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WEEK 13: HYGIENE AND COMFORT (PAIN)

PAIN STIMULUS
PAIN
• Subjective – only the person who experiences
pain knows it (diff ppl have diff stimuli) 1. Mechanical – trauma, tumor, blockage,
• 5th vital sign edema
• Unpleasant sensory and emotional experience 2. Thermal – extreme heat or cold
associated with actual or potential tissue 3. Chemical – e.g acid burns
damage – there’s pain when we see it PAIN CONCEPT TERMINOLOGIES
• Previous pain experience alters pain sensitivity
(already know what to do how to manage and 1. Pain threshold – least amount of stimuli for a
what to expect when pain is experienced) person to label a sensation as pain
2. Pain tolerance – maximum amount of painful
Pain Factors: stimuli that a person is willing to withstand
1. Location without seeking pain relief (intense)
a. Referred pain – pain is also felt on 3. Hyperaglesia or Hyperpathia – heightened
other parts response to a painful stimuli (E.g. severe pain
b. Visceral pain – from organs (pain response to paper cut)
differ from the organ’s characteristic) 4. Allodynia – non-painful stimuli causes pain -
check for underlying cause why does pain
2. Intensity – based on pain scale happen (E.g. Wind, pressure from clothes)
(quantifiable) PAIN PHYSIOLOGIC MECHANISM
a. No pain (0)
b. Mild (1-3) 1. Transduction – pain receptor excitability
c. Moderate (4-6) - Release biochemical mediators
d. Severe (7-10) (substances before pain inflammation
takes place such as prostaglandin,
3. Duration bradykinin, serotonin, histamine and
a. Acute substance P)
• Alteration of vitals is evident 2. Transmission – travel of impulse from peripheral
(Increased RR, temp, and HR, nerves to CNS (pain receptor to brain)
BP) 3. Perception – interpretation as to character and
• Sudden or slow onset of pain intensity
• Related to tissue injury, resolves 4. Modulation – descending system, brain send
with healing signals back to the spinal cord
b. Chronic (Prolonged)
• Recurring or lasting 3 months or
longer GATE CONTROL THEORY
• Extend beyond healing Peripheral nerve fibers carrying pain to the spinal cord
• Unlike acute, alteration of VS is can have their input modified at the spinal cord level
no longer evident as the body before transmission to the brain
adjusts to pain
NON-PHARMACOLOGICAL PAIN MANAGEMENT
4. Etiology 1. Cutaneous stimulation
a. Nociceptive
▪ Massage - relaxation decreases
• Due to tissue damage and muscle tension
impulse transmission ▪ Acupressure – pressure on specific
• Tissue damaged sensed by body points
nerves created an impulse to ▪ Application of heat and cold – use of
feel pain heating pad or ice compress
b. Neuropathic 2. Immobilization (learned the extend of injury
• Damage or malfunction nerves first)
due to pain ▪ Movement restriction
• Pain is not proportional ▪ Used so that to not aggravate acute
• E.g. phantom limb pain pain

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF
▪ Deliver in a timely manner – pain must be
3. Cognitive Behavioral Interventions addressed immediately especially if the pain is
▪ Environment control (quiet) severe
▪ Repatterning unhelpful thinking ▪ Empower patient and their families –
(mindset) encourage the client to verbalize for
▪ Guided imagery cooperation
▪ Distraction
- Visual (Reading or watching PATIENT CENTERED RESPONSE TO PAIN
television, computer games, ▪ Believe pain and suffering is a part of life and
watching sports) has to be endured – encourage the client that
- Auditory (Humor and music) pain can be manageable through
- Tactile (Massage, slow rhythmic cooperation as a nurse and the client
breathing, needlework (cross ▪ Deny or avoid dealing with pain until it
stitch, holding or stroking a pet) becomes unbearable – encourage the client
- Intellectual (Crossword puzzle, not to endure pain
card games) ▪ Indicator of a serious illness – pain is a common
indication of a serious illness
PATIENT CONTROLLED ANALGESIA (PCA PUMP) ▪ Enduring pain as a sign of strength
❖ Pain medications under the pt’s control ▪ Quiet in pain, not expressive
❖ Used to deliver pain medication by 2: ▪ Pain is “God’s will” – while the client’s spiritual
o Basal rate – continuous given belief is taking importance, encourage the
medication client that pain can be manageable through
o Rescue rate – medication has a time- the help of other health care workers
established (preset) ▪ Pain as unpleasant and anticipate immediate
❖ Lockout interval (for responsible administration relief from their symptoms
of pain meds): 5-20 minutes
❖ Contains a record the number of medications WHY PATIENT MAY BE RELUCTANT TO REPORT PAIN
released to the PCA pump ➢ Not wanting to be labeled as a complainer or
❖ Common for cancer patients difficult patient – avoid putting label to patients
(affects the delivery of care)
Nursing Intervention: ➢ Fear of injectable route of analgesic
administration especially children – can be
1. Assess for level of sedation and pain intervened through rewarding
2. Coordination with pain service (Pain control ➢ Unwillingness to trouble staff who are perceived
doctor) and pain nurse as busy
3. Standby naloxone (Narcan) - For fentanyl ➢ Belief the unrelieved pain is an expected,
(Pharmaco: Opioids and Narcotics) overdose normal part of recovery or aging
to avoid respiratory distress ➢ Belief that others will think they are weak if they
verbalize pain
➢ Concern with unwanted side effects – focus on
PAIN ASSESSMENT
1. Palliative or provocative factor – what can pain the client’s concern and perception and
go away or what provokes the pain to happen educate the client
(E.g temperature) ➢ Concern that use of drugs now will make the
2. Quality – is it sharp pain? drug inefficient later in life
3. Relief measures ➢ Fear that reporting pain will lead to further tests
4. Region (location) -where the pain is located and expenses – use of open communication to
specifically address patient concern’s
5. Severity – pain scale (0-10, moderate to severe) ➢ Belief that nothing can be done to control pain
6. Timing – when does the pain occur ➢ Belief the enduring pain and suffering may lead
to spiritual enlightenment (connecting pain to
religious perceptions) – pain that the client
PAIN MANAGEMENT experience regardless of their belief must not
▪ Ask about the pain regularly – observe pt’s hinder to their care
facial grimace regards pain ➢ Difference in behavioral responses to pain and
▪ Believe patients verbalization – check if the treatment reference (some pt more expressive,
patient pretends about pain some are stoic)
▪ Choose appropriate pain control – can be oral, ➢ Concern about risk associated with opioid
intravenous, topical addiction – importance of transparency to the
clients to the possible side effects, etc.

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF

PAIN AFFECTS ACTIVITIES OF DAILY LIVING ABBEY PAIN SCALE

• Sleep • Measurement of pain in people who cannot
• Appetite verbalize
• Concentration
• Work or school
• Interpersonal relationships – pain can cause
stress
• Marital relations or sex
• Home activities
• Driving and walking – loss of concentration, risk
for accidents
• Leisure activities – affects the extremities
• Emotional status (Mood, irritability, depression
and anxiety) – behavioral change due to pain

WEEK 14: HYGIENE AND COMFORT (SLEEP)

SLEEP DISORDERS DIAGNOSTICS

PHYSIOLOGICAL SLEEP MECHANISMS

POLYSOMNOGRAPHY
CIRCADIAN RHYTHM
• Physiologic measures of brain waves, eye
• 24-hour cycle internal clock
movements, and muscle tone (sleep center
• Differs from person to person (Can be a
and sleep study)
morning person or not)
• Sleep study consists of:
• Influenced by melatonin
1. Electroencephalogram (EEG) –
MELATONIN recording of the stages of sleep and
any episodes of apnea (identifying
• Linked with environmental light-dark cycle the exhibition of brain waves or brain
• Night time release activity, also used for comatose and
• Patients commonly experience sleep brain death clients)
disturbance 2. Electroculogram – detects eye
movement (detection of REM and
NREM)
SLEEP CYCLE 3. Electromyographic recording – for
muscle movement
NON-RAPID EYE MOVEMENT (NREM) 4. Electrocardiogram (ECG) – detect
any cardiac arrhythmias
• 75%-80% of sleep
• Metabolism slows down during NREM SLEEP DISORDERS
• Stage 1: Beginning of sleep (tries to relax, all
activities are done for the day)
DYSSOMNIA
• Stage 2: Most of the night, HR and temp
decreases (environment in the evening is the ❖ Problems associated with initiating or
coldest, heart rate relaxes) maintaining sleep
• Stage 3: Slow wave sleep/ deep sleep (unless ❖ Still sleepy even the client has slept
triggered by an outside stimuli) ❖ Sleep is not continuous

RAPID EYE MOVEMENT (REM)

1. Narcolepsy
• 20%-25% of sleep ▪ Excessive sleepiness but may experience
• Vivid dreams occurs fragmented sleep
• REM helps to understand the possible disorders ▪ Nur. Inv: Assess the quality of sleep if the
to the client client is refreshed or not
• Helpful for dreams and healthy brain ▪ With and without cataplexy – muscle
environment weakness less than 2 mins

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF
▪ Sleep apnea – breathing is stopped when TREATMENTS FOR OBSTRUCTIVE SLEEP APNEA
asleep
1. Continuous Positive Airway Pressure (CPAP)
2. Insomnia ▪ Provides positive sleep pressure (5-25 cm
▪ Difficulty falling asleep or maintaining it H20) in the airway during inspiration and
▪ 3 nights per week expiration to prevent airway collapse
▪ Assess what are the causes of insomnia to ▪ Keeps alveoli partially inflated even during
the client (activities before sleeping, inspiration
assessing sleep schedule)
▪ Manifestations: 2. Bilevel Positive Airway Pressure (BIPAP)
a. Long sleep latency (difficulty falling ▪ Delivers high inspiratory pressure than
asleep) CPAP
b. Fragmented awakening (frequent ▪ For severe obstructive sleep apnea
awakenings)
c. Waking up too early and can’t sleep 3. Uvulopalatopharyngoplasty (UPPP)
anymore ▪ Excision of tonsillar pillar, uvula and
d. Non-restorative sleep (feeling posterior soft palate
unrefreshed, quality of sleep is poor ▪ Due to obstruction of tonsil that causes
and unrested) obstructive sleep apnea (obstruction of
airway)
3. Periodic Limb Movement Disorder
▪ Involuntary continual movement of the 5. Parasomnias
legs and/or arms during sleep ▪ Unusual and often undesirable behaviors
▪ Can be a cramp or jerking feeling when that occur while falling asleep
asleep ▪ Types:
▪ Caused by discontinued administration of a. Somnambulism – sleep walking, individuals
laxatives are not oriented, hard to awaken (ensure
▪ Nocturnal myoclonus – jerking motion at safety to avoid injury). Somnambulism can
night caused due to lack of sleep and can be
▪ Movement: Every 0.5-10 seconds, 5-90 treated by hypnosis (optional
seconds interval Anticipatory awakening - Prevention by
▪ Treatment: - Pramipexole (Mirapex) – awakening the client to avoid sleep walking
Dopamine Agonists (increased of
dopamine to able to regulated muscle b. Sleep terrors and nightmares – can be
movement combined with somnambulism
- Medication of anti-convulsant if c. Somniloquy – sleep talking (telling one part
periodic limb disorder is already of your life)
severe - Due to emotional stress (sleep terror)
- Can be manifested by a disorder
4. Obstructive Sleep Apnea 6. CLINOMANIA
▪ Snoring can lead to obstructive sleep ▪ Excessive desire to stay in bed
apnea
▪ Sleep disordered breathing 7. NOCTURNAL LEG CRAMPS
▪ Can be anatomical (short neck) ▪ Unknown pathophysiology
▪ Due to gaining weight ▪ Due to fluid and electrolyte balance
▪ Can be caused by nasal congestion ▪ May last for 30 minutes
▪ Due to increased alcohol consumption ▪ Prevention: Vitamin B, eating in rich in
▪ Partial or complete upper airway potassium
obstruction during sleep 8. NOCTURNAL EMISSION
a. Lasts 10-90 seconds (hypoxemia ▪ Unprovoked discharge
occurs) ▪ Spontaneous orgasm
b. Oxygen level in the blood drops ▪ “Wet dreams”
o Daytime sleepiness is common ▪ Orgasm and emission of semen during
sleep

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF

SLEEP HYGIENE NOCTURNAL PENILE TUMESCENCE

❖ Interventions to promote sleep
❖ Factors: ❖ “Morning wood”
a. Environment - temperature ❖ Spontaneous erection of the pens during sleep
b. Medication – do not administer diuretics or when waking up
before sleeping ❖ Phenomenon happens to men
c. Diet – drinking of milk
d. Disease – the pain for the client to sleep
RICHMOND AGITATION SEDATION SCALE
easily
(RAAS)
❖ Intervention
a. Lighting – patient’s choice whether light
is on or off
b. Bed positioning – number of pillows
c. Loose clothing – pt’s gown
d. Hygiene measures – taking a bath
before sleeping
e. Bed linen – smooth bed linens can help
to enhance sleep
f. Voiding pre-bedtime – to lessen
awakening while sleeping
g. Assessment of sleeping pattern

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF

WEEK 15: SKIN INTEGRITY AND WOUND HEALING

ii. Observe progression of

WOUND CONTAMINATION TYPES
1. Clean wounds healing – no complications
▪ Uninfected closed wounds found
▪ No skin breakdown, the wound is on iii. Progression of activity – ADL
the inside (Activities of Daily Living)
▪ Characteristics: Bluish gray in color iv. Progression of diet
2. Clean-contaminated v. Wound evaluation –
▪ Surgical wound w/o infection observation of post-op
▪ Phases of Operative Process wounds if there’s wound
1. Pre-operative discharge etc.
i. Surgery preparation, informed vi. Doctor’s follow-up when
consent – must be in legal discharge
age and CCR (Conscious, vii. Care at home – possible
Coherent, Responsive) modifications for the client
ii. Procedure is explained and to perform ADL
the possible risks, alternative, viii. Proper wound cleaning – to
ensure that the client’s
and benefits of surgery
iii. Diagnostic tests – imaging, wound will continously heal
blood chemistry, lipid profile,
etc. 3. Contaminated Wounds
iv. Preparations the day before ▪ Open, fresh accidental wounds
surgery – following the ▪ Surgical inflammation
doctor’s order (E.g. 4. Dirty or infected wound
Administration of Laxative, ▪ Dead tissue or necrosis tissue
Skin prep for disinfection) ▪ Wound with clinical infection
v. Pre-operative teaching ▪ Surgical debridement – cleaning of
(Health Education) – tissue and removal of necrotic tissues
orientation to the client what to avoid further contamination of
are things to be expected wounds, removal of wound discharge
after surgery, “A well- to avoid further infection
informed patient is a
cooperative patient” (E.g.
WOUND TYPES
Catheterization) 1. Incision
vi. Blood request – request of ▪ Done by sharp instruments
blood products (FFP – Fresh ▪ E.g. Scalpel, Knife
Frozen Plasma, Packed RBC, 2. Contusion
Platelet Concentrate) ▪ Blow from a blunt instrument
vii. Instructions in Food Intake – ▪ Use of force
NPO (Nothing Per Orem) ▪ E.g. Baseball bat, fraternity paddles
2. Intra-operative – role of the nurse 3. Abrasion
is assisting in surgery ▪ Surface scrape
i. Scrub nurse – all instruments ▪ E.g. Dermal Abrasions, scratches
are prepared, oversees the 4. Puncture
whole process, manages the ▪ Penetration by sharp instruments
infection control in OR ▪ Risk for poor wound healing for
(sterile) undiagnosed diabetic clients
ii. Circulating nurse – found ▪ If it is not addressed, it causes poor
outside the OR wound healing and possible chance
3. Post-operative of tetanus or amputation
i. Checking for complication – ▪ E.g. Nails
signs of bleeding, infection, 5. Lacerations
observing the tubing ▪ Tissues torn apart
attached to the client ▪ E.g. Heavy machineries
(output) (E.g Jackson Pratt,
etc.)

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF

6. Penetrating Wound 4. Mixed types

▪ Tissue penetration ▪ Serosanguineous – seen after
▪ E.g. Gun shot wound operation, mixed with RBC and clear
▪ Entrance wound – the bullet entered blood white portion
inside the body ▪ Purosanguineous – mixture of blood
▪ Exit wound – bullet entered inside and and pus
escaped outside the body
▪ Considerations: Observe what vital TRANSPARENT FILM
organ hit by the gunshot and its ▪ Adhesive plastic
trajectory ▪ Protection against contamination and friction
▪ Used in IV dressing
WOUND HEALING PHASES ▪ E.g Tegaderm

1. Inflammatory Phase
▪ Hemostasis (bleeding cessation) TAPES FOR DRESSING AND SURGICAL PURPOSE
- Due to vasoconstriction - stops 1. Transpore
the bleeding 2. Leukoplast – thickest and stickiest
- Once the blood vessels are 3. Micropore – weak adhesion
dilated, the more blood will
ADHESIVE BANDAGES AND PADS
come out
❖ E.g. Band-aid
- 2 factors needed to form blood
❖ Contains different sizes
clots:
❖ Ensure that the middle part is placed in the
a. Clotting factors
wound
b. Platelets
- Scab formation - clots and PENROSE DRAIN
dead/dying tissues ▪ A soft flexible tube removes fluids under the
▪ Phagocytosis wound surgical site
- Engulf microorganism and ▪ Used in abdominal surgeries
cellular debris by macrophage ▪ Not sutured in place
- Sets as an internal defense of the ▪ Passage created from an internal wound to
body outside of the body and onto the wound
2. Proliferative phase ▪ Cleaning: Circular and drainage outward
▪ Day 3-4 to 21st day of post-injury (Closest to the center and moving out)
▪ Collagen formation – whitish protein ▪ Sterile pin purpose – placed portion outside the
substance that adds strength to the body to avoid the tube entering the body
wound (to avoid opening of the wound) ▪ When using the penrose drain, wear sterile
gloves and avoid touching the wound opening
3. Maturation Phase ▪ Done after the operation
▪ Day 21 up to 1-2 years after injury
▪ Keloid formation – hypertrophic scar BINDER
(differ and depends on the client’s skin ❖ Used for post-cesarean clients
characteristic) ❖ Supports large areas such as abdomen or
chest
WOUND EXUDATES ❖ Secured through pins, clips or Velcro
1. Serous exudates ❖ To ease wound tension
▪ Chiefly serum (clear blood portion)
▪ Watery and blister wound WOUND HEALING COMPLICATIONS
▪ Presence of small amount of blood 1. Hemorrhage
2. Purulent exudate 2. Infection
▪ Pus, leukocytes 3. Dehiscence – incision fails to heal properly
▪ Yellow discharge (layer level), overlapping of skin layers
▪ Signs/manifestation of infection 4. Evisceration – protrusion of visceral organs
▪ Possible contamination through wound opening (commonly of
3. Sanguineous exudates protrusion of abdominal organs)
▪ Large amounts of RBC
▪ Bleeding is occurring

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF

WOUND CULTURE 4. Autolytic

▪ Collection of sample from the wound to o Use of innate’s body function to clean
identify what microorganisms has entered the themselves
wound o Slowest and contraindicated in
▪ Never collect a wound culture from old infected wound
drainage o E.g. Phagocytosis
▪ Method: Tissue Biopsy o Dependent to the body function to
▪ Clean wound with normal saline (Rationale: To heal
remove skin flora)
▪ Aerobic – superficial wounds (presence of
oxygen)
▪ Anaerobic – grow within body cavities (no
oxygen, method: blood culture)

WOUND PACKING
▪ Assess size, depth and shape of wound
▪ May use gauze (Identify first how many gauze
will be packed to the client)
o Flexible and in contact with the entire
wound surface (All sides of the wound
must be packed by gauze, mostly for
clients with bed sore or cratered
wounds)
o Saturate with ordered solution (Gauze
must be saturated according to
medication ordered by the physician)

HYDROCOLLOIDS DRESSING
❖ To absorb exudates
❖ No more gauze required, the dressing already
contains medication
❖ Used in pressure ulcers
❖ E.g. Duoderm

DEBRIDEMENT
❖ Necrotic tissue removal
❖ Debridement types

1. Sharp
o Scalpel or curette or scissors
o Fastest method
o Precaution: Bleeding disorders
o Scraping of necrotic tissues
2. Mechanical
o Wet/damp to dry dressings and
whirlpools
o Layered dressings (damp to dry
dressing to avoid easy evaporation
o Whirlpools – contains medication
where the wound submerged
3. Enzymatic
o Topical agent application
o Medication application
o Slower but effective
o E.g. Santyl, Panafil

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF

WEEK 16: PSYCHOSOCIAL AND SPIRITUAL CONCERNS

SELF-CONCEPT CHANGES POSITIVE STRESS (EUSTRESS)

▪ Sense of competence (Instilling to person’s
daily living) • Can help you achieve your goals
▪ Perceived reaction of others to one’s body • Research suggest that acceptable level of
▪ Ongoing perception and interactions of the stress may even help you to focus and
thoughts and feelings of other (Differ by concentrate better
interaction) • Used as a motivation
▪ Personal and professional relationship • Mindset is important when dealing with stress
▪ Perception of events that have an impact to NEGATIVE STRESS (DISTRESS)
self (Different perception affects patient care)
▪ Master a prior and new experience (learning • Can result when there is too much pressure or
the right skill in the first time, applying to work, trauma and you are unable to cope
correction in a constructive manner, master a • Manifestations: Headache, muscle pain,
prior to new experience) irritability, trouble sleeping, lack or increased
▪ Cultural identity (adapting other culture) appetite
• Can be triggered

SELF-ESTEEM STRESSORS
❖ Overall feeling of self-worth or emotional
appraisal of self-concept ❖ Event or stimulus that disrupts the person’s sense
❖ Age specific characteristics: of equilibrium
a. Highest in childhood STRESS APPRAISAL
b. Fluctuates during adolescent
c. Adulthood and old age (varies) 1. Process by which the person interprets a
stressor as either a threat or a challenge
Nursing Dx:

➢ Disturbed body image – common for clients

NEGATIVE EFFECTS OF STRESS ON BASIC
with amputation
➢ Caregiver role strain – taking care of a clients
HUMAN NEEDS
with no rest (must have another caregiver to
1. Altered elimination patterns
cover your shift in order to rest)
2. Isolated and withdrawn – flight response
➢ Disturbed personal identity – what you know to
3. Expresses nervousness and feeling of being
yourself as a person, discovery about yourself
threatened
such as views
4. Fails to socialized with others – avoiding the
➢ Ineffective role performance – not capable to
stress
do some tasks, must know the reason of
ineffective poor performance HOMEOSTASIS BY WALTER CANNON
➢ Readiness for enhanced self-concept
➢ Chronic low self-esteem ❖ Body’s regulation of systems to maintain a steady
➢ Situational low self-esteem state
❖ A matter of balance
STRESS ❖ Nursing Dx: Ineffective coping
❖ Demand from the internal (stress is coming from
yourself that causes mental tension) or external STRESS MANAGEMENT
environment that exceeds the person’s ❖ Individualized and holistic approach to stress
immediately available resources or ability to reduction
respond ❖ Must identify the patient’s source of stress and
❖ Natural human response (ever present) what they’re going through
❖ Differ from person to person ❖ Focus:
❖ Regardless of socioeconomic status, age, 1. Balance
gender, lifestyle, education or occupation 2. Relaxation
3. Nutrition

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF

THEORIES OF STRESS EFFECTIVENESS OF INDIVIDUAL COPING

1. Walter Cannon’s fight or flight theory – going on
in a stressful situation or stay away? 1. NUMBER, DURATION AND INTENSITY OF THE
STRESSORS
2. Hans Selye’s General Adaptation Theory ▪ Every stress tolerance differs from
a. Phase 1: Alarm Reaction – reaction of person to person
stimuli such as worrying, feeling that ▪ Identify the person’s problem first
something is wrong ▪ Importance of therapeutic
b. Phase 2: Stage of Resistance – finding a communication to nurses
way on how to deal with stress, how to
cope up in a situation 2. PAST EXPERIENCES OF THE INDIVIDUALS
c. Phase 3: Stage of Exhaustion – given ▪ Gives insights what to do in a situation
coping strategy didn’t work (must find
another solution) 3. SUPPORT SYSTEMS AVAILABLE TO THE INDIVIDUAL
▪ Persons you can talk to or shoulder to
COPING AND COPING STRATEGIES cry on
▪ Individuals know when to tap on to
someone or not
COPING - dealing with change successfully or
unsuccessfully 4. PERSONAL QUALITIES OF THE PERSON
▪ Innate characteristics of an individual
COPING STRATEGY

❖ Appropriate ways in facing the problem,

❖ Natural or learned way of responding to a
changing environment or specific problem or
situation
❖ Can be negative or positive
❖ Must have human to human connection (social
support)
❖ Must be realistic and accurate to the situation
❖ Problem-solving
❖ Source of stress must be identified to know
what coping strategy must be used
❖ You can also distance away from the situation
to think freely on how to handle the problem
❖ Engage with relaxation
SEXUALITY AND SEXUAL HEALTH
2 TYPES OF COPING STRATEGIES

1. PROBLEM-FOCUSED COPING SEXUAL HEALTH

▪ Efforts to improve a situation by making
changes or taking some actions ❖ State of well-being in relation to sexuality across
▪ Utilizing problem solving strategies the life span
▪ Taking steps such as assessment, etc. ❖ Components:
▪ To develop a plan to take action a. Sexual self-concept
▪ How one values oneself as a
2. EMOTION FOCUSED COPING sexual being
▪ Thoughts and actions that relieve
emotional distress b. Body Image
▪ Somebody to talked to ▪ Influence by pregnancy,
▪ Sharing to someone about experiences aging, trauma, disease and
to relieve stress therapies
▪ Affects the sexual health’s
perception

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF

c. Gender identity SEXUAL DISORDERS

▪ One’s self-image as a female or male

d. Gender Role Behavior 1. MALE HYPOACTIVE SEXUAL DESIRE DISORDER

▪ Outward expression of one’s maleness ▪ Little or no interest in sexual fantasies or
or femaleness activities

e. Androgyny 2. EXHIBITIONISTIC DISORDER

▪ Flexibility in gender roles ▪ Sexual arousal upon exposing one’s
genitals to unsuspecting strangers
▪ Requires correcting of behavior
FACTORS INFLUENCING SEXUALITY
3. FETISHISTIC DISORDER
1. FAMILY – roles and perception to household
▪ Sexual arousal using non-living objects
2. CULTURE – giving respect and perception
towards sexuality of an individual
4. SEXUAL PAIN DISORDERS
3. RELIGION
▪ Vaginismus – involuntary spasm of the
4. PERSONAL EXPECTATIONS AND ETHICS – own
outer 1/3 of the vagina muscles
perception to one’s self
i. Vaginal penetration may be
LGBTQ+ hard
ii. Cause: Painful sex in the past,
1. LESBIAN – women attracted women trauma, vaginal inflammation
2. GAY – men attracted to men, homosexuality
3. BISEXUAL – attracted to both gender 5. PEDOPHILIC DISORDER
4. TRANSGENDER – identifies with a different ▪ Sexual activity with a child or generally
gender than their anatomic designation 13 years old below
Gender Dysphoria – strong and persistent ▪ Pedophile must be 16 years old or at
feelings of discomfort with one’s assigned least 5 years older than the victim
gender
5. QUEER – rejects gender stereotypes (go with 6. SEXUAL MASOCHISM DISORDER
the flow) ▪ Behaviors involving act of being
6. QUESTIONING – not decided on their humiliated, beaten, restrained or made
orientation to suffer
7. INTERSEX – contraindications among
chromosonal sex, gonodal sex, internal organs 7. SEXUAL SADISM
and external genital appearance ▪ Suffering of a victim excites the
individual
▪ Receives pleasure
KINSEY FAMOUS SEXUAL ORIENTATION SCALE
8. TRANSVESTIC DISORDER
▪ Cross-dressing (Dressing as opposite
sex)
▪ Conscious choice: Home or public
ASEXUALITY setting
▪ May have a name to go or with
▪ Lack of sexual orientation or no interest in
persona
pattern sexual activity
▪ Differs from celibate – abstain on being married
9. VOYEURISTIC DISORDER or “PEEPING TOM”
(conscious choice)
▪ Observing unsuspecting person who is
▪ Not a fear of sex
naked or changing clothes
▪ No sexual preference
10. INCESTS
PANSEXUALITY – attraction to members of all sexes and ▪ Pedophilia with child and adolescent
gender identities with relationship by blood, marriage
(step-parents) or live in partners

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF

11. TELEPHONE SCATALOGIA DISORDER RELIGIOUS AND HEALTH BELIEFS

▪ Obscene phone calling to an
unsuspecting person or sending
obscene messages or video images by SELF-RENEWAL
email
❖ On-going process that ideally continuous
12. NECROPHILIC DISORDER
through adult life as one becomes self-
▪ Obsession with having sexual
actualized
encounter with a cadaver
❖ Involves the ff:
13. ZOOPHILIC DISORDER
✓ Commitment to beliefs – is he or she
▪ Incorporation of animals into sexual
practicing the religion?
activity (bestiality)
✓ Connecting to the world including
14. COPROPHILIC DISORDER
natural world – does the spiritual
▪ Fixation on feces in sexual encounters
context applied to the real life?
15. KLISMAPHILIC DISORDER
✓ Times to solitude – reflecting to one’s
▪ Sexual activity that incorporates
self
enemas
✓ Episode breaks from responsibility -
16. UROPHILIC DISORDER
giving a time off to the spiritual context
▪ Involves urinating on one’s partner or
✓ Creative self-expression – expressive to
being urinated on
talking or others
17. HYPOXYPHILIA
✓ Adaption to changes – from different
▪ Desire to achieve an altered state of
experiences and how to cope with it
consciousness secondary to hypoxia
✓ Learning from down times –
while experiencing orgasm, a drug
opportunity to grow in negative and
such as nitrous oxide may be used to
positive situations, being able to know
produce hypoxia
one’s self more
▪ Suffocating
SPIRITUALITY AND NURSING
MEDICATION AND SEXUAL FUNCTION
1. Alcohol – moderate amounts to increase ❖ Not only about religious beliefs but the totality
sexual function of mind and spirit
2. Anti-anxiety agents and beta blockers – ❖ Providing and identifying the patient’s spiritual
decreased sexual desire (E.g. Metoprolol – Beta needs
blockers)

SEXUALITY RELATED NURSING DIAGNOSIS

Main:

❖ Ineffective sexuality pattern ❖ Human need that is concerned with ultimate

❖ Sexual dysfunction needs and values

Related SPIRTUALITY HEALTH - state of wellness

encompassing personal fulfillment as well as
❖ Deficient knowledge fulfilment in life and with other
❖ Ineffective relationship
❖ Pain SPIRITUALITY ASSESSMENT (JOINT COMMISSION
❖ Anxiety INTERNATIONAL - JCI)
❖ Fear
❖ Religious denomination (E.g Catholic, Islam)
❖ Disturbed body image
❖ Spiritual beliefs and practices (What practiced
in their religion)
❖ Begins upon admission of patient

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF

FAITH STAGES can the spiritual beliefs affect their health (can
be positive or negative)
1. UNDIFFERENTIATED FAITH (INFANCY)
❖ Focus on parental-infant bonding SPIRITUAL WELL-BEING IN ILLNESS
rather than a supreme being
❖ Infant has no clue what faith is
❖ Focused on infant and mother
relationship
2. INTUITIVE-PROJECTIVE FAITH (3-6 YEARS OLD)
❖ “Fantasy-filled”
❖ Faith is influenced by parents
❖ Religious practices done by the parents
is also done by the child
3. MYTHIC – LITERAL FAITH (7-12 YEARS OLD)
❖ Internalizes stories and belief and longs
for belongingness into the faith
community
❖ Already have a role and active in the
religious community
Spiritual contentment – does the spiritual needs of the
4. SYNTHETIC – CONVENTIONAL FAITH (13-20
client becoming helpful to their health?
YEARS OLD)
❖ Faith as a basis for identity and outlook Religious practices – intensity of the religious practice
❖ Influenced by many external factors been done (E.g. Pagiging madasalin)
(E.g. Media)
❖ Individual is already identifying what Social support – to have other people to process their
faith they have (Possible change of condition
religion and belief)
Severity of Illness – the severity of the illness is more
5. INDIVIDUATIVE – REFLECTIVE FAITH (21-30 YEARS
difficult to process, assessing If the faith is still there
OLD)
❖ Personal creativity and individualism Stressful Life Events – having someone on their side to
❖ Taking effort and acknowledging what cope knowing that their condition can be fluctuating
faith you have
6. CONJUNCTIVE FAITH (31-40 YEARS OLD) Spiritual Well-Being in Illness - a good outcome
❖ Deeper self and development of one’s remains a client to become well-being
social conscience
7. UNIVERSALIZING FAITH (40 YEARS OLD) SPIRITUAL RELATED NURSING DIAGNOSIS
*Spiritual Nursing Dx is difficult to identify, must have a
❖ Culminating of the work of all the
specific verbalization to the client
previous faith stages
❖ Individual has already seen different *No choice of intervention since it was the client’s
kinds of faith deeper problem
❖ Faith is no longer changed
❖ Spiritual Alienation (Loneliness) – client’s
perception that he/she is alone, no beliefs, and
NURSING SPIRITUAL HISTORY no one cares for them
❖ The person’s source of strength and hope – can ❖ Spiritual Pain (Discomfort or suffering) –
be significant others perception that God is punishing them
❖ Person’s concept of God or Deity – role of God ❖ Spiritual Anxiety (Fear of God’s wrath)
in their lives and how it influences their health, ❖ Spiritual Guilt (Failure to do the right thing)
to ensure that the client’s spiritual needs is ❖ Spiritual Anger (Anguish and Rage) – individual
respected perception that their condition is more
❖ Significance of religious practices and rituals to deserved than them
a person – nursing care can be delay to give ❖ Spiritual Loss (temporarily loss from the love of
time to clients to perform their own spiritual God) – detachment to the Supreme Being
needs ❖ Spiritual Despair (no hope of having a
❖ Person’s perceived relationship between his relationship with God)
spiritual beliefs and his state of health – how

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF

PARISH NURSING ▪ Ascribe sickness, illness, or injury to

Roles: karma
▪ Prefers to die at home
• Health counselor and educator ▪ Common to practice Vegan
• Integrator of faith and health
• Coordinator support and volunteer group 3. CATHOLICS
• They can engage to medical missions ▪ Sacraments: Anointing of the sick
• Serving humanity along with faith ▪ TV mass or conduct to chapel and
communion
Philosophy:
▪ Placement of Religious objects (E.g.
• Spiritual dimension is to be central to the Rosary or religious figures)
practice ▪ If the client requested to go to church
• Taking care of spirit and body in the hospital, it must be documented
• Focus of practice is the faith community and its and approved by the physician
ministry ▪ Devotion / Novena in times of illness
▪ May request non-meat diets and
HEALTH CARE AND RELIGIOUS BELIEFS (FICA) fasting (during lent)
1. Faith or Beliefs – being able to look how spiritual ▪ Emergency Baptism of the dying infant
beliefs affects care (E.g. For Still birth, dying infant)
2. Importance and Influence of Beliefs – beliefs
are influenced to the individual’s healthcare 4. MUSLIM
3. Community (Religious or Spiritual) ▪ Practice modest
4. Address care issue ▪ Eat “Halal Foods” – Does not eat pork
(Must be endorsed to dietary)
DIFFERENT RELIGIONS AND THEIR HEALTH ▪ Pray 5 times a day in Northeast
RESPONSES direction (Mecca) – Nurse can
schedule the activities
▪ Dry Ablution – prayers for deceased
1. BUDDHISTS
and softly strikes their hand on clean
▪ Spiritually focused person can respond
sand or stone and then gently passes
to sickness more peacefully
over the hands and then the face of
▪ You can improve your health if you are
the deceased
spiritual
▪ Ensure non-porcine insulin is used
▪ Emphasis on peace and quiet
▪ Avoid alcohol
environment
▪ Fasting during Ramadan
▪ Belief in Reincarnation
▪ A female nurse should handle a female
▪ Recites mantra and prayers with family
patient (to give culturally sensitive
▪ Many are vegan
care)
▪ Aim to achieve Nirvana
▪ Burial 24 hours after death
▪ Request for monks to pray for them
5. JEHOVAH’S WITNESS
▪ For Bible-based religious reasons, they
2. HINDUISM
do not accept Allogenic (donor-
▪ Body is not only a part but also as a
derived) blood transfusions
whole
▪ Alternatives: Crystalloids and Colloids
▪ Centered upon quietness and
▪ Animal products are acceptable (If
relaxation
slaughtered, drained the blood and
▪ Ayurvedic medicine – whole body
must be processed properly)
healing system
6. JEWISH
▪ 5 elements interact with the human
▪ Male babies are circumcised at 8 years
body:
old performed by a trained rabbi
a. Earth (Prithvi)
▪ Burial takes place 24-48 hours after
b. Water (jala)
death
c. Fire (teja)
▪ Amputated limbs must be buried with
d. Air (vayu)
the body
e. Space (akash)
▪ Kosher food
▪ Treatment: Herb, exercise, yoga,
▪ Non-kosher products – shellfish and
meditation, and massage
pork (dirty for soul)

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF

7. BAPTISTS
▪ Body as temple of the Holy Spirit
▪ Healing ritual by ministers – Laying of
hands and oil anointing
▪ Bible is central to their spiritual practice

8. IGLESIA NI CRISTO
▪ Do not celebrate Christmas or fiestas
▪ Baptism is not practiced but dedicated
at age 12-13 years old (Indoctrination)
▪ Do not eat foods mixed with blood
▪ Do not worship “idols”

9. ATHEISTS
▪ Scientific approach to treatment
▪ Offer to remove religious items in the
hospital (E.g. Crucifix)
▪ Never offer prayers to an Atheists

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF

WEEK 17: DEATH AND DYING

DEATH UNIVERSAL SIGNS OF DEATH

❖ Universal aspect of human experience • Decreased urine output – organs are now
❖ Where nurses need to be prepared – failing (E.g. Cardiac Arrest, Multiple Organ
importance of building of resilience to Failure/Organ Dysfunction (MODS)
nurses • Cold extremities – body cannot be able to
o Continuous loss of healthcare thermoregulate (inability of hypothalamus
professionals to patients without to regulate)
processing the loss can impact to • Changes in vital signs – fall of RR, HR, BP
the nurses’ emotional and mental • Change in breathing pattern – common
health, interpersonal relationship to apnea episodes
other colleagues can be helpful to • Respiratory congestion - client is almost
ease the impact of loss getting drown to their own secretions
called death rattle
LOSS – absence of something or to an individual
who has formed an attachment (attachment is POST-MORTEM CHANGES
part of the individual’s human nature)

GRIEF 1. RIGOR MORTIS – stiffening of body 2-4

❖ Elicited by a loss hours after death due to stopped
❖ Loss to the someone attached to you perfusion of the body
❖ Determined by the value place on the ▪ Decreased Muscle contraction due
person or thing that is lost to lack and declining of ATP
❖ Produces feeling including: Anger, ▪ Progression: Involuntary (E.g Heart)
frustration, loneliness, sadness, guilt, regret, and Voluntary muscles (E.g
resolution and peace Extremities)
❖ Re-emergence after years may happen
(e.g Anniversaries, Birthdays) 2. ALGOR MORTIS – gradual decrease of
❖ A person can move on but don’t forget body temp after death (malamig na
the person’s significant contribution bangkay)
▪ Hypothalamus ceases to function
ANTICIPATORY GRIEF
▪ 1C per hour fall until body is room
❖ Cognitive, affective, cultural and social temperature
reaction to an expected death felt by ▪ Skin loses elasticity
family and friends
❖ Death is already expected to someone 3. LIVOR MORTIS – discoloration of
❖ Grieving even the patient is alive surrounding tissue by hemoglobin
❖ Early grieving, preparing to the death of ▪ Breaking down of RBC
someone
❖ Individual is already adjusted after the
KUBLER ROSS’ STAGES OF GRIEVING
person’s death

DISENFRANCHISED GRIEF 1. DENIAL

▪ Rationalizing the process of death
❖ Encountered when a loss happen that 2. ANGER
cannot be openly acknowledged or ▪ Overwhelming of emotions to the
publicly shared person’s thinking
❖ E.g. Ex-partners, mistress 3. BARGAINING
▪ Having regrets (E.g. person must
have lived for a few days or weeks,
hoped to spend more time together)

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER
 FFF

4. DEPRESSION ▪ Increased the side rails of bed

▪ Person realizes that a death of ▪ Reservation of elevator
someone cannot be reversed ▪ End of the nurse’s responsibility
5. ACCEPTANCE ▪ Transferred to funeral parlor for
▪ Death is already accepted and internment
grieving already improved

VIEWING OF THE RECENTLY DEAD FAMILY

❖ Top linen is adjusted up to shoulder level
o Ensure the deceased facial
appearance is presentable
o Remove the attached tubing to
the client if possible
o Perform bed bath first before
viewing
❖ Soft lighting
o Dim lighting for the mood
preservation
❖ Provide chair to the family
o Allowing the pt’s family to spend
time together
o Paying of respect

CARE OF THE BODY AFTER DEATH

❖ Accomplish notice of death –
▪ For registration of death certificate
▪ Pronouncement of post-mortem
care
▪ Physicians must be the ones to
pronounce the time of death (must
act as a witness)
❖ Patient bath and removal of contraptions
▪ Removal of IV, nasal cannula,
catheter
▪ Patient can have few reflexes after
death (Lazarus reflex)
▪ Help with a nursing orderly
❖ Identify patient if with organ donation
wishes
▪ Can be seen in identification cards
▪ Donation cannot be compensated
(To prevent the promotion of illegal
trade of organs
▪ Depends on the client’s condition
or illness
❖ Religious wishes
▪ Anointing religious persons before
death
▪ Religious practices that must be
honored
❖ Transport to morgue
▪ Patient’s deceased body is tied

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

INSTRUCTOR: PROF. ELYWN BRIAN JAVIER