MSN added 1.pptx

MODULE TITLE:
MEDICAL AND SURGICAL NURSING I
November 8, 2022
By Abdi W 1

Learning Objectives:
After completing this unit, the learners will be able
to:
State the modern definition of nursing
Outline the historical background of nursing
world wide and in Ethiopia
Identify the contribution of significant individuals
in nursing
Describe the nursing process
Describe critical thinking as an instrument for
provision of quality care
November 8, 2022 By Abdi W 2

Nurse vs Nursing
 The word Nursing came from Latin word Nutricius which means
to nourish, to protect, to sustain.
 A Nurse is a person who cares for the sick or infirm: a licensed
health care professional who practices independently or
collaboratively.
 Nursing is a profession with in the health care sector focused on
the care of individuals, families, and communities.
 Nursing can be described as both an art and a Science, a heart
and a mind.
 As it’s heart, lies a fundamental respect for human dignity and an
intuition for a patient’s needs.
 This is supported by the mind, in the form of rigorous core
learning.
 Nursing encompasses autonomous and collaborative care of
individuals of all ages, families, groups and communities, sick or
well and in all settings.
 Nursing includes the promotion of health, prevention of illness
and the care of ill, disabled and dying people.

What is med - surg nursing ?
Surgery is a medical specialty that uses operative
manual and instrumental techniques on a person
to investigate or treat a pathological condition
such as a disease or injury, to help improved
bodily function, appearance, or to repair.
Medical surgical nursing is the single largest
specialty in the US and beyond.
Medical surgical nurses provide care to adults
with a variety of medical issues or who are
preparing for/recovering from surgery.
They have a broad knowledge base and are
experts in their practice.

1. Introduction to Medical and surgical nursing
Nursing Defined:
Florence Nightingale, in 1858 wrote that:
the goal of nursing was “to put the patient in the best
condition for nature to act upon him,”
nursing leaders have described nursing as both an art and a
science.
However, the definition of nursing has evolved over time.
Virginia Henderson in 1960 defined nursing as:
 “It is assisting the individual, sick or well in the performance
of those activities contributing to health or its recovery (to
peaceful death) that he will perform unaided, if he had the
necessary strength, will or knowledge and to do this in such
a way as to help him gain independence as rapidly as
possible”.

Nursing Definition: (continued)
The American Nurses Association
(ANA), in its Social Policy Statement (ANA, 1995),
defined nursing as:
 “the diagnosis and treatment of human responses to
health and illness”
ANA provided the following illustrative list of
phenomena that are the focus for nursing care and
research:
Self-care processes
Physiologic and pathophysiologic processes in areas
such as:
 rest, sleep, respiration, circulation, reproduction,
activity, nutrition, elimination, skin, sexuality, and
communication

Nursing Definition: (continued)
 Comfort, pain, and discomfort
 Emotions related to experiences of health and illness
 Meanings ascribed to health and illnesses
 Decision making and ability to make choices
 Perceptual orientations such as self-image and
control over one’s body and environments
 Transitions across the life span, such as birth, growth,
development, and death
 Affiliated relationships, including freedom from
oppression and abuse
 Environmental systems

Historical Background of Nursing
Nursing has a history as long as that of human kind.
Human beings have always faced the challenge of
fostering health and caring for the ill and
dependent.
Those who were especially skilled in this area stood
out and, in some instances, passed their skills along
to others.
Uprichard (1973) described the early history of
nursing using three images:
the folk (traditional) image,
the religious image, and
the renaissance image.

Historical Background of Nursing (continued)
The Folk Image of Nursing:
The Nurse as Mother
The early development of nursing was rarely
documented, so we must speculate about its character
from what we know of early civilizations.
The nurse was generally a member of the family or, if
not, then a member of the community who
demonstrated a special skill in caring for others.
Nursing in this perspective was seen largely as a
feminine role an extension of mothering.
Indeed, the word nursing itself may have been derived
from the same root as the words nourish and nurture.

Historical Background of Nursing (continued)
The Religious Image of Nursing:
The Nurse as God’s Worker
 In the Bible, a woman named Phoebe is identified as the first
deaconess, a word meaning servant or helper. Deaconess
cared for widows, orphans, and the sick.
 Olympias, a woman of Constantinople, set up a hospital to
care for the sick.
 In Rome, Marcella established a monastery for those in need
of care.
 Fabiola, who was converted to Christianity by Marcella,
established hospitals for the sick poor.
 In the middle Ages, the traditional role of the religious groups
in caring for the ill was continued by various orders of monks
and nuns.

The Religious Image of Nursing:
When the crusade attempted to regain
Jerusalem from Muslim control, the Knights
Hospitalers, and order of religious workers who
cared for the injured and fought to protect
them, marched with the armies.
During this time, unfortunately, the knowledge
of hygiene and sanitation gained by Greek,
Roman, Egyptian, and other ancient civilizations
was forgotten.
There was no growth or development in
knowledge regarding care of the sick.

The Religious Image(continued)
 Throughout the Middle Ages and into the Reformation,
religious orders ran almost all of the hospitals and provided
most of the nursing care in Europe.
 With the advent of the Reformation and the presence of
Protestant religious groups, the nature of these orders
changed.
 Women might join for a limited period of time, rather than
devoting the entire lifetime to service.
 They were again referred to as deaconess, the term used in
the early church.
 For example, a church order of deaconesses was organized
by Pastor Theodor Fleidner in Kaiserswerth, Germany
called the Sisters of Mercy of the Church of England.

The Religious Image(continued)
Another order established St. John’s House, an
Anglican Hospital in London.
 The Protestant Nursing groups were comprised
totally of women, and only one nursing order
made up of men, the Brothers Hospitalers of St.
John, remained in the Catholic Church.
The Muslim religion has a similar tradition of
service to others in the name of God. Rofiada al
Islamiah, one of the wives of Mohammand who
cared for the sick and injured, is considered the
mother of nursing in the Mideastern Muslim
countries (Meleis, 1985).

The Renaissance Image of Nursing:
The Nurse as Servant
The Renaissance saw the decline of monastic orders
and the rise in individualism and materialism.
There was a radical change from the image of the
selfless nurse that had developed in the early
Christian period and the Middle Ages.
Care of the ill was delegated to servants and those
unable to find any other means of support.
The hospitals of this time were plagued by pestilence
and filled with death; those who worked in them
were seen as corrupt and unsavory.

The Emergence of Modern Nursing
To some extent, the three early images of the nurse
were held simultaneously for hundreds of years.
Then, in the 19th century, one woman changed the
course of nursing: Florence Nightingale.
Although born to wealth and a family well placed in
Victorian English Society,
Florence Nightingale had a firm belief in Christian
ideals that made her disdainful (mocking) of a life of
luxury.
She believed her true calling was to minister to the
sick.
As an intelligent and well educated woman, she
recognized that optimum care of the sick required
education.

The Emergence of Modern Nursing(continued)
She persevered against family and social
opposition and initiated personal study and
research into sanitation and health.
She studied with Pastor Fleidner of 33, was to
reorganize the care for the sick at a hospital
established for “Gentlewomen in Distressed
Circumstances.”

Nightingale’s success in her first post led Britain’s
secretary of war to recruit her for a far more arduous
(hard) reorganization.
Britain was then engaged in a major war in the
Crimea; reports were coming back that more men
died of wounds in the hospitals than on the
battlefield.
Funds were raised and nurses recruited for Florence
Nightingale’s Crimean campaign.
When she arrived at the front, Nightingale found that
conditions in the military hospitals were abominable.
The absence of sewers and laundry facilities, the lack
of supplies, the poor food, and the disorganized
medical services contributed to a death rate of more
than 50% among the wounded.

Nightingale insisted on retaining control of all of
her supplies, funds, and personnel.
Her efforts and those of her staff reduced the
death rate among the wounded to less than 3%.
She eventually completely reformed the military’s
approach to the health care of the British soldier.

In 1860, she created a school of nursing, which was the
model for most nursing education in England.
The school was organized around three components:
1) a trained matron with undisputed authority over all
members of the staff,
2) a planned course of theoretical and practical training,
3) a home attached to the hospital in which carefully
selected students were placed in the care of “sisters”
responsible for their moral and spiritual training.
(The English term “sisters” used for secular nurses
reflects nursing’s religious history.)
Nightingale established educational standards for the
students – she concerned herself not just with health
care needs but with human needs.

Her school prepared nurses for hospital care
(where they were called “ward sisters”) and,
 for supervisory and teaching positions.
Nightingale also set up a program for preparing
“district” nurses, the public health/visiting nurses
of England.
She wrote that these district nurses needed
additional education because they would be
working more independently than the hospital
staff members.

As human needs expanded:
 nursing development broadened;
its interest and functions through the social
climates created by religious ideologies,
economic development,
industrial revolutions,
wars,
crusades,
education.
In this way modern nursing was born.

The intellectual revolution of the 18th and 19th
centuries led to a scientific revolution.
The dynamic change in economic and political
situations also influenced every corner of human
development including nursing.
It was during the time of Florence Nightingale (1820-
1910) that modern nursing developed.
She greatly modified the tradition of nursing that
existed before her era.
She also contributed to the definition of nursing “to
put the patient in best possible way for nature to
act."
Since her time modern nursing development has
rapidly occurred in many parts of the world.

History of Nursing in Ethiopia
The introduction of modern medicine was very
late.
Around 1866 missionaries came to Eritrea, (one
of the former provinces of Ethiopia) and started
to provide medical care for very few members of
the society.
 In 1908 Minlik II hospital was established in the
capital of Ethiopia.
The hospital was equipped and staffed by
Russians.

History of Nursing in Ethiopia (Continued)
Later hospital building was continued which
raised the need to train health auxiliaries and
nurses.
In 1949 the Ethiopian Red Cross, School of
Nursing was established at Hailesellasie I hospital
in Addis Ababa.
The training was given for three years.
 In 1954 HailesellasieI Public Health College was
established in Gondar to train health officer,
community health nurses and sanitarians to
address the health problem of most of the rural
population.

the Centralized school of Nursing formerly under
Ministry of health and, recently under Addis
Ababa University Medical Faculty and Nekemte
School of nursing are among the senior nurse’s
training institutions.
During the regimen of 'Dergue', the former
bedside and community health nursing training
was changed to comprehensive nursing.
An additional higher health professional training
institution was also established in Jimma(1983) to
train health professionals using educational
philosophy of community based and team
approach.

After the overthrown of the Dergue, the transitional
government of Ethiopia developed a health policy that
emphasizes :
 Health promotion
 diseases prevention
 curative and rehabilitative health service with priority to
the rural societies.
 major emphases were given to back warded and areas
affected highly by manmade calamities(catastrophes).
 Additional public health professional training institutions
were opened in Alamaya University and Dilla College of
Teacher Education and Health Sciences (1996).
 As the result of the policy more health professionals were
trained.

Concepts in ‘‘patient/client’’
the patient/client: consumer of nursing and health care
The central figure in health care services is, of course,
the patient.
 The term patient, which is derived from a Latin verb
meaning “to suffer,” has traditionally been used to
describe those who are recipients of care.
 The connotation commonly attached to the word is one
of dependence.
 For this reason, many nurses prefer to use the term
client, which is derived from a Latin verb meaning “to
lean,” connoting alliance and interdependence.

Concepts in ‘‘patient/client’’(continued)
Patients’ needs vary depending on their problem,
associated circumstances, and past experiences.
One of the nurse’s important functions in health care
delivery is:
 to identify the patient’s immediate needs and,
 take measures to address them.
The Patient’s Basic Needs:
 Certain needs are basic to all people and require satisfaction
accordingly.
 Such needs are addressed on the basis of priority,
 some needs are more pressing than others.
 Once an essential need is met, the person experiences a need on a
higher level.

Common Ethical principles
The following common ethical principles may be used to
validate moral claims.
Autonomy: this word is derived from the Greek words
autos (“self ”) and nomos (“rule” or “law”), and
therefore refers to self-rule.
 Its broad meanings, including individual rights, privacy,
and choice.
Beneficence: is the duty to do good and the active
promotion of benevolent acts (eg, goodness, kindness,
charity).( Injunction not to inflict harm (see nonmaleficence)
Confidentiality: relates to the concept of privacy.
 Information obtained from an individual will not be
disclosed to another unless it will benefit the person

Common Ethical principles(continued)
Double Effect: this is a principle that may morally
justify some actions that produce both good and
evil effects.
All four of the following criteria must be fulfilled:
1. The action itself is good or morally neutral.
2. The agent sincerely intends the good and not the
evil effect (the evil effect may be foreseen but is not
intended).
3. The good effect is not achieved by means of the evil
effect.
4. There is proportionate or favorable balance of good
over evil.

 Fidelity: is promise keeping; the duty to be faithful to one’s
commitments.
 It includes both explicit and implicit promises to another person.
 Justice: from a broad perspective, justice states that like cases should be treated
alike.
 A more restricted version of justice is distributive justice, which refers to the
distribution of social benefits and burdens based on various criteria, Such as:
 Equality
 Individual need
 Individual effort
 Societal contribution
 Individual merit
 Legal entitlement
Retributive justice is concerned with the distribution of punishment.

 Non maleficence: this is the duty not to inflict harm as well as
to prevent and remove harm.
 Paternalism: is the intentional limitation of another’s
autonomy, justified by an appeal to beneficence or the welfare
or needs of another.
 Respect for Persons: is frequently used synonymously with
autonomy.
 However, it goes beyond accepting the notion or attitude that
people have autonomous choice,
 treating other in a way that enables them to make the choice.
 Sanctity of Life: this is the perspective that life is the highest
good.
 all forms of life, including mere biologic existence, should take
precedence over external criteria for judging quality of life.
 Veracity
 Veracity is the obligation to tell the truth and not to lie or
deceive others.

Health, Wellness, and Health Promotion
Similarly, a significant portion of nursing’s workforce
formerly was focused on the care of patients with acute
conditions, but now a growing portion is directing its
efforts toward health promotion and disease prevention.
Health
Definition:
How health is perceived depends on how health is
defined.
The World Health Organization (WHO) defines health as
a “state of complete physical, mental, and social well-
being and not merely the absence of disease and
infirmity” (Hood & Leddy, 2002).

Definition of Health (continued)
Such a definition of health does not allow for any
variation in degrees of wellness or illness.
On the other hand, the concept of a health–illness
continuum allows for a greater range in describing a
person’s health status.
By viewing health and illness on a continuum, it is
possible to consider a person as having neither
complete health nor complete illness.
Instead, a person’s state of health is ever-changing
and has the potential to range from high-level
wellness to extremely poor health and imminent
death.
The model of the health–illness continuum makes it
possible to view a person as simultaneously
possessing degrees of both health and illness.

Definition of Health (continued)
The limitations of the WHO definition of health
are clear in relation to chronic illness and
disability.
A chronically ill person cannot meet the standards
of health as established by the WHO definition.
However, when viewed from the perspective of the
health–illness continuum:
 People with chronic illness or disability can be
understood as having the potential to attain a
high level of wellness, if they are successful in
meeting their health potential within the limits of
their chronic illness or disability.

WELLNESS
Definition:
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”
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.

WELLNESS Definition (continued)
With this in mind, it becomes evident that the
goal of health care providers is to promote
positive changes that are directed toward health
and well-being.
The fact that the sense of wellness has a
subjective aspect emphasizes them importance
of recognizing and responding to patient
individuality and diversity in health care and
nursing.

Disease vs illness vs sickness
“Disease ... is a pathological process, most often physical as in
throat infection, or cancer of the bronchus, sometimes
undetermined in origin, as in schizophrenia.
 The quality which identifies disease is some deviation from
a biological norm.
There is an objectivity about disease which doctors are
able to see, touch, measure, smell.
“Illness ... is a feeling, an experience of un health which is
entirely personal, interior to the person of the patient.
Often it accompanies disease, but the disease may be
undeclared, as in the early stages of cancer or tuberculosis
or diabetes.
Sometimes illness exists where no disease can be found.
The patient can offer the doctor nothing to satisfy his
senses...

Disease vs illness vs sickness (Continued)
“Sickness ... is the external and public mode of un
health.
Sickness is a social role, a status, a negotiated
position in the world, a bargain struck between the
person henceforward called ‘sick’, and a society
which is prepared to recognize and sustain him.
The security of this role depends on a number of
factors, not least the possession of that much
treasured gift, the disease.
Sickness based on illness alone is a most uncertain
status.
But even the possession of disease does not
guarantee equity in sickness.

Disease vs illness vs sickness (Continued)
Disease then, is the pathological process,
deviation from a biological norm.
 Illness is the patient’s experience of ill health,
sometimes when no disease can be found.
Sickness is the role negotiated with society.
“the conversion of emotional pain and conflict
into the camouflaged but culturally acceptable
language of body illness... .
Typically, individuals who are unhappy or
unfulfilled in their lives develop diffuse and
evolving nervous complaints and eventually seek
help.

Critical thinking:
It is defined as an intellectually disciplined process of actively
and skillfully conceptualizing, applying, analyzing,
synthesizing, and or evaluating information gathered from, or
generated by observation, experience, reflection, reasoning
or communication, as a guide to belief and action.
Critical thinking involves problem solving and decision making
process, but it is a more complex process.
Critical thinking competencies are the cognitive processes a
nurse in clinical situations include diagnostic reasoning clinical
inferences, and clinical decision-making.
The nursing process is considered the specific critical thinking
competency in nursing.
Critical thinking skill assists the nurse to look at all aspects of
a situation and then at a conclusion.

Critical thinking(Continued)
Skills needed in critical thinking include:
interpretation,
analysis,
evaluation,
inference,
explanation, and
self-regulation (Ignatavicius, 2001).

2. Nursing Process
Definition
Nursing process is a critical thinking
process that professional nurses use to
apply the best available evidence to
caregiving and promoting human
functions and responses to health and
illness
(American Nurses Association, 2010).

Nursing Process(Continued)
Nursing process is a systematic method of
providing care to clients.
The nursing process is a systematic method of
planning and providing individualized nursing
care.

Purposes of nursing process
1. To identify a client’s health status and
2. actual or potential health care problems or
needs.
3. To establish plans to meet the identified
needs.
4. To deliver specific nursing interventions to
meet those needs.
5. To provide individualized care
Linda Hall first introduces the term nursing
process in 1965.

Steps of Nursing process
It involves assessment (data collection),
nursing diagnosis,
planning,
implementation, and
evaluation

Steps of nursing process (continued)

Characteristics of Nursing Process
Cyclic
Dynamic nature,
 Client centeredness
Focus on problem solving and decision making
Interpersonal and collaborative style
Universal applicability
Use of critical thinking and clinical reasoning.

ASSESSMENT

Assessment (continued)
Definition
Assessment is the systematic and continuous
collection, organization, validation, and
documentation of data (information).

Types of assessment
The four different types of assessments are;
1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment

1. Initial nursing assessment: Performed within
specified time after admission.
To establish a complete database for problem
identification.
Eg: Nursing admission assessment
2. Problem-focused assessment :
To determine the status of a specific problem
identified in an earlier assessment.
Eg: hourly checking of vital signs of fever patient

3. Emergency assessment: During emergency
situation to identify any life threatening situation.
Eg: Rapid assessment of an individual’s airway,
breathing status, and circulation during a cardiac
arrest.
4. Time-lapsed reassessment: Several months
after initial assessment.
To compare the client’s current health status
with the data previously obtained.

Collection of data
Data collection is the process of gathering
information about a client’s health status.
It includes the health history, physical
examination, results of laboratory and
diagnostic tests, and material contributed by
other health personnel.

Types of Data
Two types: subjective data and objective data.
1. Subjective data, also referred to as symptoms
or covert data, are clear only to the person
affected and can be described only by that
person.
Itching, pain, and feelings of worry are examples
of subjective data.

Types of data (continued)
2. Objective data, also referred to as signs or
overt data, are detectable by an observer or can
be measured or tested against an accepted
standard.
They can be seen, heard, felt, or smelled, and
they are obtained by observation or physical
examination.
For example, a discoloration of the skin or a
blood pressure reading is objective data.

Sources of Data
Sources of data are primary or secondary.
1. Primary : It is the direct source of information.
The client is the primary source of data.
2. Secondary: It is the indirect source of
information.
All sources other than the client are considered
secondary sources.
Family members, health professionals, records
and reports, laboratory and diagnostic results
are secondary sources.

Methods of data collection
The methods used to collect data are
observation,
interview and examination.
Observation : It is gathering data by using the
senses. Vision, Smell and Hearing are used.
Interview : An interview is a planned
communication or a conversation
with a purpose.

Methods of data collection(continued)
There are two approaches to interviewing:
directive and nondirective.
The directive interview is highly structured and
directly ask the questions.
And the nurse controls the interview.
A nondirective interview, or rapport building
interview and the nurse allows the client to
control the interview.

STAGES OF AN INTERVIEW
An interview has three major stages:
1. The opening or introduction
2. The body or development
3. The closing

STAGES OF AN INTERVIEW(Continued)
Examination : The physical examination is a
systematic data collection method to detect
health problems.
To conduct the examination, the nurse uses
techniques of inspection, palpation,
percussion and auscultation.

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

Validation of data
The information gathered during the assessment is
“double-checked” or verified to confirm that it is
accurate and complete.
Documentation of data
To complete the assessment phase, the nurse
records client data.
Accurate documentation is essential and should
include all data collected about the client’s
health status.

Scenario
1. During the day, while being admitted to the
nursing unit from the emergency department, a
patient tells the nurse that she is short of breath
and has pain in her chest when she breathes.
Her respiratory rate is 28 and she is coughing up
yellow sputum. Her skin is hot and moist, and
her temperature is 102.2°F (39°C).
The laboratory results show white blood cell count
elevation and the sputum result is pending. The
patient says that coughing makes her head hurt and
she aches all over. Identify the subjective and
objective assessment findings for this patient.

Answer the ff questions depending on
the above scenario
Subjective data Objective data

Exercise Continued
2. For the patient described in scenario, the data
will lead the night shift nurse to complete a
focused nursing assessment of which body part(s)?
a. Abdomen
b. Arms and legs
c. Head and neck
d. Anterior and posterior chest

DIAGNOSIS

Diagnosis (continued)

Diagnosis(Continued)
Diagnosis is the second phase of the nursing
process.
In this phase, nurses use critical thinking skills
to interpret assessment data to identify client
problems.
 North American Nursing Diagnosis
Association (NANDA) define or refine nursing
diagnosis.

Definition
 The official NANDA definition of a nursing
diagnosis is:
“a clinical judgment concerning a human
response to health conditions/life processes,
or a vulnerability for that response, by an
individual, family, group, or community.”

Status of the Nursing Diagnosis
The status of nursing diagnosis are actual, health
promotion and risk.
1. An actual diagnosis is a client problem that is
present at the time of the nursing assessment.
2. A health promotion diagnosis relates to clients’
preparedness to improve their health condition.
A risk nursing diagnosis is a clinical judgement
that a problem does not exist, but the presence
of risk factors indicates that a problem may
develop if adequate care is not given.

Components of a NANDA Nursing
Diagnosis
A nursing diagnosis has three components:
(1) The problem and its definition
(2) The etiology
(3) The defining characteristics.

NANDA Nursing Diagnosis(continued)
1. The problem statement describes the client’s
health problem.
2. The etiology component of a nursing
diagnosis identifies causes of the health
problem.
3. Defining characteristics are the cluster of
signs and symptoms that indicate the presence
of health problem.

Formulating Diagnostic Statements
The basic three-part nursing diagnosis statement is
called the PES format and includes the following:
1. Problem (P): statement of the client’s health
problem (NANDA label)
2. Etiology (E): causes of the health problem
3. Signs and symptoms (S): defining characteristics
manifested by the client.

Diagnosis statement (continued)
The first two parts of the statement are linked
by” related to,” some times abbreviated R/T.
The last two parts are linked by “as evidenced
by,” some times abbreviated AEB.
E.G. Ineffective Airway Clearance related to
physiologic effects of pneumonia as evidenced by
increased sputum, coughing, abnormal breath
sounds, tachypnea, and dyspnea.

Formulating Diagnostic Statements(continued)
Acute pain related to
abdominal surgery as
evidenced by patient
discomfort and pain scale.
Problem Etiology Signs &
sympto
ms
Pain Surgery
of
Abdome
n
Pain
scale
and
discomfo
rt of
patient

Differentiating Nursing Diagnosis
from Medical Diagnosis
Nursing diagnosis Medical diagnosis
A nursing diagnosis is a statement
of nursing judgment that made by
nurse, by their education,
experience, and expertise, are
licensed to treat.
A medical diagnosis is made
by a physician.
Nursing diagnoses describe the
human response to an illness or a
health problem.
Medical diagnoses refer to
disease processes.
Nursing diagnoses may change as
the client’s responses change.
A client’s medical diagnosis
remains the same for as long
as the disease is present.

Nursing diagnosis Medical diagnosis
Ineffective breathing
pattern
Asthma
Activity intolerance Cerebrovascular
accident
Acute pain Appendicitis
Disturbed body image Amputation

PLANNING

Planning (Continued)
Planning involves decision making and problem
solving.
It is the process of formulating client goals and
designing the nursing interventions required to
prevent, reduce, or eliminate the client’s health
problems.

TYPES OF PLANNING
1. Initial Planning
2. Ongoing Planning
3. Discharge Planning

TYPES OF PLANNING(Continued)
1. Initial Planning : Planning which is done after
the initial assessment.
2. Ongoing Planning : It is a continuous
planning.
3. Discharge Planning : Planning for needs after
discharge

Planning process
Planning includes;
Setting priorities
 Establishing client goals/desired outcomes
Selecting nursing interventions and activities
Writing individualized nursing interventions on
care plans.

Setting priorities
The nurse begin planning by deciding which
nursing diagnosis requires attention first, which
second, and so on.
Nurses frequently use Maslow’s hierarchy of
needs when setting priorities.

Maslow’s hierarchy of needs

Setting priorities
Nursing diagnoses are ranked in order of
importance.
Survival needs or imminent life threatening
situations takes the highest priority.
For example, the needs for air, water and food
are survival needs.
Nursing diagnostic categories that reflect
these high priorities needs include Ineffective
Airway Clearance and deficient fluid volume.

Other Priority setting criteria
Magnitude
Severity
Feasibility
Community concern
Government concern

Establishing client goals/desired
outcomes
 After establishing priorities, the nurse set goals for each
nursing diagnosis.
Goals may be short term or long term.
 An expected outcome is a measurable client behavior that
indicates whether the person has achieved the expected
benefit of nursing care.
It may also be called a goal or objective.
An expected outcome has the following characteristics:
 Client oriented
 Specific
 Reasonable
 Measurable

Nursing interventions
A nursing intervention is any treatment, that a
nurse performs to improve patient’s health.

TYPES OF NURSING INTERVENTIONS
1. Independent interventions are those activities
that nurses are licensed to initiate on the basis of
their knowledge and skills.
2. Dependent interventions are activities carried
out under the orders or supervision of a licensed
physician.
3. Collaborative interventions are actions the nurse
carries out in collaboration with other health team
members

Nursing Intervention(continued)
Nursing intervention is also called nursing orders
or nursing actions, are activities that will most
likely produce the desired outcomes (short-term
or long-term).
To achieve this outcome, one should select
nursing interventions such as the following
examples:
Offering fluids frequently
Positioning frequently
Teaching deep breathing exercise
Monitoring vital signs
Administering oxygen, etc. accordingly.

Writing Individualized Nursing
Interventions
After choosing the appropriate nursing
interventions, the nurse writes them on the
care plan.
Nursing care plan is a written or computerized
information about the client’s care.

IMPLEMENTATION

Implementation
Implementation consists of doing and
documenting the activities.
The process of implementation includes;
Implementing the nursing interventions
Documenting nursing activities

EVALUATION

Evaluation
Evaluation is a planned, ongoing,
purposeful activity in which the nurse
determines:
(a) the client’s progress toward achievement of
goals/outcomes and
(b)the effectiveness of the nursing care plan.

Evaluation (Continued)
The evaluation includes;
 Comparing the data with desired outcomes
Continuing, modifying, or terminating the
nursing care plan.

Study Questions
1. Define nursing using modern definition.
2. List nurse professionals who significantly
contributed to professional development.
3. State the historical trends of nursing
development.
4. Mention steps in nursing process.
5. State two common ways of collecting data about
client.
6. Describe critical thinking.

Health History
• Health history is the collection of data regarding
clients health in a chronological order.
Components of Health history:
Biographic data
Chief complaint
Present health history
Past health history
Family history
Personal history
Socioeconomic history

1. Biographic data
• This includes information regarding client’s
name, age, gender, marital status, occupation,
education, etc
2. Chief Complaints
It is the brief statement of client’s problem for
which client needs care.
Eg: Client is complaining of cough since 2 weeks,
fever since yesterday and head ache since today.

3.Present Health history
It is the expansion of chief complaints. It should
include location, quality, exaggerating and
relieving factors.
Eg: Client is admitted to the hospital with the
complaint of cough with mucus secretion since 2
weeks. Cough increases during night and
decreases with rest, fever with temperature 100
oF since yesterday and head ache at fore head
since today which decreases with rest.

4. Past health History
It is the information about clients previous
experience with any disease or surgery.
This health history includes the detail of:
Childhood illness
Adult illness
Psychiatric illness
Injuries, burns, fractures etc.
Hospitalization
Surgical & diagnostic procedures
Current medication
Past Medical hx.
Past surgical hx.

5.Family History
• This is the information about the client’s family
members & their health status.
• Three generation has to be denoted in family
tree.
• Family tree is also known as genogram.
6. Personal history:
It includes personal details such as dietary pattern,
sleep pattern, activity level, elimination pattern,
alcoholism, smoking habits etc.

7. Socioeconomic history
• Collecting data regarding clients life style,
working environment, personal relation ship
with other human beings, monthly or annual
income, housing facilities,

Principle and techniques of physical examination
Physical assessment, or the physical examination, is an integral
part of nursing assessment.
Although the sequence of physical examination depends on the
circumstances and on the patient’s reason for seeking health
care, the complete examination usually proceeds as follows:
 Vital signs
 Skin
 Head, Eyes, Ears, Nose, Throat (HEENT) and lungs
 Breasts
 Cardiovascular system
 Abdomen
 Rectum
 Genitalia
 Neurologic system
 Musculoskeletal system

Principle and techniques of P/E (Continued)
The basic tools of the physical examination are
vision, hearing, touch, and smell.
These human senses may be augmented by
special tools (eg, stethoscope, ophthalmoscope,
and reflex hammer)
The four fundamental techniques used in the
physical examination are:
 inspection,
palpation,
percussion, and
auscultation

P/E (Continued)
1. INSPECTION
The first fundamental technique is inspection or
observation.
General inspection begins with the first contact with
the patient.
Vague, general statements are not a substitute for
specific descriptions based on careful observation;
for example:
“The person appears sick.” In what way does he or
she appear sick?
“The person appears chronically ill.” In what way does
he or she appear chronically ill?

1. Inspection (Continued)
 Among general observations that should be noted in the
initial examination of the patient are:
 posture and stature,
 body movements,
 nutrition,
 speech pattern, and
 vital signs.
2. PALPATION
Palpation is a vital part of the physical examination.
Many structures of the body, although not visible, may be
assessed through the techniques of light and deep
palpation .
When the abdomen is examined, auscultation is
performed before palpation and percussion to avoid
altering bowel sounds.

2. Palpation (Continued)
Voice sounds are transmitted along the bronchi to
the periphery of the lung.
These may be perceived by touch.
may be altered by disorders affecting the lungs. The
phenomenon is called tactile fremitus.
It is useful in assessing diseases of the chest.
3. PERCUSSION
Translates the application of physical force into
sound.
The principle is to set the chest wall or abdominal
wall into vibration by striking it with a firm object.
The sound produced reflects the density of the
underlying structure.

3. Percussion (Continued)
These sounds, listed in a sequence that
proceeds from the least to the most dense,
are called:
tympany,
hyperresonance,
resonance,
dullness,
 flatness.

4. AUSCULTATION
 Auscultation is the skill of
listening to sounds produced
within the body created by the
movement of air or fluid.
 Examples include breath sounds,
the spoken voice, bowel sounds,
cardiac murmurs, and heart
sounds.
 Physiologic sounds may be
normal (eg, first and second heart
sounds) or pathologic (eg, heart
murmurs in diastole, or crackles
in the lung).

Nutritional Assessment
Disorders caused by nutritional deficiency, overeating, or
eating poorly balanced meals are among the leading
causes of illness and death
evaluation of nutritional status includes one or more of
the following methods: biochemical assessment, clinical
examination, dietary data, food record, 24 hour Recall
 body mass index : is a ratio based on body weight and
height.
 BMI =
𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝐾𝑔
ℎ𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑚𝑒𝑡𝑒𝑟 2
 18.5 – 24.9 = normal
 25 - 29.9 = Over weight
 30-39 = Obese
 > 40 is extreme Obesity

Learning Objectives
In this chapter the student will learn/ be able to:
3.1 Define communicable disease.
3.2 Classification of diseases(time course & Cause)
3.3 Definition of terms
3.4 Epidemiology and scope of communicable diseases in
Ethiopia
3.5 Chain of disease transmission
3.6 Factors involved in the chain of disease transmission
3.7 Carrier& its type
3.8 Natural history of disease
3.9 Time course of infectious diseases
3.10 Levels of prevention
3.11 Principles of communicable disease control

Brain storming Question
1. What are some of communicable diseases that
create major health problems in Ethiopia?
2. Why are communicable diseases very important
in Ethiopia?
3. How do you compare the impact of
communicable disease in Ethiopia with that of the
developed world?

3.1 Definition of communicable Diseases
Communicable Diseases: These are illnesses
due to specific infectious agents or its toxic
products, which arise through transmission of
that agent, or
 its toxic products from an infected person,
animal or inanimate reservoir to a susceptible
host, either directly or indirectly, through an
intermediate plant or animal host, vector or
inanimate environment.

3.2 Classification of diseases(time course and cause)
Diseases can be classified according to two major
dimensions; namely the time course and cause.
According to the time course, they are further classified as:
 acute (characterized by a rapid onset and a short duration)
 chronic disease (characterized by prolonged duration).
Based on the cause diseases can be broadly categorized as:
 infectious, (i.e. caused by living parasitic organisms such as
viruses, bacteria, parasitic worms, insects, etc.), or
 as noninfectious (which are caused by something other
than a living parasitic organism).
Most of the common diseases in Africa are environmental
diseases (infectious) due to infection by living organisms.

3.2 Classification(Continued)
 These are called communicable diseases, because they spread
from person to person, or sometimes from animals to people.
In developed countries where they have been prevented, other
health conditions such as accidents and degenerative diseases
become the most common.
Therefore, communicable diseases remain very important in
developing countries because:
 Many of them are very common
 Some of them are serious and cause death and disability
 Some of them cause widespread out breaks of disease or
epidemics
 Most of them are preventable by fairly simple means.
 Poor socio-economic status of the individuals makes them
 vulnerable to a variety of diseases
 Low educational status
 Lack of access to modern health care service

3.3 Epidemiological Terms and Definitions
• Epidemiology- the study of the frequency,
distribution and determinants of disease and other
health related conditions in human populations, and
the application of this study to the promotion of
health and to the prevention and control of health
problems.
The causes of diseases are classified epidemiologically as:
Primary causes - Factors that are necessary for a disease to
occur, and in whose absence the disease will not occur (e.g.
infectious agents, vitamin deficiencies).
Contributing, predisposing, or aggravating factors -
Risk factors whose presence is associated with an increased
probability that disease will occur/develop later
(e.g. Poverty is the most powerful environmental determinant
in the disease occurrence, Habit of cigarette smoking leads to
lung cancer.
November 8, 2022 By Abdi W
122

3.3. Definition (Continued)
1. Epidemics - the occurrence of any health related condition
in a given population in excess of the usual frequency in that
population.
2. Endemic - a disease that is usually present in a population
or in an area at a more or less stable level.
3. Sporadic - a disease that does not occur in that
population, except at occasional and irregular intervals.
4. Pandemic - an epidemic disease which occurs worldwide
5. Disease - a state of physiological or psychological
dysfunction.
6. Infection - the entry and development or multiplication of
an infectious agent in the body of man or animal
7. Contamination – presence of living infectious agent upon
articles

3.3. Definition of terms (continued)
8. Infestation – presence of living infectious agent on the
exterior surface of the body
9. Infectious - caused by microbes and can be transmitted to
other persons.
10. Infectious agent- an agent capable of causing infection
11. Incubation period = time between initial infection and
appearance of signs or symptoms. Time depends on the type
of microbe, virulence, inoculum amount, and host resistance
12. Prodromal period - short, mild symptoms following
incubation period
13. Period of convalescence - host returns to pre-disease
state -for some diseases, person is contagious from
incubation to convalescence, for others only during illness

3.4 Epidemiology and Scope of CD in Ethiopia
During the past 70 years, there has been a dramatic fall in the
incidence of infectious diseases, particularly in developed countries.
This is due to several factors including:
 Immunization
 Anti-microbial chemotherapy
 Improved nutrition
 Better sanitation and housing
 In less developed countries, especially in the tropics, infectious
diseases continue to be one of the commonest causes of death,
particularly in children.
 Ethiopia, as part of the developing world, has two big health
problems.
These are:
 Infectious diseases (communicable diseases)
 80% of these can be prevented by simple sanitary measures.
 Nutritional problems

3.5. Chain of Disease Transmission
This refers to a logical sequence of factors or links
of a chain that are essential to the development
of the infectious agent and propagation of
disease.
One of the basic principles of communicable
disease prevention and control is the chain of
infection.
An understanding of each link in the chain will
assist in disease prevention.

3.5. Chain of Disease (Continued)
Breaking the chain of infection at one (or more)
of the various links can limit the spread of
communicable diseases.
Interventions can be targeted at any link of the
chain.
Some interventions will be specific for a
particular causative agent.
 The others such as protection of a water shed to
prevent water borne illnesses, or
School health education services to address
healthy lifestyle choices to prevent sexually
transmitted infections

3.5. Chain of Disease (Continued)
Prevention interventions are optimal from a public
health perspective.
Determining which link, or links, to direct interventions
it depends on many variables.
In some cases, elimination of the causative agent is
not feasible due to the nature of the agent.
For example, tetanus is a normal, and ubiquitous,
inhabitant of soil and animal and human intestines
but immunization of a susceptible host can prevent
tetanus.
Safe food handling practices can eliminate agents
responsible for food-borne illnesses.
Targeting the reservoir is the other appropriate to
assist in prevention and control measures.

3.6 Factors involved in the chain of disease
transmission
There are a number of socio-economic and
environmental factors that have an impact on the
spread of disease.
Some of these factors include:
 population density,
level of employment,
income,
weather condition (e.g., temperature, humidity and
sunlight),
pollutants, and geology/soil type, (Brachman,
2006).
These factors should be taken into consideration
when investigating communicable diseases.

3.6 Factors involved (Continued)
The six factors involved in the chain of disease
transmission are:
a. Infectious agent (etiology or causative agent)
b. Reservoir
c. Portal of exit
d. Mode of transmission
e. Portal of entry
f. Susceptible host

 One of the basic principles of communicable disease
prevention and control is the chain of infection.

a. Infectious agent: An organism that is capable of
producing infection or infectious disease.
On the basis of their size, etiological agents are
generally classified into:
 Metazoa (multicellular organisms). (e.g.
Helminths).
Protozoa (Unicellular organisms) (e.g. Ameobae)
Bacteria (e.g. Treponema pallidum,
Mycobacterium tuberculosis, etc.)
Fungus (e.g. Candida albicans)
Virus (e.g. Chickenpox, polio, etc.)

b. Reservoir of infection: Any person, animal,
arthropod, plant, soil or substance (or combination
of these) in which an infectious agent normally lives
and multiplies, on which it depends primarily for
survival and where it reproduces itself in such a
manner that it can be transmitted to a susceptible
host.
Types of reservoirs
1. Man: There are a number of important
pathogens that are specifically adapted to man,
such as: measles, smallpox, typhoid, meningococcal
meningitis, gonorrhea and syphilis.
The cycle of transmission is from human to human.

Reservoir (Continued)
2. Animals: Some infective agents that affect man have
their reservoir in animals.
The term “zoonosis” is applied to disease
transmission from animals to man under natural
conditions.
For example:
Bovine tuberculosis - cow to man
Brucellosis - Cows, pigs and goats to man
Anthrax - Cattle, sheep, goats, horses to man
Rabies - Dogs, foxes and other wild animals to man
Man is not an essential part (usual reservoir) of the
life cycle of the agent.

Reservoir (Continued)
3. Non-living things as reservoir: Many of the
agents are basically saprophytes living in soil and
fully adapted to live freely in nature.
Biologically, they are usually equipped to
withstand marked environmental changes in
temperature and humidity.
E.g. Clostridium botulinum etiologic agent of
Botulism.
Clostridium tetani etiologic agent of Tetanus,
Clostridium welchi etiologic agent of gas gangrene

C. Portal of exit (mode of escape from the
reservoir): This is the site through which the agent
escapes from the reservoir.
Examples include:
GIT: typhoid fever, bacillary dysentery, amoebic
dysentery, cholera, ascariasis, etc.
Respiratory: tuberculosis, common cold, etc.
Skin and mucus membranes: Syphilis

d. Mode of transmission (mechanism of transmission
of infection): Refers to the mechanisms by which an
infectious agent is transferred from one person to
another or from a reservoir to a new host.
Transmission may be direct or indirect.
1. Direct transmission: Consists of essentially
immediate transfer of infectious agents from an
infected host or reservoir to an appropriate portal
of entry.
This could be:
a. Direct Vertical
Such as: transplacental transmission of syphilis, HIV,
etc.

b. Direct horizontal
Direct touching,
biting,
kissing,
sexual intercourse,
droplet spread onto the conjunctiva or onto
mucus membrane of eye, nose or mouth during
sneezing coughing, spitting or talking;
Usually limited to a distance of about one meter or
less.

2. Indirect transmission
a. Vehicle-borne transmission: Indirect contact through
contaminated inanimate objects (fomites) like:
Bedding, toys, handkerchiefs, soiled clothes, cooking or
eating utensils, surgical instruments.
Contaminated food and water
Biological products like blood, serum, plasma or IV-fluids,
or
Any substance serving as intermediate means by which an
infectious agent is transported and introduced into a
susceptible host through a suitable portal of entry.
The agent may or may not multiply or develop in the
vehicle.

b. Vector-borne transmission: Occurs when the
infectious agent is conveyed by an arthropod
(insect) to a susceptible host.
1. Mechanical transmission: The arthropod
transports the agent by soiling its feet or proboscis,
in which case multiplication of the agent in the
vector does not occur. (e.g. common house fly.)
2. Biological transmission: This is when the agent
multiplies in the arthropod before it is transmitted,
such as the transmission of malaria by mosquito.

C. Air-borne transmission: Dissemination of microbial agent
by air to a suitable portal of entry, usually the respiratory
tract.
Two types of particles are implicated in this kind of
spread:
 dusts and droplet nuclei.
Dust: small infectious particles of widely varying size that
may arise from soil, clothes, bedding or contaminated floors
and be resuspended by air currents.
Droplet nuclei : Small residues resulting from evaporation of
fluid (droplets emitted by an infected host).
They usually remain suspended in the air for long periods of
time.

e. Portal of entry: The site in which the infectious
agent enters to the susceptible host. For example:
Mucus membrane
Skin
Respiratory tract
GIT
Blood

f. Susceptible host (host factors): A person or
animal lacking sufficient resistance to a particular
pathogenic agent to prevent disease if or when
exposed.
Occurrence of infection and its outcome are in
part determined by host factors.
The term “immunity” is used to describe the
ability of the host to resist infection.

Resistance to infection is determined by non-specific and
specific factors:
Non-specific factors
 Skin and mucus membrane
 Mucus, tears, gastric secretion
 Reflex responses such as coughing and sneezing.
Specific factors
 Genetic-hemoglobin resistant to Plasmodium falciparum
 Naturally acquired or artificially induced immunity.
 Acquired immunity may be active or passive.
Active immunity- acquired following actual infection or
immunization, (Natural or Artificial).
Passive immunity- pre-formed antibodies given to the host,
(Natural or Artificial).

3.7 Carrier and Its Type
A carrier - is an infected person or animal who does not
have apparent clinical disease but is a potential source of
infection to others.
a. Healthy or asymptomatic carriers:
 These are persons whose infection remains unapparent.
 For example, in poliovirus, meningococcus and hepatitis virus
infections, there is a high carrier rate.
b. Incubatory or precocious carriers: These are individuals or persons
who excrete the pathogen during the incubation period (i.e. before
the onset of symptoms or before the characteristic features of the
disease are manifested).
E.g. Measles, mumps, chickenpox and hepatitis.

3.7 Carrier and Its Type(Continued)
c. Convalescent Carriers: These are those who
continue to harbor the infective agent after
recovering from the illness.
E.g. Diphtheria, Hepatitis B virus.
d. Chronic Carriers: The carrier state persists for a
long period of time.
E.g. Typhoid fever, Hepatitis B virus infection

3.8 Natural history of disease
Definition:
Natural history of disease refers to the progress of a
disease process in an individual over time, in the
absence of intervention.
The process begins with exposure to or accumulation
of factors capable of causing disease.
Without medical intervention, the process ends with
recovery ,
disability,
or death.

Natural History of Disease(continued)

Knowledge of the natural history of disease
ranks alongside causal understanding in
importance for disease prevention and control.
Natural history of disease is one of the major
elements of descriptive epidemiology.

ICEBERG CONCEPT OF DISEASE

ICEBERG concept…
• The ‘’ICEBERG concept of disease’’ Is a metaphor
emphasizing that for virtually every health
problem the number of cases of ascertained
(those visible)is out weighed by those not
discovered (those invisible)disease

Models of disease causation
 Germ theory of disease
 Epidemiological Triad
 Epidemiological Tetrad
 BEINGS theory
 Web of Causation theory
 Wheel theory

Germ theory of disease
 Proposed by Robert Koch and Louis Pasteur.
 Every human disease is caused by a microbe or
germ, which is specific for that disease and one
must be able to isolate the microbe from the
diseased human being.

Epidemiological Triad

Epidemiological Triad(Continued)
Devised to enhance search for
understanding communicable disease

Agent
Is an element or substance, animate or
inanimate, the presence (or absence) of which
may initiate or perpetuate a disease process.
A disease may have a single agent, a number of
independent alternative agents or complex of
two or more factors whose combined presence is
essential for the development of the disease.

Agent characteristics
Infectivity refers to the proportion of
exposed persons who become infected.
Pathogenicity refers to the proportion of
infected persons who develop clinical
disease.
Virulence refers to the proportion of
persons with clinical disease who become
severely ill or die.

Agent characteristics(Continued)
 Hepatitis A virus in children has low pathogenicity and
low virulence, since many infected children remain
asymptomatic and few develop severe illness.
 In persons with good nutrition and health, measles
virus has high pathogenicity but low virulence, since
almost all infected persons develop the characteristic
rash and illness but few develop the life threatening
presentations of measles (pneumonia, encephalitis).
 In persons with poor nutrition and health, measles is
a more virulent disease, with mortality as high as 5-
10%.
 Rabies virus is both highly pathogenic and virulent,
since virtually 100% of all infected persons (who do
not receive treatment) progress to clinical disease
and death.

Host
• In epidemiological terminology, the human host is
referred to as “soil” and the disease agent as
“seed”.
• A person or other living animal, that affords
existence or lodgment to an infectious agent
under natural condition.
• Host factors: Intrinsic factors that influence an
individual’s exposure, susceptibility, or response
to a causative agent.

Environment
• Physical environment – Non living things
and physical factors(air, water, soil, housing,
heat, light, etc)
• Biological environment – Microbial agents,
insects, animals, plants and man himself.
• Psychosocial environment – Lifestyle,
poverty, urbanization, community life,
income, education, stress etc.

Epidemiological Tetrad

The “BEINGS” Model of Disease
Causation
 This concept postulates that human disease and its
consequences are caused by a complex interplay of nine
different factors –
 Biological factors innate in a human being,
 Behavioral factors concerned with individual lifestyles,
 Environmental factors as physical, chemical and biological
aspects of environment,
 Immunological factors,
 Nutritional factors,
 Genetic factors,
 Social factors,
 Spiritual factors and
 Services factors, related to the various aspects of health care
services.

The Theory of “Web of Causation”
 The “epidemiological triad theory” was very
effectively used by Leavel and Clark in
explaining the natural history of disease and
levels of prevention for averting such
departures from the state of health.
 But it could not explain the causation of non
communicable diseases like IHD or road
accidents.
Theory of web causation devised to address
non-communicable diseases can also be
applied to communicable disease

Example of Web of Causation

Example of Web of Causation(Continued)

Wheel theory
As medical knowledge advanced, an additional
aspect of interest that came into play is the
comparative role of “genetic” and the
“environmental” (i.e. extrinsic factors outside the
host) factors in causation of disease.
The “triad” as well as the “web” theory does not
adequately cover up this differential.
To explain such relative contribution of genetic
and environmental factors, the “wheel” theory
has been postulated.

Wheel theory(continued)
 The theory visualizes human disease in the form
of a wheel, which has a central hub representing
the genetic components and the peripheral
portion representing the environmental
component.
Like any wheel, the outer part (environmental
component) has spokes (3 in this model) and the
environmental component is thus divided into 3
sub components, representing the social,
biological and physical components of the
environment.

Wheel theory(continued)

Summary of Natural History of Disease

Summary Continued

3.9 Time Course of Infectious Diseases
Incubation period: It is the interval of time
between infection of the host and the first
appearance of symptoms and signs of the
disease.
Prodormal period: It is the interval between the
onset of symptoms of an infectious disease and
the appearance of characteristic manifestations.
For example, in a measles patient, fever and
coryza occur in the first three days and Koplick
spots in the buccal mucosa and characteristics
skin lesions appear on the fourth day.

3.9 Time Course (Continued)
Period of communicability: The period during
which that particular communicable disease
(infectious agent) is transmitted from the
infected person to the susceptible host.

3.10. Levels of prevention
The different points in the progression of a disease at which
one can intervene can be classified according to three
levels of prevention: primary, secondary, and tertiary.
Primordial prevention
 Prevention of the emergence or development of risk
factors.
 Particularly useful for chronic diseases.
 Example :Many adult health problems (e.g., obesity,
hypertension) have their early origins in childhood, because
this is the time when lifestyles are formed (smoking, eating
patterns, physical exercise).
 Efforts are directed towards discouraging children from
adopting harmful lifestyles .
 The main intervention – is through individual and mass
education.

3.10. Levels of prevention(Continued)
A. Primary prevention: The objectives here are to promote
health, prevent exposure, and prevent disease.
I. Health promotion: This consists of general non-specific
interventions that enhance health and the body’s ability to resist
disease,
 such as:
 measures aimed at the improvement of socio-economic status
through the provision of adequately paid jobs,
 education and vocational training,
 affordable and adequate housing,
 clothing, and food,
 old-age pension benefits;
 emotional and social support,
 relief of stress, etc. In short it is any intervention that
promotes a healthier and happier life.

A. Primary prevention (Continued)
II. Prevention of exposure:- This includes actions
such as:
the provision of safe and adequate water,
 proper excreta disposal,
vector control,
safe environment at home (e.g., proper storage of
insecticides and medicines, out of children’s
reach), at school and at work (e.g., proper
ventilation,
monitoring of harmful substances in factories),
and on the streets (e.g., driver licensing laws).

III. Prevention of disease:-This occurs during the
latency period between exposure and the biological
onset of disease.
An example for this is immunization.
Immunization against an infectious organism does
not prevent it from invading the immunized host, but
prevents it from establishing an infection.
Active immunization –
Means exposing the host to a specific antigen against
which it will manufacture its own protective antibodies
after an interval of about three weeks (during which the
immunized person remains susceptible to the disease).

Passive immunization means providing the host with
the antibodies necessary to fight against disease.
Both forms of immunization act after exposure.
However, for active immunization to be protective,
the timing of its administration must be at least
three weeks prior to exposure.
Passive immunization, on the other hand is
commonly given after exposure has occurred (as in
the case of exposure to rabies or tetanus), or shortly
before an exposure is expected, as in the
administration of immune globulin to prevent viral
hepatitis A).

Breastfeeding is an example of an
intervention that acts at all three levels of
primary prevention:
Health promotion: by providing optimal
nutrition for a young child, either as the sole diet
up to four months of age, or as a supplement in
later months.
Prevention of exposure: by reducing exposure of
the child to contaminated milk.
Prevention of disease after exposure: by the
provision of anti-infective factors, including
antibodies, white blood cells, and others.

B. Secondary prevention: After the biological onset
of disease, but before permanent damage sets in,
we speak of secondary prevention.
The objective here is to stop or slow the
progression of disease so as to prevent or limit
permanent damage, through:
 the early detection and treatment of disease.
 (e.g. breast cancer (prevention of the invasive
stage of the disease),
 trachoma (prevention of blindness), and syphilis
(prevention of tertiary or congenital syphilis))

C. Tertiary prevention: After permanent damage
has set in, the objective of tertiary prevention is to
limit the impact of that damage.
The impact can be physical, psychological, social
(social stigma or avoidance by others), and
financial.
Rehabilitation refers to the retraining of
remaining functions for maximum effectiveness,
and should be seen in a very broad sense, not
simply limited to the physical aspect.
Thus the provision of special disability pensions
would be a form of tertiary prevention.

3.11 Principles of communicable disease control
This refers to the reduction of the incidence and
prevalence of communicable disease to a level
where it cannot be a major public health
problem.
Methods of Communicable Disease Control
There are three main methods of controlling
communicable diseases:
1. Elimination of the Reservoir
2. Interruption of transmission
3. Protection of susceptible host

Methods of controlling (Continued)
1. Elimination of the Reservoir
A. Man as reservoir: When man is the reservoir,
eradication of an infected host is not a viable
option. Instead, the following options are
considered:
Detection and adequate treatment of cases:
arrests the communicability of the disease
(e.g. Treatment of active pulmonary
tuberculosis).

1. Elimination of the Reservoir(Continued)
Isolation: separation of infected persons for a
period of communicability of the disease.
Isolation is indicated for infectious disease with
the following features:
 High morbidity and mortality
 High infectivity
Quarantine: limitation of the movement of
apparently well person or animal who has been
exposed to the infectious disease for a duration
of the maximum incubation period of the
disease.

November 8, 2022
B. Animals as reservoir: Action will be determined by
the usefulness of the animals, how intimately they are
associated to man and the feasibility of protecting
susceptible animals.
For example:
Plague: The rat is regarded as a pest and the
objective would be to destroy the rat and exclude it
from human habitation.
Rabies: Pet (Domestic) dogs can be protected by
vaccination but stray dogs are destroyed.
Infected animals used for food are examined and
destroyed.
By Abdi W 184

C. Reservoir in non-living things: Possible to limit
man’s exposure to the affected area (e.g. Soil,
water, forest, etc.)

2. Interruption of transmission
This involves the control of the modes of transmission from
the reservoir to the potential new host through:
 Improvement of environmental sanitation and personal
hygiene
 Control of vectors
 Disinfections and sterilization
3. Protection of susceptible host: This can be achieved
through:
 Immunization: Active or Passive
 Chemo-prophylaxis- (e.g. Malaria, meningococcal
meningitis, etc.)
 Better nutrition
 Personal protection. (e.g. wearing of shoes, use of
mosquito bed net, insect repellents, etc.)

Summary
Two big health problem in Ethiopia, Infectious
diseases, Nutritional
The six factors involved in the chain of disease
transmission are:
Mode of transmission
Carrier and Its Type
Levels of Prevention

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