This document provides an introduction to medical and surgical nursing. It discusses key topics like the differences between medical and surgical nursing, Maslow's hierarchy of needs, stress responses, and stages of the stress response. The roles of nurses in medical-surgical settings are outlined. Concepts like health, illness, disease, and wellness are defined. Factors that influence psychological responses to illness like crisis and coping are also explained.

1. Wollo University
Course code: Nurs3122
Unit I. Introduction to medical & surgical nursing
BY: Wondwossen Yimam (Msc.N)
March/2014
Unit I. Introduction

2. Part I. Introduction
Medical nursing
- Deals with care of the patient with systemic
disorders
- Disturbance of visceral organs
Surgical nursing
- Deals with operative conditions
 Medical-surgical nurses are the backbone of health
and wellness care
Unit I. Introduction

3. Roles of the nurse
As a medical surgical nurse:-
o Caregiver
o Advocator
o Educator
o Coordinator
o Discharge planner
o Change agent
o Researcher
Unit I. Introduction

4. Part II. Hierarchy of human needs
Human need
 Anything that is essential to the
survival of man
• Absence may cause illness
• Presence prevent illness
Meeting unmet needs restore health
Unit I. Introduction

5. Abraham Maslow
- Maslow described a hierarchy of needs based on
the basic drives or needs that motivate people
- He hypothesized that an individual must meet
each level before he can move on to the next level
- Maslow’s hierarchy also includes self-fulfillment,
desire to know and understand, and aesthetic
needs
Unit I. Introduction

6. Abraham Maslow---
- Lower-level needs always remain, but a person’s
ability to pursue higher-level needs indicate that
he or she is moving toward psychological health
and well-being
- Such a hierarchy of needs is a useful
organizational framework that can be applied to
the various nursing models for assessment of a
patient’s strengths, limitations, and need for
nursing interventions
Unit I. Introduction

7. Maslow’s hierarchy(5-basic levels)
1.Physiological needs are a person’s most basic needs and
must be met; these biological needs include:-
o Air (Oxygen)
o Water
o Food
o Elimination
o Rest and sleep
o Freedom from pain
o Shelter
o Clothing
o Sexual expression
o Exercise
Unit I. Introduction

8. Maslow’s hierarchy(basic levels)
2.Safety and security needs
o Physical freedom from harm (physical safety)
o Maintaining comfort
o Freedom from fear
o Sustaining protection
o Order, structure
o Psychological knowledge what to expect from other(s)
and what others expect from you
Ex 1.
- Protection and freedom from harm or threatened
deprivation
Ex 2.
- Ambulating & supporting the patient in the hallway
- Using two nurses to transfer the patient
Unit I. Introduction

9. Maslow’s hierarchy(basic levels)---
3. Love, affection(care), and belonging needs
When a person seeks to overcome feelings of
loneliness and separation; this stage carries the
need for:-
o Enduring intimacy(identification with a group)
o Friendship (satisfactory interpersonal r/ship)
o Acceptance
o Giving and receiving of love and affection
Ex. Allowing the family to see a newly admitted
patient
Unit I. Introduction

10. Maslow’s hierarchy(basic levels)---
4. Self esteem (esteem - of- others)
o Self respect and respect from others
o Personal sense of achievement /status, success &
recognition/
o Independence
o Competence
o Confidence and strength
- When a person successfully meets these needs, he
feels self-confident and valuable as a person
- When a person doesn’t meet these needs, he feels
inferior, helpless, and worthless
Unit I. Introduction

11. Maslow’s hierarchy(basic levels)---
5. Self actualization
- Not all people attain self actualization
o Accepts himself
o Balance b/n rest and activity ( proper growth &
development)
o Open minded , spiritually well
o Positive outlook in life
o The person meets the need of doing what he was
“born to do”; this level includes the need for beauty,
truth, and justice
The individual possesses a feeling of self fulfillment
& the realization of self potential
Unit I. Introduction

12. Maslow’s hierarchy(basic levels)
Unit I. Introduction

14. Health
• WHO (1948) defines health as a “state of
complete physical, mental, and social well-being
and not merely the absence of disease and
infirmity”
Unit I. Introduction

15. Health---
• Health is viewed as a dynamic, ever-changing
condition that enables a person to function at an
optimum potential at any given time
• The ideal health status is one in which people
are successful in achieving their full potential
regardless of any limitations they might have
Unit I. Introduction

16. Illness
• Illness can be defined as a sickness or deviation
from a healthy state; it’s considered a broader
concept than disease
• Illness occurs when a person is no longer in a
state of perceived “normal” health
Unit I. Introduction

17. Illness
• Illness also encompasses how a patient
interprets a disease’s source and importance,
how that disease affects his behavior and
relationships with others, and how the patient
tries to remedy the problem
Unit I. Introduction

18. Illness
• Acute illness refers to a disease or condition
that has a relatively abrupt onset, high
intensity, and short duration
• If no complications occur, most acute illnesses
end in full recovery, with a patient returning to
his previous or similar level of functioning
Unit I. Introduction

19. Illness
• Chronic illness refers to a condition that
typically has a slower onset, less intensity, and a
longer duration than acute illness, with a
patient typically experiencing periods of
exacerbation
• The nurse’s goal is to help the patient regain
and maintain the highest possible level of
health, although a patient may fail to return to
his previous level of functioning
Unit I. Introduction

20. A disease
• A disease is detected when it causes a change in
metabolism or cell division that produces signs
and symptoms
• In the absence of intervention, resolution of the
disease depends on many factors functioning
over a period of time, such as the extent of the
disease and the presence of other diseases
• Manifestations of disease may include
hypofunction, hyperfunction, or increased or
decreased mechanical function
Unit I. Introduction

21. Wellness
Wellness is a condition of good physical and
emotional health sustained by a healthy lifestyle
• Wellness has been defined as being equivalent to
health.
• Cookfair (1996) indicated that wellness “includes
a conscious and deliberate approach to an
advanced state of physical, psychological, and
spiritual health and is a dynamic, fluctuating state
of being”
Unit I. Introduction

22. Wellness---
• Leddy and Pepper (1998) contended that
wellness is indicated by the capacity of the
person to perform to the best of his or her
ability, the ability to adjust and adapt to varying
situations, a reported feeling of well-being, and
a feeling that “everything is together” and
harmonious.
Unit I. Introduction

23. Wellness---
• Wellness, as a reflection of health, involves a
conscious and deliberate attempt to maximize
one’s health. Wellness does not just happen; it
requires planning and conscious commitment
and is the result of adopting lifestyle behaviors
for the purpose of attaining one’s highest
potential for well-being
Unit I. Introduction

24. Wellness---
• Wellness is not the same for every person
• The person with a chronic illness or disability
may still be able to achieve a desirable level of
wellness
• The key to wellness is to function at the highest
potential within the limitations over which there
is no control.
Unit I. Introduction

25. Health promotion
Definition: The art and science of assisting people
to change their lifestyle toward a higher state of
wellness
The following basic principles underlie the concept
of health promotion as an active process
Self responsibility
Nutritional awareness
Stress reduction and management, and
 Physical fitness
Unit I. Introduction

26. Health promotion---
Self responsibility
• Personal accountability for one’s actions or
behavior
• Taking responsibility for oneself is the key to
successful health promotion
• The concept of self-responsibility is based on the
understanding that individuals control their lives
• Each of us alone must make those choices that
determine how healthy our lifestyle is
Techniques Ex. H/promotion programs
Unit I. Introduction

27. Health promotion---
Stress management
Behaviors and techniques used to strengthen a
person’s resources against stress
Physical fitness
The condition of being physically healthy as a
result of proper exercise and nutrition
Unit I. Introduction

28. Part III. Psychological responses to illness
Stress
• Each day of your life, you will be challenged by
many mental, physical, and social demands
- How are you able to meet the challenge of these
demands?
- How do you demonstrate a balanced healthy life
style?
Unit I. Introduction

29. Psychological responses to illness---
Definition:-Stress (S)
 Is the reaction person having to excessive
pressures or other type of demand placed upon
them. It arises when they worry that they can’t
cope
 Stress (S) occurs when the Pressure (P) is greater
than the Resource®. S=P>R
 Is any demand (force, pressure, and strain) placed
on the body and the body’s reaction to it
Unit I. Introduction

30. Psychological responses to illness---
Stress (S)
• It is experienced by everyone who is living, working,
& breathing at this very moment. it is a fact of life
you can’t avoid.
* “Affects peoples of all and in all walks of life”
• A state produced by a change in the environment
that is perceived as challenging, threatening, or
damaging to the person’s dynamic balance or
equilibrium
• Stress is the body’s response to stressors or stimuli
that are perceived as threatening
• The body responds to stress physiologically and
psychologically
Unit I. Introduction

31. Psychological stress responses---
Psychological stress responses result when the
body’s ability to adapt to change is exceeded; a
person adapts to psychological stress through
coping strategies, such as:-
Problem solving
Reappraising stressors, and
Rehearsing responses to stress
The body’s psychological response to stress
varies according to the stressor’s intensity and
duration and the perceived control over the
stressor
Unit I. Introduction

32. Psychological stress responses---
• Psychological stress can cause physical
manifestations, such as :-
o Hypertension
o Digestive disorders
o Psychological manifestations (anxiety attacks and
eating disorders)
• When psychological stress exceeds a person’s
coping abilities, crisis (extreme psychological
disequilibrium) may occur
Unit I. Introduction

33. Crisis
Definition:-
A situation in which usual coping strategies
are ineffective, and the person is disorganized
or unable to solve problems appropriately
Types of crisis
1) Maturational (developmental) crisis
2) Situational crisis
3) Adventitious crisis
Unit I. Introduction

34. Types of Crisis
1) Maturational (developmental) crisis
 Predicted times of stress in every one’s life which
occurs in response to a transition from one stage to
another in the life cycle
- Marriage - Retirement - Menopause
- Pregnancy - Child birth
2) Situational crisis
 Occurs in response to a sudden unexpected event in a
person’s life
 Are parts of every day life
- Loss of job - Divorce - Abortion
- Witnessing a crime (being the victim)
- Unplanned pregnancy
- Severe physical or mental illness
- Loss of loved one
Unit I. Introduction

35. Types of Crisis---
3) Adventitious crisis
- Are not parts of every day life
- Are accidental, uncommon or unexpected events?
- Multiple loss with major environmental change
result
Examples:
-Natural disasters: - hurricanes, flood, fire,
earthquake, etc
-National disasters: - war, riots, etc
-Crime of violence: - Child abuse, rape, assault,
bombing in crowded areas, airplane crashes, group
killing, Kidnapping (taking a hostage), etc
Unit I. Introduction

36. Stress as a stimulus
• Each person handles stress differently
• How well we adapt depends on our ability to cope
• During a health history, past coping patterns and
perceptions of current stresses and anticipated
outcomes are explored to identify the person’s
overall ability to handle stress
• It is especially important to identify expectations
that the person may have of family, friends, and
caregivers in providing financial, emotional, or
physical support
Unit I. Introduction

37. Stress as a stimulus---
Stressors
• The stimulus or change that evokes a response is
the stressor
• Not all stress is bad. It is important to identify
how you respond to stressful events
• Although some stress can result in beneficial out
comes, excessive and long term stress often
responsible for disastrous consequences on the
health and quality of life
• This will determine the impact that these
experiences have on your life
Unit I. Introduction

38. Stress as a stimulus---
• Stress is a stimulus that causes a response
• Stress is viewed as external to the individual
• Is any stimulus that directly or indirectly
stimulates neurons of the hypothalamus to
release corticotrophin hormone (CTH)
Stress can be:-
o Biophysical
o Chemical
o Psychosocial
o Cultural
Unit I. Introduction

39. Stressors can be---
• Biophysical (such as disease, trauma, and
overexertion)
• Chemical (such as pollution, drugs, and alcohol)
• Psychosocial (such as job loss, divorce, and
bankruptcy) or
• Cultural (such as traveling alone, being separated
from family members during hospitalization, and
delegating decision making to health care
providers)
Unit I. Introduction

40. Common terms
• Coping - is a problem solving process that the
person uses to manage the stresses or events with
which, he/she is presented.
• Adaptation - the process by which the human
system modifies itself to conform to the
environment. Therefore, the ability to cope with and
adapt to stress is a crucial determinate of human
well-being
Adaptation is a constant, ongoing process that
requires a change in structure, function, or behavior
so that the person is better suited to the
environment
Unit I. Introduction

41. Common terms---
• Psychological homeostasis: - to remain healthy,
humans also must maintain psychological
homeostasis, or a state of mental well being each
person needs to feel loved and that he/she
belongs to feel safe and secure, and to have self
esteem
• When these needs are not met or the threat to
need attainment occurs, the person uses
homeostatic measures in the form of coping or
defense mechanism to return to emotional
balance.
Unit I. Introduction

42. Stages of stress response
(General adaptation syndrome)
o Selye’s stress theory
Hans Selye’s theory describes a general adaptation
syndrome that consists of three stages of a
hormonally controlled stress response
Stage 1 : Alarm response
Stage 2 : Adaptation (stage of resistance)
Stage 3 : Exhaustion
According to Selye, stress can result from positive
or negative events
Unit I. Introduction

43. Stage 1: Alarm response (“fight or flight” response)
• In this stage the person is alerted to the presence
of a stressor and the need to act
• It is initial response that prepares the body for
immediate action
• It involves production of hormones like
epinephrine - which  B/P, HR, RR, dilates pupil,
 Blood glucose,  alertness
• It may last for few minutes or may continue for
several hours
Unit I. Introduction

44. Alarm response (“fight or flight” response)---
o Physiologic responses to stress involve the central
nervous system, hypothalamus, sympathetic
nervous system, anterior and posterior pituitary
gland, adrenal medulla, and adrenal cortex
o Hormones and catecholamines are secreted or
stimulated by these organs in response to a
stressor
◗ Their release results in the body’s fight-or-flight
response to stress
• Blood vessels dilate, heart rate increases, the rate
and depth of respirations increase, and
bronchodilation occurs; these reactions increase
the oxygen supply to organs and muscles
Unit I. Introduction

45. Alarm response (“fight or flight” response)---
• The arterioles in the skin, kidneys, and
abdominal viscera constrict; blood is shunted
from the GI tract and periphery to the brain,
heart, and major muscles
• Gluconeogenesis increases; decreased insulin
secretion and increased fatty acid metabolism
increase the amount of glucose available for
energy
• Localized sweat production increases, and
muscles become tense
Unit I. Introduction

46. Alarm response (“fight or flight” response)---
• Pain tolerance increases as endorphins
(endogenous opiates) are released
• Repeated physiologic stress responses can
damage the body, resulting in problems such as
kidney failure, gastric ulcers, and exacerbation of
an existing disorder
• The body’s level of physiologic response to stress
varies according to the stimuli; most physiologic
stress responses aren’t helpful in coping with the
daily stresses of life
Unit I. Introduction

47. Stage 2 : Stage of resistance (adaptation)
• In this stage, the pituitary gland secretes
corticotropin
• Corticotropin stimulates the production of
glucocorticoids and mineralocorticoids, which
promote and inhibit inflammation, allowing the
body to protect or surrender tissue--- Hormone
level stabilized.
• Body attempts to adapt to the stressor and
mobilizes coping mechanisms
• The body begins coping with the new state of
adaptation and return to normal.
Unit I. Introduction

48. Stage 3 : Stage of exhaustion
• This stage can lead to disease or death
• It happens when the body can no longer resist
the stressor or cannot maintain its adaptation
• If the body has sufficient energy resources to
continued adaptation, then rest, recovery and
return to normal may be the end result
• If adaptation is not adequate or if the body is
unable to mobilize further defense, then
exhaustion ensures, and death may be the
outcome
Unit I. Introduction

49. Symptoms of stress
A/ Physical symptoms
Sleep pattern changes, fatigue, digestion changes, loss of
sexual drive, headaches, aches & pains, infections,
dizziness, fainting, palpitations, etc
B/ Mental symptoms
Lack of concentration, memory lapses, difficulty in
making decisions, confusion, disorientation, etc
C/ Behavioral symptoms
Appetite changes, increased smoking, restlessness, nail
biting, fidgeting, hypochondria, etc
D/ Emotional symptoms
Bouts of depression, fits of rage(anger), deterioration of
personal hygiene & appearance, tearfulness, impatience,
etc
Unit I. Introduction

50. Stress management techniques
Change your thinking
A/ Reframing B/ Positive thinking
Change your behaviors
A/ Assertiveness B/ Get organized
C/ Ventilation D/ Humor
E /Diversion & distraction
F/ Time management
Change your life styles
A/ Diet B/ Smoking & alcohol
C/ Exercise D/ Sleep
E/ Leisure F/ Relaxation
Unit I. Introduction

51. Stress management techniques---
Change your thinking
A/ Reframing
- It is a technique to change the way you look at
things in order to feel better about them
- There are many ways to interpret the same
situation so pick the one you like
- Reframing does not change the external reality,
but helps you view things in a different light and
less stressfully
Ex 1 . Salary payment/yr for renaissance dam
EX 2. Current grading system
Unit I. Introduction

52. Stress management techniques---
Change your thinking---
B/ Positive (optimistic) thinking
-Forget powerlessness, dejection(unhappiness),
hopelessness, and failure
-Stress leaves us vulnerable to negative suggestion
so focus on positives;
. Focus on your strengths
. Learn from the stress you are under
. Look for opportunities
. Seek out the positive-make a change
Unit I. Introduction

53. Change your behaviors
A/ Assertiveness: helps to manage stressful
situations, and will, in time, help to reduce their
frequency
- Lack of assertiveness often shows low self esteem
and low confidence
- The key to assertiveness is verbal and non verbal
communication
- Extending our range of communication skills will
improve our assertiveness
Unit I. Introduction

54. Assertiveness---
Equality and basic rights
1/ The right to express my feelings
2/ The right to express opinions/beliefs
3/ The right to say “yes/ no “ for your self
4/ The right to change your mind
5/ The right to say “I don’t understand”
6/ The right to be yourself, not acting for the benefit of
others
7/ The right to decline responsibility for other people’s
problems.
8/ The right to make reasonable requests of others
9/ The right to set my own properties
10/ The right to be listened to, and taken seriously
Unit I. Introduction

55. Change your behaviors---
Assertive skills
• Establish good eye contact/don’t stare
• Stand or sit comfortably- don’t fidget
• Talk in a firm, steady voice
• Use body language
• Concise and to the point, etc
 Benefits of being assertiveness
- High self esteem - Less self conscious - Less anxious
- Manage stress successfully
- Feeling of self-control
- Appreciate your self and others more easily
Unit I. Introduction

56. Change your behaviors---
B/ Get organized
- Poor organization is one of the most common
causes of stress
- A structured approach offers security against
“out of the blue “problems
- Prioritizing objectives, duties and activities make
them manageable and achievable
- Don’t over load your mind. Organization will help
to avoid personal and professional chaos
Unit I. Introduction

57. Change your behaviors---
A/ Assertiveness-----
B/ Get organized-----
C/ Ventilation
“ A problem shared is a problem halved”
D/ Humor (comedy ,Joking )
E /Diversion & distraction
F/ Time management
Unit I. Introduction

58. Change your life style
A/ Diet: Good nutrition will improve your ability to
appropriately respond to stress. Reducing
caffeine intake will help you manage your anxiety
(2 and1/2 cups of coffee doubles the epinephrine
level)
B/ Smoking & alcohol cessation is important
C/ Exercise:- Aerobic exercise can reduce anxiety
up to 50%
Exercise improves blood circulation, lowers b/d
pressure, clears the mind of worrying thoughts,
improves self-image, increases social contact and
makes you feel better about yourself
Unit I. Introduction

59. Change your life style---
D/ Sleep is a good stress reducer, provide plenty of
daytime energy, wake refreshed after night’s
sleep, difficult to cope when tired
E/ Leisure (free time , vacation): - depending on
our interest, gives you a break from stresses,
provides outlet for relief, and provides social
contact
F/ Relaxation:- recognize what activities you
consider relaxing ,Ex. Going for walks, meeting
with friends, reading for pleasure, listing for
music, taking a bath, etc
Unit I. Introduction

60. Change your life style---
Relaxation techniques
_ Deep breathing _ Progressive relaxation
_ Meditation _ Yoga and bio feed back
Relaxation training
- Childbirth
- Recovery from myocardial infarction
- Before painful procedures
- After surgery
Unit I. Introduction

61. Change your life style---
Benefits of relaxation
- Lowers b/d pressure
- Combats fatigue
- Promotes sleep
- Reduces pain
- Eases muscle tension
- Decreases mental worries
- Increases concentration
- Increases productivity
- Increases clear thinking
Unit I. Introduction

62. Factor affecting normal coping and adaptation
• Roles and relationship
• Nutrition and metabolism
• Activity and exercise
• Sleep and rest
• Safety and security
• Previous experience
Unit I. Introduction

63. Part IV. Pain
Definitions
• Aristotle called pain the “passion of the soul”,
While our notions of pain may not be quite as
romantic as Aristotle’s
• Stern back – “Private, personal sensation of
hurt”.
–Harmful stimuli which signal impending tissue
damage
Unit I. Introduction

64. Pain---
Definitions---
– “Whatever experiencing person says it exists
whenever he/she says it does” (McCaffery &
Beebe, 1989)
- This definition is regarded important for nurses
because health practitioners must rely on the
client’s description of the pain because it is a
subjective symptom that only the client can
identify and describe
Unit I. Introduction

65. Pain---
Medical definitions
Pain is an unpleasant sensory and emotional experience
resulting from actual or potential tissue damage
• Pain (the fifth vital sign) is the body’s mechanism of self
preservation (Campbell, 1995)
- Pain acts as a warning sign to alert you when damage to your
body is occurring or may occur
- It is important for us to recognize the constructive
functions of pain
- In fact, the inability to experience pain is a dangerous condition
b/se injury can occur and go unnoticed
EX. Chronic diabetes
Unit I. Introduction

66. Pain---
• Pain is processed in the thalamus, midbrain, and
cortex
• Certain neurotransmitters, such as histamine,
serotonin, and prostaglandins, enhance pain
impulse transmission
• Other neurotransmitters, such as endogenous
opiates, endorphins, and enkephalins, inhibit pain
impulse transmission; chronic pain syndrome may
be related to a deficiency of these inhibitory
neurotransmitters
Unit I. Introduction

67. Origin of pain
• Cutaneous:-superficial pain originating from
cutaneous tissue
• Deep somatic pain:-diffuse or scattered, that
originate from tendon, ligament, blood vessels
and nerves
• Visceral pain:-poorly localized and originate from
abdomen, thorax or cranium
• Referred pain:- pain perceived, in an area that is
distant from point of origin
• Psychogenic pain:- no physical cause of pain is
identified
Unit I. Introduction

68. Causes of pain
• Biological factors
– Angina, tumors, pleural pain, joint pain, etc
• Chemical factors
– Inflammation
- Lead, alcohol, drugs, poisons  that damage or
destroys cells
• Physical factors
– Trauma, temperature extremes, electrical burn,
etc
• Psychogenic factors – Anxiety, depression
Unit I. Introduction

69. Pain theories
All current pain-control theories are hypothetical;
none completely explain the pain experience and
all its components
Traditional theories
i/The specificity theory holds that highly specific
structures and pathways exist for pain
transmission; this biologically oriented theory
doesn’t explain pain tolerance and ignores social,
cultural, and empirical factors that influence pain
Unit I. Introduction

70. Traditional theories---
ii/ Pattern theory – pain results from the
transmission of the nerve impulses that originate
from and are coded at the peripheral stimulation
site rather than from adequate stimulation of
specific receptors
EX - Phantom pain (pain felt in a body part this is
no longer present such as an amputated foot)
Unit I. Introduction

71. Contemporary theories
i/Gate control theory (Melzack and Wall, 1996)
• It recognizes the relationship between pain and
emotion
• The gate control theory was important because it
was the first theory to suggest that psychological
factors play a role in the perception of pain
• The theory states that nerve fibers of small
diameter transmit excitatory pain stimuli while
the big diameter nerve fibers inhibit pain
impulses
• There is a gate at dorsal horn of spinal cord which
determines what type of impulse reaches brain
Unit I. Introduction

72. Contemporary theories---
Gate control theory (Melzack and Wall)----
• Once pain is transmitted to the cerebral cortex,
perception is affected by the patient’s mental state,
emotions and past experience
- Endogenous opiates – emphasizes the role of
biochemical’s in pain modulation
• Enkephalins and endorphins act at neuron synapses
to influence the integration of pain and activation of
the brain’s analgesic system
• Melzack (1996) extended the gate control theory
after carefully analyzing phantom limb pain. He
proposed that a large, widespread network of
neurons exists that consists of loops between the
thalamus and cortex and between the cortex and the
limbic system. Melzack labeled this network the
neuromatrix. Unit I. Introduction

73. Contemporary theories---
• The gate control theory describes a hypothetical
gate mechanism in the spinal cord that allows
nerve fibers to receive pain sensations; the gate
can be closed to pain sensation by occupying the
receptor sites with other stimuli
• This theory has encouraged a holistic approach
to pain control and research by considering non
biological components of pain
• Pain management techniques, such as cutaneous
stimulation, distraction, and acupuncture, are
partly based on this theory
Unit I. Introduction

74. Pain pathway
• Nociception: activation of sensory transduction in
nerves by thermal, mechanical, or chemical energy
impinging on specialized nerve endings. The
nerves involved convey information about tissue
damage to the central nervous system
• Nociceptor: a sensory receptor preferentially
sensitive to a noxious stimulus (pain receptors)
• Non-nociceptors: are nerve fibers that usually
does not transmit pain
• Pain results when nociceptors (sensory receptors
of pain) are stimulated by chemicals, thermal or
mechanical factors. Unit I. Introduction

75. Nociceptors---
• Nociceptors are free nerve endings in the skin that
respond only to intense, potentially damaging stimuli.
• The joints, skeletal muscle, fascia, tendons, and cornea
also have nociceptors that have the potential to
transmit stimuli that produce pain. However, the large
internal organs (viscera) do not contain nerve endings
that respond only to painful stimuli
• Pain originating in these organs (viscera) results from
intense stimulation of receptors that have other
purposes
• For example, inflammation, stretching, ischemia,
dilation, and spasm of the internal organs all cause an
intense response in these multipurpose fibers and can
cause severe pain Unit I. Introduction

76. Pain pathway---
The impulse is transmitted from the nociceptors to the
spinal cord along two peripheral nerve fibers
• There are two main types of fibers involved in the
transmission of nociception
A – Delta fibers (Aδ)
- Smaller, myelinated Aδ (A delta) fibers transmit
localized pain rapidly, which produces the initial “fast
pain.”
C - Fibers – are larger, unmyelinated fibers that
transmit what is called second pain. This type of pain
has dull, aching, or burning qualities that last longer
than the initial fast pain. The type and concentration
of nerve fibers to transmit pain vary by tissue type.
Unit I. Introduction

77. Manifestation of pain
• ed blood pressure
• ed heart rate
• ed respiratory rate
• Dilated pupil
• Perspiration and pallor
• ed blood glucose
• Verbal response, crying, reporting pain
• Non-verbal response – positioning, rubbing
painful area.
• ed muscle tension.
Unit I. Introduction

78. Pain threshold & tolerance
• Pain threshold: the point at which a stimulus is
perceived as painful
= is the point at which a patient experiences pain
• Pain tolerance: the highest intensity of pain that the
person is willing to tolerate. occurs when a person
who has been taking opioids becomes less sensitive
to their analgesic properties. Characterized by the
need for increasing doses to maintain the same
level of pain relief.
- It is affected by individual, psychosocial, cultural,
religious, and environmental factors; it influences
pain duration and intensity
Unit I. Introduction

79. Factors that affect pain response
• Pain is primarily a physical problem that has
psychological effects
• The physical and psychological sources of pain
are often complex and intertwined, with
causative factors difficult to isolate
• Psychogenic pain is pain without a physiologic
basis; this term isn’t helpful because all physical
causes of pain can’t be diagnosed, and all pain is
real to the patient
Unit I. Introduction

80. Factors affecting pain perception
• Anxiety
• Fear
• Depression
• Gender
• Age
• Fatigue
• Lack of knowledge
• Culture, values and beliefs
• Placebo effect
Unit I. Introduction

81. Pain assessment
◗ 0 to 10 rating scale: The patient is asked to rate
pain on a scale of 0 to 10, with 0 being no pain
and 10 being the worst pain imaginable
◗ Face rating scale: The patient is shown
illustrations of five or more faces demonstrating
varying levels of emotion, from happy to sad; by
selecting the face that most closely approximates
the pain sensation, the patient helps the nurse
gauge the effectiveness of interventions
Unit I. Introduction

82. Pain assessment---
◗ Visual analog scale: The patient places a
mark on the scale, ranging from no pain to
pain as bad as it can be, to indicate his current
level of pain
◗ Body diagram: The patient draws the location
and radiation of pain on a paper illustration of
the body
Unit I. Introduction

83. Pain assessment---
◗ Questionnaire: The patient answers questions
about the pain’s location, intensity, quality, onset,
and relieving and aggravating factors
◗ Pain flow chart: The nurse documents variations
in pain, vital signs, and LOC in response to
treatments; these forms are particularly useful for
monitoring patient response to epidural opioid
infusions and for titrating dosages
Unit I. Introduction

84. Pain assessment---
• Pain also can be assessed by observing for
objective signs, such as facial grimacing; elevated
blood pressure and increased pulse and
respiratory rates; muscle tension; restlessness or
an inability to concentrate; decreased interest in
surroundings and increased focus on pain;
perspiration and pallor; crying, moaning, or
verbalizations of pain; and guarding the painful
body part
Unit I. Introduction

85. Assess the characteristics of pain
PQRST
• Provokes: What causes pain?
• Quality: What does it feel like?
(Boring, cramping, crushing, dull , Hammering,
lancination, penetrating, Piercing, sharp, tearing,
throbbing ,etc)
• Radiates: Where does the pain radiate?
• Severity: How severe is the pain
(Mild, moderate, severe, constant)
• Time: When did the pain start
(Acute ,chronic , intractable)
Unit I. Introduction

86. Assess the patient’s behavioral responses to the
pain experience
- Verbal statement
- Vocal response
- Facial expression
- Body movement
- Physical contact with others
- Affect of pain on ability to communicate and
carry out usual activities of daily living
Unit I. Introduction

87. Assess factors that influence responses to pain
- Ethnic and cultural factors
- Previous pain experiences
- Meaning of pain experience
- Patients response to pain relief strategies
Unit I. Introduction

88. General pain relief techniques
A/ Cognitive relief stimulation
o Anticipatory guidance
o Distraction
B/ Physical pain relief
o Cutaneous - Contra lateral stimulation, massaging or
rubbing
o Transcutaneous electric nerve /TENS/
C/ Behavioral pain relieving techniques
o Deep breathing ( 5 inhale & 5 exhale ) for 10-20 minutes
o Progressive muscle relaxation
o Yoga and abdominal breathing
o Guided imagery, Meditation
o Placebo, Hypnosis
o Acupuncture, Local anesthesia
o Medications Unit I. Introduction

89. C/ Behavioral pain relieving techniques
o Deep breathing
-Take a slow, deep breath, & slowly release your
breath
- Count for five for your inhale & five for your
exhale to establish a slow rhythm of breathing
- Feel your stomach expanding & releasing with
each long inhale & exhale
- Minimum recommended length is 10-20 minutes
Unit I. Introduction

90. C/ Behavioral pain relieving techniques---
o Progressive muscle relaxation
- Involves deliberately tensing specific muscle
groups for a short period of time & then
releasing the tension
- Start by tightening one group of muscles (ex.
Lower arm)& hold the tension for 8 seconds
- Then quickly release your tension, letting all the
pain & tension flow out as you exhale
- Repeat the tension relaxation cycle with the same
muscle then proceed to other muscle groups
Unit I. Introduction

91. C/ Behavioral pain relieving techniques---
o Yoga and abdominal breathing
o Guided imagery (the use of one’s imagination to cause relaxation and pain
relief.(it is as simple as child thinking of happy things.) Use your imagination to
take you to a calm, peaceful place. Hear the soothing sounds of nature (the
sounds of birds, the rustle of the leaves on the trees. Feel the gentle breeze on
your face. )
o Meditation (A technique of mind control that leads to inner feelings of calm and
peacefulness and may result in experiences of transcendental awareness and self-
realization.)
o Placebo( It is inactive substance given to satisfy a person’s demand for a drug)
o Hypnosis
o Acupuncture
o Local anesthesia
o Medications
Unit I. Introduction

92. Part VI. Terminal illness
Definitions
• Terminal illness: progressive, irreversible illness that
despite cure-focused medical treatment will result in
the patient’s death
• Hospice care: a coordinated program of
interdisciplinary care and services provided primarily
in the home to terminally ill patients and their
families.
- Freestanding, hospital-based, and community or
home-based settings
• Palliative care: comprehensive care for patients
whose disease is not responsive to cure; care also
extends to patients’ families
Unit I. Introduction

93. Terminal illness---
• The needs of patients with terminal illnesses are
best met by a comprehensive multidisciplinary
program that focuses on quality of life, palliation
of symptoms, and provision of psychosocial and
spiritual support for the patient and family when
cure and control of the disease are no longer
possible
• Although physicians, social workers, clergy,
dietitians, pharmacists, physical therapists, and
volunteers are involved in patient care, nurses
are most often the coordinators of all hospice
activities
Unit I. Introduction

94. Terminal illness---
According to Saunders, the principles underlying
hospice are as follows:
• Death must be accepted
• The patient’s total care is best managed by an
interdisciplinary team whose members
communicate regularly with each other
• Pain and other symptoms of terminal illness must be
managed
• The patient and family should be viewed as a single
unit of care
• Home care of the dying is necessary
• Bereavement care must be provided to family
members
• Research and education should be ongoing
Unit I. Introduction

95. Eligibility criteria for hospice care
General
• Serious, progressive illness
• Limited life expectancy
• Informed choice of palliative care (futile Rx) over
cure-focused treatment
Hospice-specific
• Presence of a family member or other caregiver
continuously in the home when the patient is no
longer able to safely care for him/herself (some
hospices have created special services within
their programs for patients who live alone, but
this varies widely) Unit I. Introduction

96. Part VIII. Care for elderly patients
• Elderly people frequently do not report
symptoms, perhaps because they fear a serious
illness may be diagnosed or because they accept
such symptoms as part of the aging process
• The aged patient has less physiologic reserve (the
ability of an organ to return to normal after a
disturbance in its equilibrium) than the younger
patient
Unit I. Introduction

97. Care for elderly patients --
• Cardiac reserves are lower; renal and hepatic
functions are depressed; and gastrointestinal activity
is likely to be reduced
• Dehydration, constipation, and malnutrition may be
evident.
• Sensory limitations, such as impaired vision or
hearing and reduced tactile sensitivity, are often the
reasons for falls and burns. Therefore, the nurse
must be alert to maintaining a safe environment.
Arthritis is common in older people and may affect
mobility, making it difficult for the patient to turn
from one side to the other or ambulate without
discomfort
Unit I. Introduction

98. Care for elderly patients --
• As age advances more, the ability to perspire
decreases. Because decreased perspiration leads
to dry, itchy skin, which becomes fragile and is
easily abraded, precautions are taken when
moving an elderly person
• Decreased subcutaneous fat makes older people
more susceptible to temperature changes
• Most elderly people have experienced personal
illnesses and possibly life-threatening illnesses of
friends and family. Such experiences may result
in fears about the surgery and about the future
Unit I. Introduction

99. Physiological changes in elderly people
Cardiovascular system
• Decreased cardiac output; diminished ability to
respond to stress; heart rate and stroke volume
do not increase with maximum demand; slower
heart recovery rate; increased blood pressure
Subjective and objective findings
• Complaints of fatigue with increased activity
• Increased heart rate & recovery time
• Normal BP ≤140/90 mm Hg
Unit I. Introduction

100. Physiological changes in elderly people---
Respiratory system
• Increase in residual lung volume; decrease in
vital capacity; decreased gas exchange and
diffusing capacity; decreased cough efficiency
Subjective and objective findings
• Fatigue and breathlessness with sustained
activity; impaired healing of tissues as a result of
decreased oxygenation; difficulty coughing up
secretions
Unit I. Introduction

101. Physiological changes in elderly people---
Integumentary system
• Decreased protection against trauma and sun
exposure; decreased protection against
temperature extremes; diminished secretion of
natural oils and perspiration
Subjective and objective findings
• Skin appears thin and wrinkled; complaints of
injuries, bruises, and sunburn; complaints of
intolerance to heat; bone structure is prominent;
dry skin
Unit I. Introduction

102. Physiological changes in elderly people---
Reproductive system
• Female: Vaginal narrowing and decreased
elasticity; decreased vaginal secretions
• Male: Decreased size of penis and testes
• Male and female: Slower sexual response
Subjective and objective findings
• Female: Painful intercourse; vaginal bleeding
following intercourse; vaginal itching and
irritation; delayed orgasm
• Male: Delayed erection and achievement of
orgasm
Unit I. Introduction

103. Physiological changes in elderly people---
Musculoskeletal system
• Loss of bone density; loss of muscle strength and
size; degenerated joint cartilage
Subjective and objective findings
• Height loss; prone to fractures; kyphosis; back
pain; loss of strength, flexibility, and endurance;
joint pain
Unit I. Introduction

104. Physiological changes in elderly people---
Genitourinary system
• Male: Benign prostatic hyperplasia
• Female: Relaxed perineal muscles, detrusor
instability (urge incontinence), urethral dysfunction
(stress urinary incontinence)
Subjective and objective findings
• Male: Urinary retention; irritative voiding symptoms
including frequency, feeling of incomplete bladder
emptying, multiple nighttime voiding
• Female: Urgency/frequency syndrome, decreased
“warning time,” bathroom mapping; drops of urine
lost with cough, laugh, position change
Unit I. Introduction

105. Physiological changes in elderly people---
Gastrointestinal system
• Decreased salivation; difficulty swallowing food;
delayed esophageal and gastric emptying;
reduced gastrointestinal motility
Subjective and objective findings
• Complaints of dry mouth; complaints of fullness,
heartburn, and indigestion; constipation,
flatulence, and abdominal discomfort
Unit I. Introduction

106. Physiological changes in elderly people---
Nervous system
• Reduced speed in nerve conduction; increased
confusion with physical illness and loss of
environmental cues; reduced cerebral circulation
(becomes faint, loses balance)
Subjective and objective findings
• Slower to respond and react; learning takes
longer; becomes confused with hospital
admission; faintness; frequent falls
Unit I. Introduction

107. Physiological changes in elderly people---
Special senses
• Vision: Diminished ability to focus on close objects;
inability to tolerate glare; difficulty adjusting to
changes of light intensity; decreased ability to
distinguish colors
• Hearing: Decreased ability to hear high frequency
sounds
• Taste and smell: Decreased ability to taste and smell
Subjective and objective findings
• Vision: Holds objects far away from face; complains
of glare; poor night vision; confuses colors
• Hearing: gives inappropriate responses; asks people
to repeat words; strains forward to hear.
• Taste and smell: Uses excessive sugar and salt
Unit I. Introduction

108. Part IX. Nursing process
• An organized /systematic/ sequence of problem-
solving steps used to identify and to manage the
health problems of clients
• Systematic problem-solving process that guides
all nursing actions
• Nursing diagnosis & treatment of human
responses to actual or potential health problems
Unit I. Introduction

109. Nursing process
• It is accepted for clinical practice established by
the American Nurses Association
How is the nursing process related to critical
thinking?
• Nursing is a problem solving process that uses
many individual critical thinking skills
Wollo University

110. Nursing process---
History of the nursing process
o In the 1970s, the American Nurses Association
(ANA) mandated that the nursing process be part
of nursing practice and instituted a five-step
process (assessment, diagnosis, planning,
implementation, and evaluation)
o In 1982, the North American Nursing Diagnosis
Association, now known as NANDA International
(NANDA-I), was established to develop, review,
and update nursing diagnoses; this organization
meets every 2 years
Unit I. Introduction

111. Nursing process---
History of the nursing process---
 The ANA’s Standards of Clinical Nursing Practice
(1998) include an additional component entitled
“outcome identification” and establish the
sequence of steps in the following order:
o Assessment
o Diagnosis
o Outcome identification
o Planning
o Implementation, and
o Evaluation Unit I. Introduction

112. Components of the Nursing Process

113. Nursing process---
Benefits of the nursing process
o Provides an orderly & systematic method for
planning & providing care
o Enhances nursing efficiency by standardizing nursing
practice
o Facilitates documentation of care
o Provides a unity of language for the nursing
profession
o Is economical
o Stresses the independent function of nurses
o Increases care quality through the use of deliberate
actions
Unit I. Introduction

114. Benefits of the nursing process---
For the client
• Continuity of care
• Prevention of omission and duplication
• Individualized care
• Increased client participation
For the nurse
• Job satisfaction
• Continual learning
• Increased self confidence
• Staffing assignments
• Standards of practice
For the profession
• Promotes collaboration
• Helps people to understand what nurses do

115. Nursing process---
The nursing process has seven distinct
characteristics
o Within the legal scope of nursing
o Based on knowledge-requiring critical thinking
o Planned-organized and systematic
o Client-centered
o Goal-directed
o Prioritized
o Cyclic and dynamic rather than static
Unit I. Introduction

116. Purposes of the nursing process
o The nursing process provides a basis for problem
solving, clinical decisions, and individualized
patient care
o It uses the scientific method of observation,
measurement, data collection, and data analysis
to evaluate the needs of patients and their
families
o The nursing process provides an organized and
universal method of communication for nurses in
education, practice, and research
Unit I. Introduction

117. Purposes of the nursing process---
o Through the nursing process, nurses have
adopted a body of knowledge that’s unique to
nursing; this knowledge encompasses illness,
illness prevention, and health maintenance.
“When an apple is cut, others see seeds in the apple.
We, as nurses, see apples in the seeds.” (Martha
Rogers, nurse theorist)
Unit I. Introduction

118. Components of the nursing process
( Steps of the nursing process)
A/ Assessment
Assessment skills
1. Physical examination 2. Interviewing
3. Observation 4. Intuition
Various frameworks are available for acquiring the
assessment data, such as:-
• Gordon’s 11 functional health patterns
• Maslow’s hierarchy of needs
• Erik Erikson’s 8th stages of development, etc
Wollo University

119. Components of the nursing process---
( Steps of the nursing process)
A/ Assessment
• Various frameworks are available for acquiring the
assessment data, such as Gorden’s 11 functional health
patterns, Maslow’s hierarchy of needs, and Erikson’s
“eight stages of man”
(Objective and subjective = data collection)
1. Conduct the health history
2. Perform the physical assessment
3. Interview the patient’s family or significant others
4. Study the health record
5. Organize, analyze, synthesize, and summarize the
collected data
Unit I. Introduction

120. Data resources
• Client
• Other individuals
• Previous records
• Consultations
• Diagnostics studies
• Relevant literature

122. Types of nursing assessments
1. Initial
• Performed on entry to healthcare facility
• More comprehensive than subsequent
assessments
• Often includes: health history, physical exam,
psychosocial assessment
2. Focused
• Limited to particular patient problem
• Only performed when comprehensive patient
database already exists

123. Types of nursing assessments
3. Emergency
• Life threatening situation
• Focus on rapid identification of problems
• Assessment follows ABCs
4. Time-Lapsed
• Occurs after initial assessment & period of time has
elapsed (3 months or more)
• Compares current status to previous baseline
5. Ongoing

124. Gordon’s 11 functional health patterns
• Individual assignment

125. Erik Erikson’s 8th stages of development
Stage 1. Infancy—Trust Vs Mistrust
-Trust that their world is a safe place
-Family plays key role in how the child meets this challenge
Stage 2. Early childhood—Autonomy Vs Shame
- Doubt (I am ? ) - Shame - Identity crisis
Stage 3. Preschool—Initiative Vs Guilt
- Experience guilt at failing to meet the expectations of
parents & others
Stage 4. School age— Industry Vs Inferiority
- Tries to develop a sense of self-worth by refining skills
- Feels fear that they do not measure up

126. Erik Erikson’s 8th stages of development
Stage 5. Adolescence—Identity Vs Role confusion
- Unique- Self image
- Self identity will emerge !
Stage 6. Young adult—Intimacy Vs Isolation
Stage 7. Middle adulthood—Generativity Vs Stagnation
- One person can make a difference & every person should
try
- Self absorption
- Contributing the lives of others in the family
- I am always truthful, positive & helping others
Stage 8. Old age—Integrity Vs Despair
- Look back over missed opportunities

127. Nursing diagnosis
= Analysis of data
 Statement describing client’s actual or potential response
to health problems
 Clinical judgment about an individual, family or community
response to actual or potential health problems & life
processes
 Provides basis for selection of nursing interventions to
achieve outcomes for which the nurse is accountable
1. Identify the patient’s nursing problems
2. Identify the defining characteristics of the nursing
problems
3. Identify the etiology of the nursing problems
4. State nursing diagnoses concisely and precisely
Professional nurses are responsible for making nursing
diagnosis
Unit I. Introduction

128. Nursing diagnosis versus medical diagnosis
 Nursing diagnosis
• Focus on identifying human response to health and
illness
• Describe problems treated by nurses within the scope
of independent nursing practice
• Change from day to day as client responses
 Medical diagnosis
• Identifies disease
• Describes problems for which the physician directs
the primary treatment
• Remains the same as long as the disease is present
Unit I. Introduction

129. Nursing diagnosis
How to make an accurate nursing Dx?
• Know the various NANDA diagnoses
• Collect valid and pertinent data
- Cluster relevant data
• Differentiate nursing from collaborative problems
• Formulate the diagnosis correctly
• Focus on the priority diagnosis!
• Your Dx should be amenable
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130. Types of nursing diagnosis
1/ Actual nursing diagnosis – judgment about a clients response to a
health problem at the time of assessment and is signified by the
presence of associated signs and symptom
– Presence of major defining characteristics (cluster of signs &
symptoms often associated with the diagnosis)
– Data base contains evidence of signs & symptoms or defining
characteristics
Format – 3 part (Problem, Etiology and Signs and Symptoms )
Examples
– Impaired communication related to language barrier as evidenced
by inability to speak or understand Amharic & by use of Oromifa
– Diarrhea related to dumping syndrome as evidenced by liquid
stools & abdominal cramping
Unit I. Introduction

131. Actual nursing diagnosis
EX---
• Pain related to surgical incision as evidence by
verbal comments and body posture.
• Impaired skin integrity related to prolonged
immobility secondary to fractured pelvis, as
evidenced by a 2 cm lesion on back.
• Fluid volume deficit related to persistent
diarrhea as evidenced by dry skin, poor skin
turgor, dry lips and buccal mucosa and
weakness.
Unit I. Introduction

132. Types of nursing diagnosis---
2/ Risk nursing diagnosis – Clinical judgment about a clients vulnerability to
develop a problem.
Format – 2 part (Problem + Etiology or Cause and Risk Factors)
Risk for (High Risk)
– Client is more vulnerable to develop problems than others in the
same or a similar situation
– Data base contains evidence of the related (risk) factors (factors that
can cause of contribute to the problem) of the diagnosis, but no
evidence of the defining characteristics
Examples
– Risk for constipation related to immobility & inadequate fluid intake
– Risk of infection related to compromised nutrition
- High risk for impaired skin integrity related to immobility secondary to
pain.
- Risk for injury related to lack of awareness of hazards.
- Risk for infection r/t surgical procedure.
Outcome:- The client will demonstrate no signs or symptoms of infection
Unit I. Introduction

133. Types of nursing diagnosis---
3/ Possible nursing diagnosis – Evidence about a certain problem is
unclear and need to gather more data to support it. It is one that the
nurse is not quite sure, more data must be collected before making a
decision. It is statement that describes a suspected. Format – 2 part
statement
Ex. Possible disturbed body image r/t isolating behaviors post surgery
4/ Wellness nursing diagnosis – Clinical judgment about an individual,
family and community in transition from a specific level of wellness
to a higher level of wellness
Two cues should be present: 1/ A desire for increased wellness
2/ Effective present status or function
Format – Potential + desired higher level of wellness
- Readiness for + higher level of wellness
EX:- Potential for impaired air way function
-Readiness for enhanced family process
- Readiness for enhanced nutrition
Unit I. Introduction

134. Types of nursing diagnosis---
5/ Syndrome nursing diagnosis
Syndrome
– Comprises a cluster of actual or risk nursing diagnoses
that are predicted to present because of a certain
situation or event
• They comprise a cluster of predicted actual or high – risk
nursing diagnoses related to a certain event or situation
• The clinical advantage of a syndrome diagnosis is that it
alerts the nurse to a “complex clinical condition requiring
expert nursing assessments and interventions
Unit I. Introduction

135. Types of nursing diagnosis---
NANDA (North American Nursing Diagnosis Association)
provides 5 syndrome diagnoses
This diagnosis is only a one part statement
Format – 1 part statement (rape trauma syndrome)
1/ Rape trauma syndrome (anxiety, disturbed sleep pattern,
fear, high risk for ineffective sexuality patterns, grieving, pain)
2/ Disuse syndrome (risk for constipation, risk for impaired
respiratory function, risk for infection, risk for thrombosis, risk
for activity intolerance, risk for injury, impaired physical
mobility, risk for disturbed thought processes, risk for
disturbed body image, risk for powerlessness, risk for
impaired tissue integrity)
3/ Post-trauma syndrome
4/ Relocation stress syndrome and
5/ Impaired environmental interpretation syndrome
Unit I. Introduction

136. Types of nursing diagnosis---
6/Collaborative problems
• Potential complications of trauma, disease, or treatment
• Certain physiologic complications that nurses monitor to
detect onset or change in status
Writing nursing diagnoses
 Avoids value judgments
 Does not use medical terminology
EX. Incorrect: Potential for pneumonia
Correct: Ineffective airway clearance related to poor
coughing effort
- Potential for impaired air way function
 Focuses on the person’s response to the medical problem
 States only one problem at a time
EX. Incorrect: pain and fear related to diagnostic procedure.
Correct: pain related to diagnostic procedure
Unit I. Introduction

137. Planning
= Goals prioritize
Establishing priorities based on Maslow’s Hierarchy of
needs
EX. 1
– Confused client with O2 deficit may continually climb
out of bed to open the window in hospital room
– Basic need for oxygen supersedes concerns about
safety
EX. 2
– Individual lacking sleep because of anxiety may not be
able to focus on pre-op teaching, even though the
information is important for safety in the post-
operative period Unit I. Introduction

138. Planning---
1. Assign priority to the nursing diagnoses
Prioritizing
EX. For a client admitted for scheduled lung surgery
Assessment data lead to identifying three responses of concern
• Fear
• Altered breathing pattern
• High risk for infection
o Physiologic
• Altered breathing patterns r/t decreased lung expansion, fear
o Safety
• High risk for infection r/t hazards of invasive procedure,
history of previous infections
o Security
• Fear r/t outcome of surgery, anticipated pain, need for chest
tube postoperatively
Unit I. Introduction

139. Planning---
2. Specify the goals
a. Develop immediate, intermediate, and long-term
goals
b. State the goals in realistic and measurable terms.
3. Identify nursing interventions appropriate for
goal attainment
4. Establish expected outcomes
a. Make sure that the outcomes are realistic and
measurable.
b. Identify critical times for the attainment of
outcomes. Unit I. Introduction

140. Planning---
Example 1
• Goal: The client will report a reduction in pain &
improve mobility by discharge
• Outcome: The client will complete bath without
assistance; relate a reduction in pain and request less
pain medication; remain out of bed from 1100-1400
and 1700-1900
Example 2
• Goal: Client’s pressure ulcer will heal within 7 days
• Outcome: Erythema will be reduced in 2 days;
diameter of ulcer will decrease from 5 cm to 2 cm in 5
days; ulcer will have no drainage in 2 days; skin
overlying ulcer will be closed in 7 days
Unit I. Introduction

141. Purposes of goals & outcomes
oDefine how the nurse & client know that the
human response identified in the nursing
diagnosis has been prevented, modified, or
corrected
oServe as a blueprint for evaluation
oHelp determine effectiveness of nursing
interventions
o They are the measuring sticks of the plan of care
o They are motivating factors
Unit I. Introduction

142. Components of outcomes
• Subject: Who is the person expected to achieve
the outcome?
• Verb: What actions must the person take to
achieve the outcome?
• Condition: Under what circumstances is the
person to perform the actions?
• Performance criteria: How well is the person to
perform the actions?
• Target time: By when is the person expected to be
able to perform the actions?
Unit I. Introduction

143. Nursing outcomes
 Are derived from nursing diagnosis
Look at the first part of the nursing diagnosis - That is the
word before r/t
Ex 1
Nsg Dx:- Activity intolerance r/t prolonged immobility
Restate the clause in a statement that describes improvement,
control, or absence of the problem
Outcome;- The client will demonstrate increased tolerance
while ambulating
Documented as measurable goals
• Use verbs
• Describe exactly what you expect to see or hear
• Avoid vague statements like “understand”
Unit I. Introduction

144. Planning---
5. Develop the written plan of nursing care
a. Include nursing diagnoses, goals, nursing
interventions, expected outcomes, and critical
times.
b. Write all entries precisely, concisely, and
systematically.
c. Keep the plan current and flexible to meet the
patient’s changing problems and needs.
6. Involve the patient, family or significant others,
nursing team members, and other health team
members in all aspects of planning.
Unit I. Introduction

146. Interventions
o NIC = Nursing Interventions Classification ( are linked to
NANDA Dx)
o CCC= Clinical Care Classification
o OMAHA system
NIC,CCC, & OMAHA system include interventions to
address health promotion, cultural & spiritual needs
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148. Interventions
Steps
1. Put the plan of nursing care into action
2. Coordinate the activities of the patient, family or
significant others, nursing team members, and
other health team members.
3. Record the patient’s responses to the nursing
actions
4. Reassess the client
5. Determine the nurses need for assistance
Unit I. Introduction

149. Types of nursing interventions
A/ Dependent interventions
– Physician-initiated
– Response to medical diagnosis
– Requires nursing responsibilities & technical nursing knowledge
B/ Independent interventions
– Nurse-initiated
– Related to Nursing Diagnosis & client-centered goals
– Requires no supervision or direction from others
– Does not require physician’s order
C/ Collaborative interventions
– Requires knowledge, skills, & expertise of multiple health care
professionals
– Requires critical nursing judgment & decision making
– Desired outcomes cannot be met using only nursing expertise
Unit I. Introduction

150. Evaluation
– Was the outcome achieved?
– Was the outcome appropriate?
– Was the nursing diagnosis resolved?
– Were the interventions appropriate?
– Does the plan of care need revisions?
 Three possible outcomes of evaluation
– Outcomes not met – continue plan as written
– Outcomes not met – modify the plan
– Outcomes met – terminate the plan
Unit I. Introduction

151. Steps in evaluation
1. Collect data
2. Compare the patient’s actual outcomes with the
expected outcomes. Determine the extent to which
the expected outcomes were achieved
3. Include the patient, family or significant others,
nursing team members, and other health care team
members in the evaluation
4. Identify alterations that need to be made in the
nursing diagnoses, collaborative problems, goals,
nursing interventions, and expected outcomes
5. Continue all steps of the nursing process:
assessment, diagnosis, planning, implementation,
and evaluation. Unit I. Introduction

152. A Nursing orders contains
• Date Subject
• Action verb Times & limits Signature
Ex 1.
Dx : Impaired physical mobility related to left sided weakness as
manifested by decreased muscle strength in left leg and arm,
slowed gait, dragging foot
Goal: The client will stand and pivot from bed to wheelchair or
commode
Nursing orders
1) Passive ROM t.i.d. to left arm and leg
2) Physical therapy b.i.d. for practice at parallel bars
3) Apply left leg brace and sling to left arm when up
4) Assist to balance on right leg at bedside before and after physical
therapy daily
Meyer, RN, Signature____ Date ____

153. A Nursing orders contains
Ex 2.
Dx: Risk for Injury related to motor deficit
Goal: The client will transfer from bed to wheelchair
without injury
Nursing orders
1) Keep side rails up and trapeze over bed
2) Use shoe & nonskid sole on right foot (leg brace on left)
before transfer
3) Dangle for 5 minutes before attempting to stand
4) Lock wheels on wheelchair before transfer
5) Obtain help of second assistant
6) Block left foot to avoid slipping during pivot
7) Place signal light on right side within reach at all times
Meyer, RN, Signature____ Date ____

154. A Nursing orders contains
Ex 3
Dx: Situational Low Self-Esteem related to dependence
on others as manifested by statements, “I need as
much help as a baby; I feel so useless; How
embarrassing to be so dependent.”
Goal: The client will identify one or more examples of
improved mobility and self-care
Nursing orders
1.) Allow to express feelings without disagreeing or
interrupting.
2.) Reinforce concept that the right side of body is
unaffected.
3.) Help to set and accomplish one realistic goal daily.
S. Moore, RN ,Signature____ Date ____

155. Nursing process summary
Example
Assessment
You note that the person complains that his throat
and mouth are dry. His temperature is elevated to
100oF. His record shows that he hasn’t had anything
to drink all morning. He states that he knows he
should be drinking fluids, but he doesn’t like water,
especially when warm, and hates to keep bothering
the nurses for juices.
Diagnosis
Fluid Volume Deficit: r/t insufficient fluid intake &
fever
Unit I. Introduction

156. Nursing process summary ---
Planning
You set a goal of drinking at least 2500 ml/day
Implementation
You offer preferred fluids at set intervals during a 24
hour period
Evaluation
You determine if he’s meeting the established goal of
drinking 2500 ml/day of liquid. If not, you determine
why not, and make the necessary changes. If his
condition is improved and he no longer has even a
potential for fluid volume deficit, then you terminate
the plan and allow the person to determine his own
pattern of drinking fluids.
Unit I. Introduction

157. Summary
The Steps of the nursing process
• Assessment: Getting the facts
• Diagnosis: What is the problem?
• Planning: What do you want to happen?
• Outcome identification: How can you make it
happen?
• Implementation: Doing, delegating, documenting
• Evaluation: Did it work?

158. NANDA-I taxonomy II by domain, 2011 G.C
1/ Domain: Health promotion
● Impaired home maintenance
● Ineffective health maintenance
● Ineffective family therapeutic regimen
management
● Ineffective self-health management
● Readiness for enhanced immunization status
● Readiness for enhanced nutrition
● Readiness for enhanced self-health management
● Self-neglect
Unit I. Introduction

159. Nursing diagnosis (NANDA 2011)
2/ Domain: Nutrition
● Deficient fluid volume
● Excess fluid volume
● Imbalanced nutrition: Less than body requirements
● Imbalanced nutrition: More than body requirements
● Impaired swallowing
● Ineffective infant feeding pattern
● Neonatal jaundice
● Readiness for enhanced fl uid balance
● Risk for deficient fluid volume
● Risk for electrolyte imbalance
● Risk for imbalanced fluid volume
● Risk for imbalanced nutrition: More than body requirements
● Risk for impaired liver function
● Risk for unstable blood glucose level
Unit I. Introduction

160. Nursing diagnosis (NANDA 2011)
3/ Domain: Elimination and exchange
● Bowel incontinence
● Constipation
● Diarrhea
● Dysfunctional gastrointestinal motility
● Functional urinary incontinence
● Impaired gas exchange
● Impaired urinary elimination
● Overflow urinary incontinence
● Perceived constipation
● Readiness for enhanced urinary elimination
● Reflex urinary incontinence
● Risk for constipation
● Risk for dysfunctional gastrointestinal motility
● Risk for urge urinary incontinence
● Stress urinary incontinence
● Urge urinary incontinence
● Urinary retention Unit I. Introduction

161. Nursing diagnosis (NANDA 2011)
4/ Domain: Activity/rest
● Activity intolerance
● Bathing self-care deficit
● Decreased cardiac output
● Deficient diversional activity
● Delayed surgical recovery
● Disturbed energy field
● Disturbed sleep pattern
● Dressing self-care deficit
● Dysfunctional ventilatory weaning response
● Fatigue
● Feeding self-care deficit
Unit I. Introduction

162. Nursing diagnosis (NANDA 2011)
4/ Domain: Activity/rest---
● Feeding self-care deficit
● Impaired bed mobility
● Impaired physical mobility
● Impaired spontaneous ventilation
● Impaired transfer ability
● Impaired walking
● Impaired wheelchair mobility
● Ineffective breathing pattern
● Ineffective peripheral tissue perfusion
● Insomnia
Unit I. Introduction

163. Nursing diagnosis (NANDA 2011)
Domain: Activity/rest---
● Readiness for enhanced self-care
● Readiness for enhanced sleep
● Risk for activity intolerance
● Risk for bleeding
● Risk for decreased cardiac tissue perfusion
● Risk for disuse syndrome
● Risk for ineffective cerebral tissue perfusion
● Risk for ineffective gastrointestinal perfusion
● Risk for ineffective renal perfusion
● Risk for shock
● Sedentary lifestyle
● Sleep deprivation
● Toileting self-care deficit
Unit I. Introduction

164. Nursing diagnosis (NANDA 2011)
5/ Domain: Perception/cognition
● Acute confusion
● Chronic confusion
● Deficient knowledge
● Disturbed sensory perception (specify: visual, auditory,
kinesthetic, gustatory, tactile, olfactory)
● Impaired environmental interpretation syndrome
● Impaired memory
● Impaired verbal communication
● Ineffective activity planning
● Readiness for enhanced communication
● Readiness for enhanced decision making
● Readiness for enhanced knowledge
● Risk for acute confusion
● Unilateral neglect
● Wandering Unit I. Introduction

165. Nursing diagnosis (NANDA 2011)
6/ Domain: Self-perception
● Chronic low self-esteem
● Disturbed body image
● Disturbed personal identity
● Hopelessness
● Powerlessness
● Readiness for enhanced power
● Readiness for enhanced self-concept
● Risk for compromised human dignity
● Risk for loneliness
● Risk for powerlessness
● Risk for situational low self-esteem
● Situational low self-esteem
Unit I. Introduction

166. Nursing diagnosis (NANDA 2011)
7/ Domain: Role relationships
● Caregiver role strain
● Dysfunctional family processes
● Effective breast-feeding
● Impaired parenting
● Impaired social interaction
● Ineffective breast-feeding
● Ineffective role performance
● Interrupted breast-feeding
● Interrupted family processes
● Parental role conflict
● Readiness for enhanced family processes
● Readiness for enhanced parenting
● Readiness for enhanced relationship
● Risk for caregiver role strain
● Risk for impaired attachment
● Risk for impaired parentingUnit I. Introduction

167. Nursing diagnosis (NANDA 2011)
8/ Domain: Sexuality
● Ineffective sexuality pattern
● Readiness for enhanced childbearing process
● Risk for disturbed maternal/fetal dyad
● Sexual dysfunction
Unit I. Introduction

168. Nursing diagnosis (NANDA 2011)
9/ Domain: Coping/stress tolerance
● Anxiety
● Autonomic dysreflexia
● Chronic sorrow
● Complicated grieving
● Compromised family coping
● Death anxiety
● Decreased intracranial adaptive capacity
● Defensive coping
● Disabled family coping
● Disorganized infant behavior
● Fear
● Grieving
● Impaired individual resilience
● Ineffective community coping
Unit I. Introduction

169. Nursing diagnosis (NANDA 2011)
9/ Domain: Coping/stress tolerance ---
● Ineffective coping
● Ineffective denial
● Post trauma syndrome
● Rape-trauma syndrome
● Readiness for enhanced community coping
● Readiness for enhanced coping
● Readiness for enhanced family coping
● Readiness for enhanced organized infant behavior
● Readiness for enhanced resilience
● Relocation stress syndrome
● Risk for autonomic dysreflexia
● Risk for complicated grieving
● Risk for compromised resilience
● Risk for disorganized infant behavior
Unit I. Introduction

170. Nursing diagnosis (NANDA 2011)
10/ Domain: Life principles
● Decisional conflict
● Impaired religiosity
● Moral distress
● Noncompliance
● Readiness for enhanced hope
● Readiness for enhanced religiosity
● Readiness for enhanced spiritual well-being
● Risk for impaired religiosity
● Risk for spiritual distress
● Spiritual distress Unit I. Introduction

171. Nursing diagnosis (NANDA 2011)
11/ Domain: Safety/protection
● Contamination
● Hyperthermia
● Hypothermia
● Impaired dentition
● Impaired oral mucous membrane
● Impaired skin integrity
● Impaired tissue integrity
● Ineffective airway clearance
● Ineffective protection
● Ineffective thermoregulation
● Latex allergy response
● Risk for aspiration
● Risk for contamination
● Risk for falls
Unit I. Introduction

172. Nursing diagnosis (NANDA 2011)
11/ Domain: Safety/protection---
● Risk for imbalanced body temperature
● Risk for impaired skin integrity
● Risk for infection
● Risk for injury
● Risk for latex allergy response
● Risk for other-directed violence
● Risk for perioperative positioning injury
● Risk for peripheral neurovascular dysfunction
● Risk for poisoning
● Risk for self-directed violence
● Risk for self-mutilation
● Risk for sudden infant death syndrome
● Risk for suffocation
● Risk for suicide
● Risk for trauma
● Risk for vascular trauma
● Self-mutilation Unit I. Introduction

173. Nursing diagnosis (NANDA 2011)
12/ Domain: Comfort
● Acute pain
● Chronic pain
● Impaired comfort
● Nausea
● Readiness for enhanced comfort
● Social isolation
13/ Domain: Growth/development
● Adult failure to thrive
● Delayed growth and development
● Risk for delayed development
● Risk for disproportionate growth
Unit I. Introduction

174. Unit I. Introduction
Ghana Kids

175. Yakenyelay!
Unit I. Introduction