight (Wt.); Height
(ht); BMI
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63. 1. Inspection- to use the sense of vision, smell, & hearing
to observe the normal condition or any deviations from
normal.
Technique
oexpose body parts being observed
oalways look before touching
ouse good lighting
oobserve for color, size, location, texture, symmetry
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64. 2. Palpation:- to touch & feel body parts with hands in
order to determine the following
otexture (roughness/smoothness)
otemperature (warm/hot/cold)
omoisture (dry, wet, or moist)
omotion (vibration)
oconsistency of structures (solid /fluid filled)
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65. Types
Light palpation: – used to feel surface abnormalities
(mass, tenderness)
Deep palpation: – used to feel internal organs &
masses for size, shape.
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66. 3. Percussion
- to tap a portion of the body to elicit tenderness or
sound that vary with the density of the underlying
organ (structures).
oDirect percussion- to elicit tenderness or pain
- directly tap body part with 1or 2 finger tips
oIndirect percussion- to elicit one of the sounds over the
chest or abdomen tympany, resonance, hyper resonance,
dullness, flatness.
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67. Percussion note and their origin
- Tympany- enclosed air (is a drum like sound by percussion
the air filled stomach).
- Resonance- is the sound elicited over air-filled lung.
Hyper resonance- more air (audible when one percuss
over air inflated tissue, e.g. emphysema)
- Dullness- more solid tissue (percussion of the liver
produces dull sound).
- Flatness-very dense tissue- e.g. percussion of the thigh
bone.
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68. 4. Auscultation- is the process of listening to sounds produced
within the body.
Auscultation can be
oDirect auscultation - the use of unaided ear
oIndirect auscultation- the use of stethoscope
• Stethoscope has two parts :- diaphragm & bell
- Diaphragm:- used to detect high pitched sounds (breath
sounds, normal heart sounds, & bowel sounds,)
- Bell: - used to detect low pitched sounds (abnormal
heart sounds) 60
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69. Stethoscope
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70. Assessment Formats
Commonly used formats
1. Systematic Approach
2. Gordon's/Functional Approach

71. Systematic approach
• All review of systems=Subjective data
• In systematic approach; after review of system
there is the need of performing physical
examination through the P/E technics (Inspection,
Palpation, percussion and auscultation)

72. Gordon’s/ functional Approach
 When you assess your patient/client using the
functional health pattern approach, either you can take
subjective data first and then do physical examination,
or you may take both subjective and objective data at
the same time for every pattern.
 Both ways are satisfactory as far as you are flexible
and systematic
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73. Outline:
1. Date
2. Time
3. Identification
4. Source of referral
5. Source of information.
6. Date of admission(if
admitted).
6. Medical diagnosis(if
established)
8. Condition on admission
9. Vital sign
10. Assessment of the eleven
functional health patterns.
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74. Eleven functional health patterns:
1. Health Perception and Health Management Pattern
2. Activity and Exercise Pattern
3. Nutrition and Metabolism Pattern
4. Elimination Pattern
5. Sleep and rest Pattern
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75. Eleven functional health patterns…
6. Cognition and Perception Pattern
7. Self-perception and Self-concept Pattern
8. Roles and Relationship Pattern
9. Coping and stress tolerance Pattern
10.Sexuality and Reproduction Pattern
11. Values and Belief Pattern
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76. 1. Health Perception-Health Management Pattern
• Subjective Data
• C/C, HPI, PMH, Current medication history
• Health maintenance practice
• Last immunization:
• Compliance with treatment
• Objective Data
• Appearance, Grooming, No of appointments he/she
lost and Drugs not taken timely

77. 2. Activity and Exercise Pattern
Three areas may assessed:
a. Mobility and self care
b. Respiratory function
c. Cardiovascular function
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78. a. Mobility and self care
Subjective data :
 DLA-bathing, toileting, grooming, feeding.
 Simple motor activities-sitting, standing, walking
 Home maintenance skills – cooking, shopping, house
keeping
 Any restriction of activity or exercise
 Any thing that the patient is not doing any longer
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79. Mobility and self care…
Objective data:
 Musculoskeletal assessment
 Motor examination (gait, posture, balance,
coordination, abnormal movement, and body position)
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80. Activity and Exercise…
b. Respiration function
Subjective data :
• Risk factors for lung diseases such as smoking, exposure
to pollutants, etc.
• RS dysfun such as cough, sputum, chest pain, etc.
• Medications
Objective data :
• Respiratory pattern asst
• Ass’t of lung and thorax
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81. Activity and Exercise…
c. Cardiovascular functioning
Subjective data :
 Risk factors for CVD such as family history, smoking, elevated
cholesterol, hypertension, etc.
 S/CV dysfun such fainting, palpitation, dizziness.
 Impact of CV problem on function
 Medications
Objective data :
• Cardiovascular assessment
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82. 3. Nutrition and metabolism pattern
• This reflects how well the body is able to ingest, digest
and metabolize food, use it to maintain tissue integrity and
fluid and electrolyte balance, and to fight infection.
Subjective data:
• Normal food and fluid intake
• Alteration in normal eating pattern including dietary
restrictions and patient response to it.
• NVD
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83. Nutrition and metabolism pattern…
Objective data:
 General physical survey including wt, ht and BMI
 Mouth examination (buccal mucosa, teeth, lips, gum
tongue)
 Abdominal examination
 Examination of cranial nerves: V, IX,X, XI and XII.
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84. Nutrition and metabolism pattern…
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85. 4. Elimination Pattern
• Subjective Data bowel Habits
• Normal bowel movement pattern.
• Recent changes in bowel movement pattern.
• Color and consistency of stool.
• Hx. Of bowel surgery
• Objective Data in bowel habit
• Inspection of feces
• Abdominal examination
• Rectal examination
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86. Bladder Habits
• Subjective data
• Urinary habits
• Normal Vs Abnormal- color, amount
• Changes in pattern( frequency, quantity)
• Hx. of Bladder Surgery
• Effects of urinary problems in daily activities.
• Objective Data
• Inspection of Urine
• Examination of lower Abdomen

87. 5. Sleep and rest pattern:
Subjective Data:
• Normal hours sleep per day
• Nap during day(when and how)
• Problems with obtaining adequate sleep and rest
• Any measure taken to induce sleep including
medication and aids to reduce sleep.
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88. Sleep and rest pattern…
Objective data:
 Frequent yawning
 Decreased attention span
 Dark circles or puffiness around the eyes
 Continual dozing during the day
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89. 6. Cognitive - Sensory-Perceptual Pattern
• Subjective data
• Memory status
• Thought
• Ability of: Speaking
• Reading and Writing
• Educational status
• Academic standing/rank

90. Cognitive - Sensory-Perceptual Pattern…
• Objective data
• LOC
• Glasgow Coma Scale
• Orientation
• Mood: Happy/pleasant
• Memory and Language
• Judgment

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92. Sensory Function
• Subjective data
• Visual problems:
• Aids of vision
• Hearing problems:
• Aids for hearing
• Taste
• Smell
• Sensation

93. Sensory Function
• Objective data
• Visual acuity:
• Visual field
• Hearing
• Sensations:

94. pain
• Subjective Data
• Any pain/discomfort
• Duration
• Objective data
• Tenderness of any body
• Diaphoresis
• Body position
• Guarding
• Refusal to move body part

95. 7. Self-perception Self-concept patterns
• Subjective Data
• Self-description
• Feeling differently because of illness
• Things frequently make you angry, Annoyed, Fearful, Anxious,
Depressed
• Objective Data
• Eye contact
• Posture
• Expression
• Voice and speech pattern

96. 8. Role-Relationship Pattern
• Subjective data
• Employment/Dependent
• Primary role at work
• Primary role at home
• Living arrangement
• Belong to social group
• History of conflicts with other’s
• Objective data
• Interaction with family members and significant others
• Visitor’s flow

97. 9. Stress tolerance-Coping pattern.
• Subjective Data
• Any big changes in your life in last year
• Who is most helpful in talking things over?
• Stressor and Resent stress
• When tense, what helps? Use any medications, drugs,
alcohol to relax?
• Objective Data
• Refer to the Mental Status Assessment.

98. 10. Sexuality-Reproductive Pattern
• Subjective Data
 Female
• Menstrual history
• party
• Gravidity
• Abortion
• Male-Female
• Contraception used
• Problems with sexual activities
• STDs, Pain, Burning, Discomfort during intercourse,
Discharge

99. • Objective Data
• Male -Testicular self- examination
• Female- Breasts self-examination
Genitalia
• Inspections
• Palpation

100. 11. Value- Belief Pattern
• Subjective Data
• Values
• Goals
• Source of hope/strength
• significant religious persons
• Religious practices
• Relationship with God
Objective Data
• Observe religious practices
• Bible , clergy
• client's behavior for signs of spiritual distress

101. This is All about assessment!
• Any questions
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102. 2. Nursing diagnosis
- according to NANDA (2005) nursing diagnosis is
defined as;
“a clinical judgment about individual, family, or
community responses to actual or potential health
problems/ life processes.”
- in these phase, nurses use critical thinking skills to
interpret assessment data & identifying client
strength & problems.
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103. Components of nursing diagnosis
Has three components:
1. The problem statement (diagnostic label)
2. The etiology, &
3. The defining characteristics (S/S)
1. Problem statement
- describes the client’s health problem or human
response for which nursing therapy is given.
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104. - it describes the client’s health status clearly &
concisely in a few words.
- E.g. knowledge deficit (medication) or knowledge
deficit (dietary adjustment)
2. Etiology (related factors & risk factors)
- describe the conditions, circumstances, or etiologies
that contribute to the problem.
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105. - etiology may include client behaviors,
environmental factors, or interaction of the two.
- NANDA uses the term related factors to describe
the etiology or likely cause of actual nursing
diagnosis
- the term risk for is used to describe the etiology of
high risk (potential) nursing diagnosis, because
there are no subjective & objective sign present
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106. 3. Defining characteristics
- are the clusters of objective & subjective data (sign
/symptoms) that indicate the presence of a particular
health problem.
- for actual nursing diagnosis, the defining
characteristics are the client’s s/s.
- use of the phrase “as evidenced by” (AEB) to
connect the etiology & defining characteristic
statements.
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107. Formulating the diagnostic statement
1. Actual nursing diagnosis
describes a human response to a health problem that
is being manifested.
an actual nursing diagnosis consists of 3 parts
(diagnostic label + r/to etiology + s/s)
o E.g. pain (acute) r/to tissue trauma AEB verbal
report of pain, irritability, restlessness, increased
B/P.
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108. 2. Potential /Risk nursing diagnosis
describes human responses to health conditions/life
processes that may develop in a vulnerable individual,
family or community.
it is supported by that contribute to increased
vulnerability risk factors.
it is not possible to have a third part for risk or
possible diagnosis because s/s does not exist.
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109. it has two parts:- the problem statement and the
etiology or risk factor.
the problem statement and the risk factors are
connected by the term “related to”
Examples
high risk for chronic constipation related to
prolonged laxative use.
high risk for ineffective breast feeding related to
breast engorgement.
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110. 3. Wellness nursing diagnosis
is a diagnostic statement that describe the human
response to levels of wellness in an individual,
family, or community
human response that have a potential for
enhancement to higher state
transition from specific level of wellness to higher
level of wellness
wellness nursing diagnosis has one part statement.
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111. E.g. potential for enhanced parenting, or motivated
to achieve a high level of wellness
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112. 4. Possible nursing diagnosis
is made when not enough evidence supports the
presence of the problem,
but the nurse thinks that it is highly probable & wants
to collect more information.
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113. Common errors in nursing diagnosis
Using the medical diagnosis
E.g. Incorrect: - self care deficit r/to cerebro-vascular
accident (stroke).
Correct: -Self care deficit r/to neuromuscular
impairment secondary to CVA.
Relating the problem with an unchangeable situation
E.g. Incorrect: - knowledge deficit r/to pregnancy
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114. Confusing the etiology or s/s for the problem
E.g. Incorrect: - lung congestion r/to bed rest
Correct: - Ineffective airway clearance r/to operation
on the chest.
Use of a procedure instead of the human response
E.g. Incorrect: - catheterization r/to urinary retention
Correct: - Urinary retention r/to perineal swelling
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115. Lack of specificity
E.g. Incorrect: - constipation r/to nutritional intake
Correct: - constipation related to inadequate dietary
bulk intake,
Combining two nursing diagnosis
E.g. Incorrect: - anxiety & fear r/to separation from
parent
Correct: - anxiety (specify) r/to change in
environment & unmet need or fear r/to separation
from parent.
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116.  Relating one nursing diagnosis to another
E.g. Incorrect:- ineffective individual coping r/to
anxiety
Correct: - anxiety (specify) r/to change in role
functioning & socio economic status
Use of judgmental language
E.g. Incorrect: - pain (chronic) r/to secondary gain
Correct: - pain related to recurrent muscle spasm
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117. 3. Planning-refers to the development of nursing strategies
designed to improve patient problems.
- the written nursing care plan directs the activities of
the nursing staff in the provision of patient care.
Purpose of planning
-direct client care activities
-promote continuity of care
-focus charting requirements
-allow the delegation of specific activities
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118. Planning activities
i. Establishing priorities
- nursing priorities based on the identified nursing
diagnosis & patient needs.
- this skill requires clinical expertise & practice.
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119. Maslow’s hierarchy of needs
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120. Priority 1 - Life threatening problems & those
interfering with physiological needs.
E.g.: problems with respiration, circulation, nutrition,
hydration, elimination, temperature regulation, physical
comfort.
Priority 2 - Problems interfering with safety &security.
E.g. : environmental hazards & fear.
Priority 3 - Problems interfering with love &belonging.
E.g. : isolation or loss of a loved one.
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121. Priority 4 - Problems interfering with self esteem.
E.g. : inability to perform normal activities.
Priority 5 - Problems interfering with the ability to
achieve personal goals.
ii. Establish pt. goal & outcome criteria
A patient goal:- is a broad, general statement about the
state of the patient after the nursing interventions are
carried out.
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122. Long term & short term goals.
Long-term goals- to be achieved over a longer period
of time, often weeks or months.
Short-term goals- that can be met relatively quickly,
often in less than a week.
Goals should be patient-centered and SMART
E.g. ambulate 30 feet using a quad cane.
Pt. will eat 75% of meal.
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123. Outcome criteria- of the patient’s behaviors & the time
period in which the goals are to be achieved, as well as
any special circumstances related to achieving the
outcome.
- are specific, measurable, realistic statements of goal
attainment.
- to be specific & measurable, criteria requirements must
be met in writing outcome criteria.
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124. - Outcome criteria answers the questions who? , What
actions? , under what circumstances? , how well? &
when?
E.g. For the stroke patient whose Goal is ambulation
with cane; The outcome criteria would be: the patient
(who) ambulates (what action) with a cane (under
what circumstances) 30 feet (how well) before shift
change (when)
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125. iii. Plan nursing intervention
- are any treatment, based upon clinical judgment &
knowledge that a nurse performs to enhance client
outcomes.
- determine w/c nursing interventions are appropriate for
a specific pt. requires clinical knowledge & practice.
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126. 4. Implementation- “Doing”….
- in which the nurse puts the nursing care plan in to
action.
- broadly defined, implementing consists of doing,
delegating, & recording.
- any treatment, based up on clinical judgment &
knowledge, which a nurse performs to enhance
patient/client out comes
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127. - nursing interventions include both direct & indirect
care: nurse initiated, physician initiated or other
provider initiated treatments.
5. Evaluation
- it is defined as the judgment of the effectiveness of
nursing care to meet client goals based on the client’s
behavioral responses.
- this phase involves a thorough, systematic review of the
effectiveness of nursing interventions & a determination
of client goals achievement.
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128. - it also is ongoing throughout the nursing process.
- the identified nursing diagnosis, client goals,
outcome criteria, & nursing interventions are guide
for evaluation
- through the evaluation process, the appropriateness,
accuracy, relevance of these nursing care
components can be determined.
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129. 129

130. Group Assignment (20%)
1. Approach to the Respiratory System
2. Approach to Cardiovascular Examination
3. Approach to the Gastrointestinal System (GIS)
4. Approach to Genitourinary system
5. Approach to Glands
6. Approach to Musculoskeletal System
7. Approach to the Integumentary System
8. Approach to Special Examinations
9. Approach to Examination of the Nervous System
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