Unit: 1 Nursing Process

By : Ibne Amin
Faculty Institute of Nursing Sciences,
Khyber Medical University , Peshawar
 Objectives
1. Define nursing process.
2. Describe the purposes of nursing process.
3. Identify the components of the nursing process
4. Discuss the requirements for effective use of the
nursing process
5. Describe the functional health approach to the
nursing process
 Nursing Process
The nursing process is a dynamic & modified form of
scientific method used in nursing profession to
assess client needs and create a course of action to
address and solve patient problems.
OR
An organized sequence of problem -solving steps used
to identify and to manage the health problems of
clients.
It is accepted for clinical practice established by the
American Nurses Association
 Purpose Of Nursing Process
‡dŽŝĚĞŶƚŝĨLJĂĐůŝĞŶƚ͛ƐŚ
potential health care problems or needs.
‡ To establish plans to meet the identified needs.
‡ To deliver specific nursing interventions to meet
those needs.
‡Purpose is to provide client care that is :
Individualized
Holistic
Effective
Efficient
 Components Of Nursing Process
The Nursing Process utilizes the following steps
1. Assessment (data collection),
2. Nursing diagnosis,
3. Planning,
4. Implementation
5. Evaluation.

± Steps remain the same

± Applications and result are different
Components of Nursing Process
 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
 1. ASSESSMENT
It involves
‡Collection of data
‡Organizing the data
‡Validating the data
‡Documenting the data

Assessment is the systematic and continuous collection,

organization, validation, and documentation of data
(information).
 1. ASSESSMENT
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

The ultimate Purpose of assessment is data collection

 1. ASSESSMENT

1. Initial nursing assessment:

‡ Performed within specified time after admission.
‡To establish a complete database for problem
identification.
‡Eg: Nursing admission assessment
 1. 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
 1. ASSESSMENT
3. Emergency assessment:
During emergency situation to identify any life
threatening situation. Eg: Rapid assessment of an
ŝŶĚŝǀŝĚƵĂů͛ƐĂŝƌǁĂLJ͕ďƌĞ
.
during a cardiac arrest
 1. ASSESSMENT
4. Time-lapsed reassessment:
Several months after initial assessment. To compare th
ĐůŝĞŶƚ͛ƐĐƵƌƌĞŶƚŚĞĂůƚŚ
obtained
COMPONENTS OF ASSESSMENT
 1. ASSESSMENT
Collection of data
Data collection is the process of gathering information
ĂďŽƵƚĂĐůŝĞŶƚ͛ƐŚĞĂůƚŚ
history, physical examination, results of laboratory
and diagnostic tests, and material contributed by
other health personnel.
 1. ASSESSMENT
Types of Data
:
1. Subjective data
2. 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.
 1. ASSESSMENT
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
 1. ASSESSMENT
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
 1. ASSESSMENT
Organization of data
The nurse uses a format that organizes the assessmen
data systematically. This is often referred to as
nursing health history or nursing assessment form
 1. ASSESSMENT
Validation of data
The information gathered during the assessment is
͞ĚŽƵďůĞ -ĐŚĞĐŬĞĚ͟ŽƌǀĞƌŝĨŝĞĚ
accurate and complete.
 1. ASSESSMENT
Documentation of data
To complete the assessment phase, the nurse records
client data. Accurate documentation is essential and
ƐŚŽƵůĚŝŶĐůƵĚĞĂůůĚĂƚĂ
health status.
 2. DIAGNOSIS
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.
(NANDA) define or refine nursing diagnosis.
The official NANDA definition of a nursing diagnosis is:
͞ĂĐůŝŶŝĐĂůũƵĚŐŵĞŶƚĐŽŶĐ
health conditions/life processes, or a vulnerability for
that response, by an individual, family, group, or
ĐŽŵŵƵŶŝƚLJ͘͟
 2. DIAGNOSIS
Diagnosing is to :
1.Analyza data
2. Identify health problems,risks and strengths
3. Formulate diagnostic statement
 Status of the Nursing Diagnoses
͞^ƚĂƚƵƐƌĞĨĞƌƐƚŽƚŚĞĂĐƚ
ĚŝĂŐŶŽƐŝƐŽƌƚŚĞĐĂƚĞŐŽƌ
(NANDA International, 2009, p. 44).The kinds of
nursing diagnoses according to status are
1. Actual
2. Health promotion
3. Risk
4. Wellness.
5. Possible Nursing Diagnosis
6. Syndrome Nursing diagnosis
 1. Actual Diagnosis
An actual diagnosis is a client peoblem that is present
at the time of Nursing assessment. Examples are
ineffective breathing pattern and anxiety.
It is based on the presence of associated signs and
symptoms
 2. Health Promotion Diagnosis
A health promotion diagnosis relates to
ĐůŝĞŶƚƐ͛ƉƌĞƉĂƌĞĚŶĞƐƐ
to improve their health condition. These
diagnosis labels begin with the phrase
Readiness for Enhanced, as in Readiness for
Enhanced Nutrition
 3. Risk Nursing Diagnosis
A risk nursing diagnosis is a clinical judgment that a
problem does not exist, but the presence of risk
factors indicates that a problem is likely to develop
unless nurses intervene.

For example, all people admitted to a hospital have some

possibility of acquiring an infection; however, a client with
diabetes or a compromised immune system is at higher risk
than others. Therefore, the nurse would appropriately use the
ůĂďĞůZŝƐŬĨŽƌ/ŶĨĞĐƚŝŽŶƚŽ
 4. Wellness Nursing Diagnosis
It is clinical judgment about an individual, group
or community in transition from a specific
level of wellness to a higher level of wellness.
Eg: Family coping: potential for growth related
to unexpected birth of twins.
 5. Possible Nursing Diagnosis
It describe a suspected problem for which current and
available data are insufficient to validate the
problem. eg: Possible social isolation related to
unknown etiology.

Eg: An elderly widow who lives alone is admitted to the

hospital. The nurse notices that she has no visitors and is
pleased with attention and conversation from the
nursing staff .The nurse may write a nursing diagnosis of
possible social isolation related to unknown etiology.
 6. Syndrome Nursing Diagnosis
It is a cluster of nursing diagnosis that frequently go
together and present a clinical picture.
Eg:
‡Chronic Pain syndrome
‡Rape Trauma Syndrome
‡Disuse syndrome (long term bed riddenpatients)

‡ Clusters of diagnoses associated with Disuse syndrome

syndrome include Impaired Physical Mobility,Riskfor Impaired
Tissue Integrity, Risk for Activity Intolerance, Risk for
Constipation, Risk for Infection, Risk for Injury, Risk for
Powerlessness, Impaired Gas Exchange, and .so on
 Components of a Nursing Diagnosis
A nursing diagnosis has three components:
(1) The problem statement or Diagnostic Lable
(2) The etiology (related factors & risk factors)
(3) Signs & Symptoms or the defining characteristics
 1.Problem Statement (Diagnostic Label)

It Describes the patient health status or response to

health problems for which nursing therapy is given.
The purpose of the diagnostic label is to direct the
formation of client goals and desired outcomes. It
may also suggest some nursing interventions.

Eg: for example, Deficient Knowledge (Medications) or

Deficient Knowledge (Dietary Adjustments).
Similarly., Activity intolerance or Constipation etc
 2. Etiology (Related Factors & Risk Factors)
The etiology component of a nursing diagnosis
identifies causes of the health problem.These are
causative factors that have influenced the clients
actual or potential response to the healthproblem

Eg: Activity intolerance related to generalized weakness

or obesity or sedentary lifestyle. Constipation related
to inadequate fluid intake or inadequate fiber intake.
 3. Defining characteristics (S/S)
Defining characteristics are the cluster of signs and
symptoms that indicate the presence of a particular
diagnostic label or health problem.

e.g Fluid volume deficit related to decreased oral intake

manifested by dry skin and mucus membranes.
 The Diagnostic Process
The diagnostic process has three steps:
‡ Analyzing data
‡Identifying health problems, risks, and strengths
‡Formulating diagnostic statements.
 Formulating Diagnostic statement
Most nursing diagnosis are written as two part or three
parts statements
Basic Two Part Statements : It is also called PE format
Problem (P)ʹstatement of the patients response
Etiology (E)ʹfactors contributing to or probable cause
of the response
Example:Problem(P)relatedtoEtiology(E)
Activity intolerance related to generalized
weaknessorobesity
 Formulating Diagnostic statement
Basic Three Part Statements
It is also called as
PESformat & includes:
1.Problem (P)ʹ^ƚĂƚĞŵĞŶƚŽĨƚŚĞƉĂ
2.Etiology (E)
Factors contributing to or probablecausesoftheresponses
3.Signs & Symptoms (S)
Defining characteristicsevidencedbytheclient
Example: Problem related to etiology as evidentced by
signs &symptoms
Activity intolerance related to generalized weakness
evidenced by fatigue
 Difference between Nursing Diagnosis
Medical Diagnosis
Nursing Diagnosis Medical Diagnosis
‡ It is a statement of nursing ‡ It is made by a physician
judgment and refers to a and refers to a condition
condition that nurses are that only a physician cant
licensed to treat. reat.
‡ It is a statement of nursing ‡ It is a statement of medical
judgment. judgmen.
‡ It describe a patients ‡ Medical diagnoses refer to
physical, sociocultural, disease processes OR It
psychologic and spiritual ĚĞƐĐƌŝďĞƐĂƉĂ
responses to an illness or specific pathophysiologic
ahealthproblem responses to an illness.
 Difference between Nursing Diagnosis
Medical Diagnosis
Nursing Diagnosis Medical Diagnosis
‡ These responses vary ‡ These responses are fairly
among individuals uniform from one client to
another
‡ dŚĞƉĂƚŝĞŶƚ͛ƐŶƵƌƐŝŶŐ ‡ dŚĞƉĂƚŝĞŶƚ͛Ɛŵ
diagnosis change as the diagnosis remains the same
ĐůŝĞŶƚ͛ƐƌĞƐƉŽŶƐĞĐŚĂŶŐĞ for as long as the disease
process is present
‡ Nursing diagnosis relate to
‡ Nurses are obligated to carry
ƚŚĞŶƵƌƐĞ͛ƐŝŶĚĞƉĞŶĚĞŶƚ out physician prescribed
function treatment (dependent
‡ Eg:Tepid sponging for fever function). Eg: Tab. Paracetamol
500mg forfever
 Difference between Nursing Diagnosis
Medical Diagnosis
Nursing Diagnosis Medical Diagnosis
‡ Ineffective breathing ‡ Asthma

pattern
‡ Cerebrovascular accident
‡ Activity intolerance

‡ Acute pain
‡ Appendicitis

‡ Disturbed body image ‡ Amputation

 PLANNING
Planning is the third phase of the nursing process, in which
the nurse and client develop client goals/ desired
outcomes and nursing strategies to prevent, reduce or
ĂůůĞǀŝĂƚĞƚŚĞĐůŝĞŶƚ͛ƐŚĞĂ

It is the process of formulating client goals and designing

the nursing interventions required to prevent, reduce, or
ĞůŝŵŝŶĂƚĞƚŚĞĐůŝĞŶƚ͛ƐŚĞĂ
Planning involves decision making and problem solving.
 Types Of Planning
1. Initial Planning :Planning which is done after the initial
assessment. The nurse who performs the admission
assessment usually develops the initial comprehensive
plan of care.
2. Ongoing Planning : It is a continuous planning. As nurses
ŽďƚĂŝŶŶĞǁŝŶĨŽƌŵĂƚŝŽŶĂŶ
responses to care, they can individualize the initial care
plan further. It occurs at the beginning of a shift as the
nurse plans the care to be given that day
3. Discharge Planning :The process of anticipating and
planning for needs after discharge, is a crucial part of a
comprehensive health care and should be addressed in
ĞĂĐŚĐůŝĞŶƚ͛ƐĐĂƌĞƉůĂŶ͘
 Planning Process
It involves
‡Prioritize problems/ diagnosis
‡Formulate goals/desired outcomes
‡Select Nursing intervension
‡Write Nursing intervention
 Planning Process
1. Setting priorities
‡The nurse begin planning by deciding which nursing
diagnosis requires attention first, which second, and
so on.
‡EƵƌƐĞƐĨƌĞƋƵĞŶƚůLJƵƐĞDĂ
when setting priorities.
‡Example: In this physiologic needs such as air, food
and water are basic to life and receive higher priority
than the need for security or activity
Maslow's Hierarchy of Needs
 Planning Process
2. Establishing client goals/desired outcomes

After establishing priorities, the nurse set goals for each

nursing diagnosis. Goals may be short term or long
term
Client goals / desired outcomes: It is a specific and
measurable behavior or response that reflects a
clients highest possible level of wellness and
independence in function.
 Types of Goals
Short Term Goals Long Term Goaals
‡ It is an objective that is ‡ It is an objective that is
expected to achieved / with expected to believe over a
in a short time, usually less longer time frame, usually
than a week Example: over weeksormonths
Client will achieve comfort Example: Client will adhere
with in 24 hours post to post operative activity
operatively restrict
‡ Clientwill raise right arm to ‡ Client will regain full use of
shoulder heightby Frida right arm in 6 weeks ions for
one month
 Planning Process
3. Nursing interventions
A nursing intervention is any treatment, that a nurse
ƉĞƌĨŽƌŵƐƚŽŝŵƉƌŽǀĞƉĂƚŝ
OR
These are the actions that nurses perform to achieve
the clients goals
 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
 4. IMPLEMENTATION
‡In the nursing process, implementing is the action
phase in which the nurse performs the nursing
interventions. Implementing consists of doing and
documenting the activities that are the specific nursing
actions needed to carry out the interventions.
‡The nurse performs or delegates the nursing activities
for the interventions that were developed in the
planning step and then concludes the implementing
step by recording nursing activities and the resulting
client responses.
 Process of Implementing
‡The process of implementing normally includes the
following:

‡ Reassessing the client

‡ ĞƚĞƌŵŝŶŝŶŐƚŚĞŶƵƌƐĞ͛Ɛ
‡ Implementing the nursing interventions
‡Supervising the delegated care
‡ Documenting nursing activities.
 Process of Implementing
1. Reassessing the Client
Just before implementing an intervention, the nurse must reassess the
client to make sure the intervention is still needed.
Ϯ͘ĞƚĞƌŵŝŶŝŶŐƚŚĞEƵƌƐĞ͛ƐEĞĞĚ
When implementing some nursing interventions, the nurse may
require assistance for one or more of the following reasons:

‡ The nurse is unable to implement the nursing activity safely or efficiently alone
(e.g., ambulating an unsteady obese client).
‡ Assistance would reduce stress on the client (e.g., turning a person who
experiences acute pain when moved).
‡ The nurse lacks the knowledge or skills to implement a particular nursing activity
(e.g., a nurse who is not familiar with a particular model of traction equipment
needs assistance the first time it is applied).
 Process of Implementing
3. Implementing the Nursing Interventions
It is important to explain to the client what
interventions will be done, what sensations to
expect, what the client is expected to do, and what
the expected outcome is.
For many nursing activities, it is also important to
ĞŶƐƵƌĞƚŚĞĐůŝĞŶƚ͛ƐƉƌŝǀ
doors, pulling curtains, or draping the client.
 Process of Implementing
4. Supervising Delegated Care
‡If care has been delegated to other health care
ƉĞƌƐŽŶŶĞů͕ƚŚĞŶƵƌƐĞƌĞƐƉŽ
care must ensure that the activities have been
implemented according to the care plan.
‡Other caregivers may be required to communicate their
activities to the nurse by documenting them on the client
record, reporting verbally, or filling out a written form.
‡The nurse validates and responds to any adverse finding
or client responses. This may involve modifying the
nursing care plan.
 Process of Implementing
5. Documenting nursing activities.
After carrying out the nursing activities, the nurse
completes the implementing phase by recording the
interventions and client responses in the nursing
progress notes.
 EVALUATION
Evaluation is a planned, ongoing, purposeful activity in
which the nurse determines
;ĂͿƚŚĞĐůŝĞŶƚ͛ƐƉƌŽŐƌĞƐƐ
goals/outcomes and
(b)the effectiveness of the nursing care plan.
 References

ŬŽnjŝĞƌΘƌď͛Ɛ&ƵŶĚĂŵĞ th

edition( Audrey Berman ,Shirlee J. Synder).

www.slideshare.com

www.google.com
 By: Ibne Amin
Khyber Medical University ,Peshawar
 Objectives
At the end of this unit, learners will be able to:

1. Define value/belief pattern

2. Explain how behaviors related to values
3. Identify sources of professional nursing values
4. Apply cultural and developmental perspective
when identifying values
5. Examine values conflict and resolution in nursing
care situations
Educational Platform
 Introduction:
Values are important in nursing and health care as they
underpin all aspects of professional practice , including
decision making , choose between alternatives , and
resolve conflict . Values can be divided into three levels
of expressions
1. Beliefs
2. values themselves
3. Attitudes

Educational Platform
 Terminologies
‡Value: Beliefs or attitudes about the worth of a
person, object, idea or action.

‡Belief: Beliefs are the assumptions we make about

ourselves, about others in the world and about how
we expect things to be.

‡Attitude: Feelings toward a person, object or idea

(e.g, acceptance, rejection, etc.)

Educational Platform
 Relevent terms
Assumptions:Assumptions are beliefs that are regarded as so valuable
and obviously correct that they are taken for granted and rarely
examined or questioned.

Honesty:A facet of moral character that connotes positive and

virtuous attributes such as integrity, truthfulness, and
straightforwardness, along with the absence of lying, cheating, or
theft.

Code: Any system of principles, rules or regulations relating to one

subject.

Conduct :The manner of guiding or carrying one's self, personal

deportment, mode of action, behavior.

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 Relevent terms
Decision: A choice or judgment

Environment:The surroundings of, and influences on, a

particular item of interest.

Moral: Of or relating to principles of right and wrong in

behavior, especially for teaching right behavior

Attitude is the way a person expresses or applies their beliefs

and values, and is expressed through words and behavior.
example I get really upset when I hear about cruelty to
children and animals, or I hate school

Educational Platform
 BELIEF
‡ A Belief is a state of the mind which regards a thing to
be true or Having confidence that something is true .
‡A belief is an internal feeling that something is true, even
though that belief may be unproven & irrational, e.g I
belief that there is life after death
‡Beliefs are the assumptions and convictions that are held
to be true, by an individual or a group, regarding
concepts, events, people, and things
‡Beliefs are held without recourse to proof or evidence.
‡ Beliefs can be influenced by many factors , including
knowledge , experience , culture , and religion.
‡The most basic value and the one that changes least

Educational Platform
 Belief
‡Beliefs goes beyond the obvious, based more on faith
than fact.
‡One of the main beliefs in nursing is that patients will get
better with good care .
‡Another belief may be that this, rather than other work,
is ultimately satisfactory .
‡Belief Systems: Often deal with issues which cannot be
explained by reason or logic ʹcreation, the meaning of
life, afterlife
‡Values have major influence on person's behavior and
attitude and serve as broad guidelines in all situations

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 ŽŶƚŝ͙͘
A belief systemis an ideology or set of principles that
helps us to interpret our everyday reality. This could
be in the form of religion, political affiliation,
philosophy, or spirituality, among many other things.
Thesebeliefs are shaped and influenced by a number
of different factors. Our knowledge on a certain
topic, the way we were raised, and even peer
pressure from others can help to create and even
change our belief systems.

Educational Platform
 Types of Beliefs
1. Commendatory ("I believe I am a good writer)
2. Existentialism (Belief in God)

± Monotheism
± Polytheism
± Atheistic

Educational Platform
 Value
‡ They are also beliefs and are defined ͞ĞůŝĞĨƐĂďŽ
as:
ĚĞƐŝƌĂďůĞŽƌŐŽŽĚĂŶĚǁŚĂƚŝƐ
‡ Values are ideals that guide or qualify your personal conduct,
interaction with others, and involvement in your career. Like mora
they
‡ Help you to distinguish what is right from what is wrong &

.
‡ Inform you on how you can conduct your life in a meaningful way

‡ Value is a measure of the worth or importance a person attaches

something; our values are often reflected in the way we live our liv
example I value freedom of speech.

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

standard to guide its behavior in preferences in all situations

Educational Platform
 Types of Values
‡Religious Value
‡Personal Value
‡Cultural Value
‡Humanistic
‡Optimistic
‡Democratic
‡Motivational Value

Educational Platform
 Types of values
Religious values
Religious values are ethical principles founded in
religious traditions, texts and beliefs. In contrast to
personal values, religious-based values are based on
scriptures and a religion's established norms

They help people determine which actions to take, and

to make judgments about right or wrong and good or
bad

Educational Platform
 Types of values
Personal Values
Personal values are principles that define you as an
individual. Personal values, such as honesty, reliability,
and trust, determine how you will face the world and
relate with people
Cultural Values
Cultural values, like the practice of your faith and customs,
are principles that sustain connections with your cultural
roots. They help you feel connected to a larger
community of people with similar backgrounds.

Educational Platform
 Types of values
Humanistic values
They proclaim the importance of the individual.
Respect the whole person.
Treat people with respect and dignity.
Assume that every one has intrinsic worth.
View all people as having the potential for growth & development.
Optimistic values
They post that people are basically good.
Progress is possible and desirable.
Rationality, reason, and goodwill are the tools for making progress.

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 Types of values
Democratic Values
‡They assert the sanctity of the individual.
‡The right of people to be free from misuse of power.
‡Use of fair and equitable treatment for all.
‡Need for justice through rule of law.

Motivational Values
‡Internal and external Values that stimulate desire and
energy in people to be continually interested and
committed to a job, role or subject, or to make an
effort to attain a goal

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 Types of values
Motivational Value

‡Achievement: personal success through demonstrating

competence according to the social standards
‡Hedonism:pleasure and sensuous gratification for oneself

‡Stimulation: excitement, novelty and challenge in life

‡Self Direction:independent thought and action choosing,

creating, exploring
‡Power: social status and prestige, control or dominance
over the people and resources

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 Types ofvalues
Rituals

A ritual is a formalized, predetermined set of symbolic

actions performed in a particular environment at a
regular, recurring interval. The set of actions that
comprise a ritual often include, but are not limited
to, such things as recitation, singing, group
processions, repetitive dance, manipulation of sacred
objects Examples are, - Hindus performing Puja,
Catholics taking Communion. Muslims praying.

Educational Platform
 Values Transmission
Values are learned through observation and
experience. We accumulate our values from
childhood via teaching and observation of our
parents, teachers, religious leaders, and other
influential and powerful people.
sĂůƵĞƐĂƌĞŚŝŐŚůLJŝŶĨůƵĞŶ
sociocultural environment, and peer groups. For
example, if a parent consistently demonstrates
honesty in dealing, the child will probably begin to
value honesty.
Similarly, some cultures prefer folk treatment over new
medicine which is learned from culture.
Educational Platform
 Values Influence on Behavior
‡ Values can have a positive influence on a person's behavior a
he or she tries to emulate the conduct he or she holds as
valuable.
‡ Values are one important element that affect who we are and
how we behave towards others.
‡ Companies can influence a person's behavior with codes of
conduct, ethics committees, and a punishment and reward
system.
‡ Sometimes there will be a gap between a person's values and
behavior. Organizational strategies, such as a reward system,
can close that gap.
± If we deem something valuable then we do what we can to emulate that value. If a
person values honesty, then they will strive to be honest. If a person values transparenc
then they will work hard to be transparent. Values are one important element that
affect who we are and how we behavePlatform
Educational towards others
 Professional values for nurses
‡ Be kind and considerate to those for whom they provide care,
and to their carers and families
‡ Listen to, and work in partnership with those for whom they
provide care
‡ Work constructively with colleagues to provide
patientcentered care, recognising that multi
-disciplinary
teamwork, encouraging constructive challenge from all team
members, safety -focused leadership and a culture based on
openness and learning when things go wrong are
fundamental to achieve high quality care.
‡ &ŽůůŽǁƚŚĞŝƌĞŵƉůŽLJŝŶŐŽƌĐŽŶƚƌĂĐƚŝŶŐ
concerns about the safety or dignity of people receiving care

Educational Platform
 Professional values for nurses
Be open and honest with people receiving care if
something goes wrong.
Nurses ' professional values are acquired during
socilizationinto nursing from codes of ethics , nursing
experiences , teachers ,and peers . The American
Association of Colleges of Nursing

(AACN , 1998) identified five values essential for the

professional nurse altruism , autonomy ,
humandignity , integrity , and social justice .
Educational Platform
 Professional values for nurses
Altruism is a concern for the welfare and well
-being of
others. In professional practice, altruism is reflected by the
nurse's concern for the welfare of patients, other nurses,
and other health care providers.

Autonomy is the right to self-determination. Professional

practice reflects autonomy when the nurse respects
patients' rights to make decisions about their health care.

Human dignityis respect for the inherent worth and

uniqueness of individuals and populations. In professional
practice, human dignity is reflected when the nurse values
and respects all patients and colleagues.

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 Cont
Integrity is acting in accordance with an appropriate
code of ethics and accepted standards of practice.
Integrity is reflected in professional practice when the
nurse is honest and provides care based on an ethical
framework that is accepted within the profession.

Social justiceis upholding moral, legal, and humanistic

principles. This value is reflected in professional
practice when the nurse works to ensure equal
treatment under the law and equal access to quality
health care

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 PROFESSIONAL BEHAVIORS
¾Demonstrates understanding of cultures, beliefs, and
perspectives of others.
¾Advocates for patients, particularly the most vulnerable,
¾Takes risks on behalf of patients and colleagues.
¾ Mentors other professionals.

¾Plans care in partnership with patients.

¾ Honors the right of patients and families to make decisions
about health care,
¾ Provides information so patients can make informed
choices

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 PROFESSIONAL BEHAVIORS
¾ Provides culturally competent and sensitive care.

¾Protects the patient's privacy.

¾Preserves the confidentiality of patients and health

care providers.

¾Designs care with sensitivity to individual patient

needs,

¾Provides honest information to patients and the public.

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 PROFESSIONAL BEHAVIORS
¾ Documents care accurately and honestly.

¾Demonstrates accountability for own actions.

Supports fairness and nondiscrimination in the
delivery of care.

¾Promotes universal access to health care.

¾Encourages legislation and policy consistent with the

advancement of nursing care and health care.
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Typical Value conflict and Sample Controvercies
1. Loyalty-honesty Should you tell your parents about your
2. Competition-Cooperation ƐĞƐƚĞƌ͛ƐĚƌƵŐŚĂďŝ
Do you support grading system?
3. Freedom of press -
Is it wise to hold weekly presidential
national security press conference?
4. Equality-individualism Are racial qoutas for employment fair?
5. Order-freedom of speech Shoud we imprison those with radical ideas?
Should you choose a dangerous
6. Securityʹ excitement profession?
7. Generosityʹ material Is it desirable to give financial help to a
success beggar?
8. Rationality ʹspontaneity Should you check the odds before
placing a bet?
9. Traditionʹ novelty Should divorces be easily available?

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 Ethics
The study of moral rules and principles that govern a person's
behaviour or the conducting of an activity.
‡ Justice & Equality
‡Respect for human dignity
‡Relationships to patients
‡The nature of health problems
‡The right to self
-determination
‡Relationships with colleagues and others
‡Privacy of patient's interests
‡Conflict Resolution among Nurses
‡ Collaboration
‡Professional boundaries
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 SUMMARY
‡ Values are learned and change in response to life situations
as persons develops
‡ How value influence attitudes and how they together
influence professional behavior.
‡ Most values are derived from four main sources that influence
our personal and professional attitudes(Science ,Culture
,Religion and Experience)
‡ people arrive at their own values through Choosing , Prizing
and then acting on them
‡Values important in nursing settings as( values of health ,
health care , caring and nursing

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THANK YOU
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 References
‡Tschudin, Verena ,RGN,...etc. .(1998).Ethics in
Nursing. The caring relationship
-2nd ed. British
Library p(28-45).
‡SimonS.B.,Howe.,L.W.@Kirshenbaum,H.(1995).Value
Clarification: Ahandbook of practical strategies for
teachers and students .New York: Hart.

‡Fundamental of nursing by Erab & Koizer

th edition)
(6

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Self-concept /self Perception

By: Ibne Amin

(INS ),Khyber Medical university
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 Introduction
Self Conceptis an individual conceptualization about
how one thinks about himself or herself.
It is a subjective sense of unconscious and conscious
thoughts, attitude and perceptions.
Self concept provides a frame of reference that effects
the management of all situations and relationship
with others.

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 Objectives
At the end of this unit, learners will be able to:

1. Define self perception/ self concept pattern.

2. Describe the functions of self and self concept
3. Discuss how self concept develops through out the
life span
4. Discuss factors that can effect self concept
5. Identify possible manifestation of altered self concept
6. Apply nursing process for a person with an altered
self concept

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 Definition of Self Concept
Self concept is an individuals identity about how one
thinks about himself or herself. It means how one
thinks or how one feels about himself or herself. (By
ŽƵŐůĞƐ͞ϭϵϲϲ͟Ϳ
Self-ĐŽŶĐĞƉƚŝƐŽŶĞ͛ƐŵĞŶƚĂ
Self concept is the way we picture ourselves including
our traits and values.

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 Self-Concept /Self Perception
‡The set of beliefs that we hold about who we are is
called the self concept.
‡ It can also be defined as the sum total of an
ŝŶĚŝǀŝĚƵĂů͛ƐďĞůŝĞĨƐĂďŽ
attributes.
‡It is basically the individuals image of the kind of
person he or she is. Especially included in this are th
awareness of being (What I am)and awareness of
function (What I can do).

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 Self-Concept /Self Perception
Perception:the ability to see, hear, or become aware of
something through the senses

Self-Perception:is one's self

-concept, self-knowledge,
selfesteem, & self-assessments in order to define one's -self
schemas

Self-Schema:refers to the beliefs and ideas people have

about themselves

Self Concept:A self-concept is a reflection of the reactions of

others towards an individual

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 dŚĞZŽůĞŽĨƚ
Self: A person's essential being that distinguishes them
from others, especially considered as the object of
introspection
Capacity for self
-reflection is necessary for self
-
understanding

WƌŝǀĂƚĞ͕͞/ŶŶĞƌ͟^ĞůĨ
WƵďůŝĐ͕͞KƵƚĞƌ͟^ĞůĨ

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 The ABCs of the Self
The self concept includes
1.Cognitive aspect
2. Behavioral aspect
3. Affective aspect

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 COGNITIVE ASPECT: SELF SCHEM
^ĞůĨƐĐŚĞŵĂƐĂƌĞ͞ĐŽŐŶ
about the self, derived from past experience,
that organize and guide the processing of -self
ƌĞůĂƚĞĚŝŶĨŽƌŵĂƚŝŽŶ͟
How do we come to know ourselves, develop a
selfconcept, and maintain a stable sense of
identity?

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AFFECTIVE/EVALUATIVE ASPECT : SELF ES

͞ƐĞůĨĞƐƚĞĞŵƌĞĨůĞĐƚƐƚŚĞ
ĂŶŝŶĚŝǀŝĚƵĂů͛ƐĂĐƚƵĂůƐ
am) and some ideal self image (who I would really
ůŝŬĞƚŽďĞͿ͘͟
How do we evaluate ourselves, enhance our-self
images, and defend against threats to our -self
esteem?
William James (1890) expressed the relationship this way.
Self esteem= success/pretension
Pretension (ideals against which individuals assess their actual self
image)

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 BEHAVIORALASPECT : SELF PERCEPT

How do we regulate our actions and present ourselves

according to interpersonal demands?
Darl Bem (1972) influential self perception theory
reflects we observe our behavior and the situation in
which it took place, make attributions about why the
behavior occurred, and draw conclusions about our
own characteristic and disposition.
In other words we come to understand ourselves the
same way we perceive and understand others.

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 Johari Window

Known by self Unknown by Self

Known byother OPEN ARENABLIND SPOT

FACADE
Unknown byother HIDDEN UNKNOWN

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 Mechanism of Self Concept

There are three mechanisms of self concept,

Ideal Self}
ZĞĂů^ĞůĨ΃͙͙͙͙͙͙WŽƐŝƚŝǀĞƐĞ
Public Self}

Characteristics of a Positive Self

-Concept
‡Self-confidence
‡Ability to accept criticism and not become defensive
‡Setting obtainable goals
‡Willingness to take risks and try new experiences

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 Components of Self
-Concept
A positive self concept gives a sense of meaning
wholeness, and consistency. It has following
components:
i. Self Identity
ii. Body Image
iii. Role Performance
iv. Self esteem

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Interrelationship of Components of Self
-Concept

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 Components of Self
-Concept
1.Self Identity
A sense of personal
identity is what sets one person
apart as a unique individual.

/ĚĞŶƚŝƚLJŝŶĐůƵĚĞƐĂƉĞƌƐŽ
identity, family status, occupation, and roles.

KŶĞ͛ƐƉĞƌƐŽŶĂůŝĚĞŶƚŝƚLJď
childhood and is constantly reinforced and modified
throughout life.
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 Components of Self
-Concept
2.Body Image
ŽĚLJŝŵĂŐĞŝƐĂŶĂƚƚŝƚƵĚĞ
attributes and characteristics, appearance, and
performance.

Body image is dynamic because any change in body

structure or function, including the normal changes
of growth and development, can affect it.

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 Components of Self
-Concept
3. Self-esteem
Self-esteem is the judgement of personal performance
compared with self -ideal.
Self-esteem is derived from a sense of giving and receiving
love, and being respected by others.
Self-ideal serves as an internal regulator to support -self
respect and self-esteem
Two sources for esteem are self and others
.
A person develops high self-esteemwhen he or She
receives positive Feed back from both Self and others.
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Components of Self
-Concept

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 Components of Self
-Concept
4. Role Performance
Role refers to a set of expected behaviors determined by
familial, cultural, and social norms.

The level of self

-esteem is dependent upon the
selfperception of adequate role performance in these
various social roles.
Stressors Affecting Role Performance
Role Overload
Role Conflict
Whenever a person is unable to fulfill role responsibilities,
self-concept is impaired.

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 Dimension of Self
-Concept
Self-knowledgeͶ ͞tŚŽĂŵ/͍͟

Self-ExpectationͶ ͞tŚŽŽƌǁŚĂƚĚŽ/

Social SelfʹHow person perceived by others?

Self-EvaluationͶ ͞,ŽǁǁĞůůĚŽ/ůŝ

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 Self-knowledge
Global Self
: is the term used to describe the composite
of all basic facts, qualities, traits, images and feelings
one holds about oneself. It includes:
1. Basic facts: sex, age, race, occupation, cultural
background, sexual orientation
Ϯ͘WĞƌƐŽŶ͛ƐƉŽƐŝƚŝŽŶǁŝƚŚ
3. Qualities or traits that describe typical behaviours,
feelings, moods and other characteristics (generous,
hot-headed , ambitious, intelligent etc)

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 Self-Expectation
‡/ŶǀŽůǀĞƐƚŚĞ͞ŝĚĞĂů͟ƐĞů --- the self a person wants to
be. It is the setting of present and future goals.
‡Expectations for self flow from various sources.
‡The ideal self constitutes the self one want to be.
‡Self expectations develop unconsciously early in
childhood and are based on image of role models
such as parents
‡Self-Ideal is the perception of behavior based on
personal standards and self -expectations.

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 Social Self
Social self is how a person perceived by others and
society.
The Self in a Social Context/background
They focus on explaining an individual's actions within a
group/society

It investigates the question of how the personal self

relates to the social environment

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 Self-Evaluation
Self esteemis the evaluative andaffective component
of self concept
The appraisal of oneself in relationship to others,
events, or situations.

DĂƐůŽǁ͛Ɛ^ƵďƐĞƚƐŽĨƐƚĞĞ
1. Self-esteem (strength, achievement, mastery,
competence, ..)
2. Respect needs or the need for esteem from others

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 Development of Self
-Concept
Self-concept evolves throughout life and depends to an
ĞdžƚĞŶƚŽŶĂŶŝŶĚŝǀŝĚƵĂů͛Ɛ
Formation of Self-Concept
1. Infant learns physical self different from environment.
2. If basic needs are met, child has positive feelings of
self.
3. ŚŝůĚŝŶƚĞƌŶĂůŝnjĞƐŽƚŚĞƌ
self.
4. Child or adult internalizes standards of society.

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 Stages in Development of Self
Self-awareness (Newborn (28
-Days)infancy=1year)

Self-recognition (18 months) Toddler and

Self-definition (3 years) Preschooler

Self-concept (6 to7years) School Age Adolescence

Adulthood Stages

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 DEVELOPMENT OF SELF
-CONCEPT
Various psychosocial theories have been developed to explain
the development of self
-ĐŽŶĐĞƉƚ͘ĚŝƐĐƵƐƐ
theory of psychosocial development related to -concept
self
are follow.
ƌŝŬƐŽŶ͛ƐdŚĞŽƌLJ
ƌŝŬƐŽŶ͛Ɛ;ϭϵϲϯͿƉƐLJĐŚŽƐŽĐŝĂů
development proceeds throughout life. Each of his eight
developmental stages includes psychosocial tasks that need t
be mastered.

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Educational Platform
 Factors Affecting Self
-perception
‡Altered Health Status
‡Experience
‡Developmental considerations
‡ Heredity & Culture
‡Internal and external resources
‡History of success and failure
‡Crisis or life stressors & coping
‡Aging, illness, or trauma

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Obtaining a Client History of Self
-Concept
‡ How would you describe yourself?
‡ How do others describe you?
‡ What has been your greatest accomplishment?
‡ How does this make you feel?
‡ When you receive praise, do you feel worthy of it?
‡ What do you admire most about yourself?
‡ How do you react when you experience failure?
‡ How do you cope with failure?
‡ Have you experienced past or recent changes in body image,
- self
esteem, or role performance?
‡ Have you experienced feelings of powerlessness or hopelessness?
‡ Who do you consider your support group?
‡ What do you do to make yourself laugh

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 Nursing Diagnosis
‡ Disturbed Body Image
‡ Parental Role Conflict
‡ Disturbed Personal Identity
‡ Ineffective Role Performance
‡ Chronic Low Self-Esteem
‡ Situational Low Self
-Esteem
‡ Disturbed Personal Identity
‡ Anxiety
‡ Social Isolation
‡ Hopelessness
‡ Powerlessness
‡ Risk for Compromised Human Dignity
‡ Risk for Loneliness

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 Activities/Helping Patients Maintain Sense of
Self
‡Communicate worth with looks, speech, and judicious
touch.
‡Acknowledge patient status, role, and individuality.
‡Speak to patient respectfully.
‡Offer simple explanations for procedures.
‡DŽǀĞƉĂƚŝĞŶƚ͛ƐďŽĚLJƌĞƐƉĞ
‡ZĞƐƉĞĐƚƉĂƚŝĞŶƚ͛ƐƉƌŝǀĂĐLJ
‡Acknowledge and allow expression of negative feelings
‡Help patients recognize strengths and explore
alternatives.

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 ŽŶƚŝ͙
‡ The following are activities that the nurse can teach the client
ƚŽĞŶŐĂŐĞŝŶƚŽŝŶĐƌĞĂƐĞŽŶĞ -esteem:
‡ Taking good care of self
‡ Taking time to do enjoyable activities
‡ Spending time with people that make you feel good about
yourself
‡ Learning something new
‡ Forgiving yourself
‡ Doing something nice for someone else
‡ Positive self
-talk
‡ Giving yourself rewards
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 Self Concept and Nursing Process
Assessment:
i. Observefor behavior that suggestan alteration in
the ĐůŝĞŶƚ͛Ɛ
self concept.
ii. Assessthe ĐůŝĞŶƚ͛Ɛcultural background.
iii. Determine the ĐůŝĞŶƚ͛Ɛ feelings and perceptions
about changesin body image,self esteemor role
iv.Assessthe quality of the clients relationship.
v. Assessthe ĐůŝĞŶƚ͛Ɛ copingskills.

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 Self Concept and Nursing Process
Nursing Diagnosis
Although their multiple nursing diagnosis label for
altered self concept the following list provides
examples of self concept, related nursing diagnosis.
i. Impaired adjustment.
ii. Anxiety
iii. Disturbed body image.
iv. Caregiver role strain

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 Self Concept and Nursing Process
v. Decisional conflict.
vi. Ineffective coping.
vii. Fear
viii. Hopelessness
ix. Low self esteem
x. Risk for loneliness
xi. Ineffective sexuality pattern
xii. Risk for self directed violence.

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 Self Concept and Nursing Process
Planning:
i. Select therapies that strengthen or maintain the
ĐůŝĞŶƚ͛ƐĐŽƉŝŶŐƐŬŝůůƐ͘
ii. Involve the client to ensure that realistic therapies
are chosen.
iii. Minimize stressors affecting the clients self concept.

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 Self Concept and Nursing Process
Implementation
As with all the step of the nursing process, a
therapeutic nurse client relationship is central to the
implementation phase. Once the goal and outcome
criteria have been developed, the nurse considers
nursing interventions for promoting a healthy self
concept and helping the client move towards the
goals.

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 Health Promotion:
The nurse may work with clients to help them develop
healthy life style behaviorsthat contribute to positive
self concept. To facilitate the client for adequatesleep
and rest and stress reducing practices may make
health self concept. E.g. Guidedimaginary.

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 References
‡Sandy L. Brook introduction to nursing self concept,
3rd edition.
‡DŝĐŚĂĞůĞƚƚŵĂŶ&Z^
‡dŚŽŵĂƐ&ƵůůĞƌWŚͬ͘DWZ
1955.
‡:ŽŚŶ:ĂĐŬƐŽŶD͘͞DĂŶƵĂů th

edition.
‡Bell state university school of nursing (2001). Clinical
preceptor information, retrieved March 5, 2003.

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Educational Platform
 Concept of Pain

By: Awal Sher Khan

Lecturer
Khyber Medical university
 Introduction
‡Pain is the fifth Vital sign and is regarded as
a symptomof an underlying condition
‡Pain is a complex experience consisting of
physiological and a psychological response to a
noxious stimulus.
‡ Pain is a warning mechanism that protects an
organism by influencing it to withdraw from harmful
stimuli; it is primarily associated with
injury or the
threat of injury.
‡Pain is subjective and difficult to quantify, because it
has both an affective and a sensory component
 Objectives
At the end of this unit, learners will be able to:
‡Define the process of pain (physiological changes)
‡Describe the different theories of pain theory.
‡Differentiate between acute and chronic pain
‡Discuss the non -pharmacologic interventions pain
management.
‡Identify pharmacologic interventions for pain
management
 Definition of Pain
The International Association for the Study of Pain
(IASP) defines pain asan" unpleasant sensory and
emotional experience that is associated with actual
or potential tissue damage , or described in terms of
such damage.
 Pain Process
‡A nociceptor is a receptor of a sensory neuron (nerve
cell) that responds to potentially damaging stimuli by
sending signals to the spinal cord and brain. This
process, called nociception, usually causes the
perception of pain
‡Distributed throughout the body (skin, viscera,
muscles, joints, meninges) they can be stimulated by
mechanical, thermal or chemical stimuli.
 Pain Process
‡There are four major processes: transduction,
transmission, modulation, and perception
 Transduction
‡Transduction refers to the process by which a painful
physical or chemical stimulus is transformed into a
signal that can be carried (via transmission) to the
central nervous system and perceived as pain.
 Transmission
Once transduction is complete transmission of pain
begins, Painful stimuli produce nerve impulses that
travel along efferent nerve fibers.
‡A-delta fiber (fast myelinated)
Send sharp localized and distinct sensation
‡C-fiber (Slow unmyelinated)
Slow impulses e.g needle stick,
 Perception
‡Perception of pain occurs when the pain impulse has
been transmitted to the cortex and the person
develops conscious awareness of the intensity,
location, and quality of pain
 Modulation
‡Modulation of pain refers to activation of neural
pathways that inhibit transmission of pain
‡The periaqueductal gray (PAG), dorsolateral pontine
tegmentum (DLPT), and rostroventral medulla (RVM)
are the key regions of the brain involved in this
descending pain modulation
 Theories of Pain
‡Several theoretical frameworks have been
proposed to explain the physiological basis of
pain, although none yet completely accounts
for all aspects of pain perception.
‡A number of theories have been postulated to
describemechanisms underlying pain
perception. Some of which are:
 Theories of Pain
‡Intensive Theory (Erb, 1874)
‡Strong's Theory (Strong, 1895)
‡Specificity Theory(Von Frey, 1895)
‡Pattern Theory(Goldschneider (1920)
‡Central Summation Theory (Livingstone, 1943
‡Sensory Interaction Theory (Noordenbos,
1959)
‡Gate Control Theory (Melzack and Wall, 1965)
 Gate Control Theory
‡Ronald Melzack and Patrick Wall
proposed the Ga
te Control Theory in 1965.
‡The gate control theory of pain assertsthat non-
painful input closesthe "gates" to painful input,
which prevents pain sensationfrom traveling to
the central nervoussystem.
‡Therefore, stimulation by non-noxious input is
able to suppresspain.
 Types of Pain
‡There are several ways to categorize pain. One is to
separate it into acute and chronic pain.
‡Acute paintypically comes on suddenly and has a
limited duration. It's frequently caused by damage to
tissue such as bone, muscle, or organs, and the onse
is often accompanied by anxiety or emotional
distress.
‡Chronic painlasts longer than acute pain and is
generally somewhat resistant to medical treatment.
It's usually associated with a long
-term illness, such
as osteoarthritis
 Types of Pain
‡Pain is often classified by the kind of damage that
causes it.
‡The two main categories are pain caused by tissue
damage, also called nociceptive pain, and pain
caused bynerve damage, also called neuropathic
pain.
‡A third category ispsychogenic pain, which is pain
that is affected by psychological factors
 Types of Pain
‡Somatic pain, visceral pain and Cutaneous is anothe
classification of pain based on origin
‡Somatic paincomes from the skin. muscles, and soft
tissues,
‡while visceral paincomes from the internal organs.
‡Cutaneous pain : is caused by stimulation of the
cutaneous nerve endings in the skin.
Non-pharmacological interventions
‡Non-pharmacological pain therapy refers to
interventions that do not involve the use of
medications to treat pain.
‡The goals of non-pharmacological interventions are
to decrease fear, distress and anxiety, and to reduce
pain and provide patients with a sense of control.
‡The advantage of non -pharmacological treatments is
that they are relatively inexpensive and safe
Non-pharmacological interventions
Non-pharmacological therapies are typically
categorized into:
‡Physical (sensory) interventions
‡Psychological interventions
 Physical (sensory) interventions
‡Physical (sensory) interventions typically are patient
-
specific and inhibit nociceptive input and pain
perception.
‡Some measures that can reduce pain intensity and
improve the patient quality of life such as massage,
positioning, hot and cold treatment, transcutaneous
electrical nerve stimulation (TENS), acupuncture and
progressive muscle relaxation
 Psychological interventions
‡Continuous pain may lead to development of
maladaptive status and behavior that worsen day to
day function, increase distress, or enhancing the
experience of pain
‡Most commonly used psychological interventions
are: cognitive behavioral therapy, mindfulness
-based
stress reduction, acceptance and commitment
therapy (ACT), meditation, guided imagery and
biofeedback.
‡Others: Spirituality and religion in pain management
and music therapy.
 Pharmacological interventions
‡Pharmacological pain therapy refers to interventions
that involve the use of medications to treat pain.
‡A wide range of drugs are used to
managepain resulting from inflammation in
response to tissue damage, chemical
agents/pathogens (nociceptive pain) or nerve
damage (neuropathic pain).
 Pharmacological interventions
WHO Analgesic Ladder Step-31
‡Originally developed by the World Health
Organization (WHO) to improve management
of cancer pain
‡The 3 step WHO analgesic ladder is also used for
providing stepwise pain relief for pain due to other
causes.
 Pharmacological interventions
Non-opioid medications: Step -1WHO Analgesic ladder
Mild to Moderate pain:
‡Non-steroidal anti-inflammatory drugs (NSAIDs)
‡Paracetamol also known as acetaminophen
‡Aspirin also known as acetylsalicylic acid
(ASA)
 Pharmacological interventions
Compound analgesics: Step 2 on the WHO analgesic
ladder ʹmild to moderate pain
‡Compound analgesics are a combination of drugs in
single tablet usually including codeine (a weak
opiate) and aspirin or paracetamol.
‡Examples include co -codamol and co-dydramol
which contain codeine and paracetamol in various
formulas (8/500, 10/500, 15/500, 30/500) where the
first number refers to the amount of codeine and the
second to paracetamol
 Pharmacological interventions
Opioid medications: Step 3 on the WHO analgesic
ladder ʹsevere pain
‡Medications derived from morphine (or synthetic
analogs)ŵŝŵŝĐƚŚĞďŽĚLJ͛ƐŽǁŶ
are strongest and most effective painkillers currently
available.
‡Opioid medications include morphine, oxycodone,
codeine, tramadol, buprenorphine, fentanyl and
diamorphine (heroin)
 Pharmacological interventions
‡Adjuvants:The WHO analgesic ladder recommends
that patients are prescribed additional medication to
manage the symptoms of neuropathic pain. These
drugs include tricyclic antidepressants and
antiepileptic drugs
‡Topical analgesics:Topical analgesics can provide
localized pain relief and are used to treat acute and
chronic pain, such as musculoskeletal and
neuropathic pain, as well as muscle pain related to
trauma.
‡Topical analgesics includerubefacients,topical
NSAIDs and local anaesthetics.
 Group Assignment ; Give brief description
of the following Pain Management
theories.
1. Intensive Theory (Erb, 1874)
2. Strong's Theory (Strong, 1895)
3. Specificity Theory(Von Frey, 1895)
4. Pattern Theory(Goldschneider (1920)
5. Central Summation Theory (Livingstone, 1943)
6. Sensory Interaction Theory (Noordenbos, 1959)
‡ Note : Submit it before Monday , nd
22Nov ,2021 at
awalsh.ins@kmu.edu.pk
Concept of Nutrition and Dietary
Pattern
Shabnam
Faculty INS
-KMU
 Objectives
At the end of this unit learners will be able to:
1. Define nutrition/metabolic pattern.
2. Review essential nutrients and examples of good
dietary sources for each.
3. Review normal digestion, absorption, and
metabolism of carbohydrates, fats, and proteins.
4. Discuss nutritional considerations across the life span
5. list factors that can effect dietary pattern
6. Describe manifestations of altered nutrition
7. Explain nursing interventions to promote optimal
nutrition and
 Nutrition-Metabolic pattern
Pattern of food and fluid consumption relative to metabolic
need and pattern.
Nutrition: The science related to the food requirements of
the body.
 Nutrition
‡Nutrition is the intake of food, considered in relation to
ƚŚĞďŽĚLJ͛ƐĚŝĞƚĂƌLJŶĞĞĚƐ͘
‡Good nutritionʹan adequate, well balanced diet
combined with regular physical activityʹis a cornerstone
of good health.
‡Poor nutrition can lead to reduced immunity, increased
susceptibility to disease, impaired physical and mental
development, and reduced productivity (WHO)
.
 Nutrition Nutrient
This field of study focuses Nutrients are chemical
on substances in foods that compounds in food that
help living things to grow are used by the body to
and stay healthy. The foods function properly and
we eat provide energy and maintain health. Examples
nutrients such as protein fat, include proteins, fats,
Carbohydraye,vitamins, carbohydrates, vitamins,
minerals and water. and minerals.
 Essential nutrients
Essential nutrients for body growth are include:
ƒProtein
ƒFats
ƒ Carbohydrates
 Protein
According to the Dietary Reference Intakes published by th
USDA 10% - 35% of calories should come from protein.
ƒUsed for building, growth or recovery of cells and tissues
ƒMajor constituent of hormones, enzymes and antibodies.
ƒ Found in meat, fish, eggs, pulses etc.
 Fats
According to the Dietary Reference Intakes published
By the USDA 20% - 35% of calories should come from
fat.
ƒSource of energy (1 gram of fat yields 9 k cales).
ƒComponent of cell membranes.
ƒ Found in solid fats and liquid oils, in dairy products.
ƒ Absorbing certain vitamins ( like vitamins A, D, E, K
ƒ Providing cushioning for the organs.
ƒFat is found in meat, poultry, nuts, milk products,
butters and margarines, oils, fish, grain products.
 Carbohydrate

Reference Intakes published by the USDA, -45% 65%

of calories should come from carbohydrate.
ƒ Source of energy (1 gm yields 4 kcals).
ƒ Helps in digestion and bowel function.
ƒ All of the tissues and cells in our body can use
glucose for energy.
ƒCarbohydrates can be stored in the muscles and liver
and later used for energy.
ƒ Fiber refers to certain types of carbohydrates that our
body cannot digest. These carbohydrates pass through
the intestinal tract intact and help to move waste out of
the body.
ƒCarbohydrate present in foods; include bread, rice,
cereals, pasta, potatoes, flour, porridge and chapattis
 Digestion of carbohydrate
Carbohydrates are broken down to provide glucose for
Energy.
Digestion occurs by enzymes lining the wall of the small
intestine. Once absorbed, galactose and fructose are
metabolized further by the liver to produce glucose and
minimal amounts of other metabolites.
Most commonly, carbohydrate metabolism results in the
production of glucose molecules which are the most
efficient source of energy (ATP) for our muscles and our
brains.
 Digestion of protein
Proteins are decomposed to single amino acids by digestion
the gastro-intestinal tract. Digestion typically begins in the
stomach when pepsinogen is converted to pepsin by the
action of hydrochloric acid, and continued by trypsin and
chymotrypsin(secreted by pancreas) in the small intestine.
 Digestion of fat
Fatsare mainly digestedin the smallintestine. Thepresence
of fat in the smallintestine produceshormonethat stimulate
the releaseof pancreaticlipasefrom the pancreasand bile
from the liver which helpsin the emulsificationof fats into
fatty acidsand glycerolfor absorptionof fatty acids.
Only freely dissolvedmonoglyceridesand fatty acidscan
be absorbed.
Nutritional consideration across
life span
 Babiesʹbirth to six months of age
Breast milk is preferred to infant formula where possible,
as it contains many protective and immunological factors
ƚŚĂƚďĞŶĞĨŝƚƚŚĞďĂďLJ͛ƐĚĞ
Breast milk generally supplies a baby with the required
amounts of nutrients, fluids and energy up to about six
months of age. It is recommended that infants be
exclusively breastfed up to around six months of age.
Food for babiesʹsix to 12 months of age

ǀŽŝĚĐŽǁ͛ƐŵŝůŬĂƐĂĚƌŝŶŬ
in the first 12months. Small
amounts can be used in
cereals and custards. All milk
used should be pasteurized.
 Cont.
ƒAvoid whole nuts, seeds or similar hard foods to reduce
the risk of choking.
ƒ Feed babies during any illness and feed up after illness.
ƒGive ample liquids if your baby has diarrhea.
ƒOccasional exposure of the skin to sunlight is usually
ĞŶŽƵŐŚƚŽƉƌŽǀŝĚĞĂďĂďLJ͛ -D requirements.
 Food for young children
Once a child is eating solids, offer a wide range of foods
to ensure adequate nutrition.
ƒYoung children are often selective with food, but should
be encouraged to eat a wide variety of foods.
ƒIf a child is gaining inappropriate weight for growth, limit
energy-dense, nutrient-poor snack foods. Increase your
ĐŚŝůĚ͛ƐƉŚLJƐŝĐĂůĂĐƚŝǀŝƚLJ
ƒ Ensure your child has enough fluids, especially water.
ƒ Fruit juices should be limited and soft drinks avoided.
 Food for children entering their
teenage years
‡The extra energy required for growth and physical activity
needs to be obtained from foods that also provide
ŶƵƚƌŝĞŶƚƐ͕ŝŶƐƚĞĂĚŽĨũƵƐƚ
‡Milk, yoghurt and cheese (mostly reduced fat) should be
included to boost calcium intake
ʹthis is especially
important for growing bones.
 ŽŶƚŝ͙
ƒAdolescent girls should be particularly encouraged to
consume milk and milk products.
ƒTakeaway and fast foods need to be balanced with
nutrient-dense foods such as wholegrain breads and
cereals, fruits, legumes, nuts, vegetables, fish and
lean meats.
 Older teenagers and young adults
Moving away from home, starting work or study, and the
changing lifestyle that accompanies the late teens and
early 20s can cause dietary changes
ƒMake a deliberate effort to keep physically active.
ƒ Reduce the amount of fats and salt in the daily diet.
ƒ Be careful to include foods rich in iron and calcium.
ƒ Establish healthy eating habits that will be carried on
into later life.
 Food for older people
Many people eat less as they get older, this can make it
harder to make sure your diet has enough variety to
include all the nutrition you need.
Recommendations include:
ƒ Be as active as possible to encourage your appetite
and maintain muscle mass.
ƒRemain healthy with well -balanced eating and regular
exercise.
ƒIf possible, try to spend some time outside each day to
boost your vitamin D synthesis for healthy bones.
ƒ Limit foods that are high in energy and low in nutrients
such as cakes, sweet biscuits and soft drinks.
ƒ Choose foods that are naturally high in fiber to
encourage bowel health.
ƒ Limit the use of table salt, especially during cooking.
ƒEat foods that are nutrient dense rather than energy
dense, including eggs, lean meats, fish,-fat
lowdairy
foods, nuts and seeds, legumes, fruit and vegetables,
wholegrain breads and cereals.
 Manifestations of altered nutrition
ƒDisturbed GI function ƒObesity
ƒCardiovascular function ƒ Underweight
ƒ Dry lips ƒ Altered bowel patterns
ƒ Bleeding gums ƒAltered skin, teeth, hair,
ƒ Coated/ dry tongue ƒand mucous membrane
ƒ Vision loss ƒ Overweight
 Manifestations of altered nutrition
ƒDehydration ƒImpact on activities of
ƒ Fatigue daily living
ƒ Skin manifestations, ƒ General manifestations,
include, poor wound Weight loss
healing ƒ Muscle wasting
ƒ Ulceration ƒ Muscle weakness
ƒ Dry skin
 Assessment
When conducting a nutrition assessment, check the
patient for:
ƒ Skin integrity
ƒ Trouble chewing
ƒ Edema
ƒ Swallowing disorders
ƒ Electrolyte abnormalities
ƒ Weight history
ƒ Hand-grip strength (have
ƒ Height and weight
the patient squeeze your
ƒ Measurement hand).
 Nutritional-Metabolic Pattern
Purpose
ƒThe purpose of assessing the client's nutritional
-
metabolic pattern is to determine the client dietary
habits and metabolic needs.
ƒThe conditions of hair, skin, nails, teeth and mucous
membranes are assessed.
 Subjective Data
Guideline Questions

Dietary and FluidIntake

ƒDescribe the type and amount of food you eat at
breakfast, lunch, and supper on an average day
ƒDo follow any certain type of diet? Explain.
ƒWhat time do you usually eat your meals?
KEd͙
ƒDo you find it difficult to eat meals on time? Explain.
ƒWhat types of snacks do you eat? How often?
ƒDo you take any vitamin supplements? Describe.
ƒDo you consider your diet high in fat? Sugar? Salt?
KEd͙
ƒDo you find it difficult to tolerate certain foods? Specify.
What kind of fluids do you usually drink? How much per
day?
ƒDo you have difficulty chewing or swallowing food?
ƒWhen was your last dental exam? What were the
result?
ƒDo you ever experience sore throat, sore tongue, sore
gums? Describe
KEd͙

ƒDo you everexperiencenausea and vomiting?

Describe.
ƒDo you ever experience
abdominalpains? Describe.
ƒDo you use antacids? How often? What kind?
CONDITION OF HAIR & NAILS
ƒDescribe the condition of your hair,
nails?
ƒDo you have excessively oily or dry hair?
ƒHave you had difficulty with scalp itching or sores?
ƒDo you use anyspecialhair or scalp care products?
ƒHave you noticed any changes in your nails? Col
ƒCracking? Shape? Lines?
CONDITION OF SKIN
ƒDescribethe condition of your skin.
ƒHow well and how quickly does your skin heal?
ƒDo you have any skin lesions?
Describe?
ƒDo you have excessive oily or dry skin?
ƒDo you have any itching? What do you do for relief?
METABOLISM
ƒWhat would you consider to be your "ideal weight"?
ƒHave you had any recent weight gains or losses?
ƒHave you used any measures to gain or lose weight?
Describe.
ƒDo you have any intolerance to heat or cold?
ƒHave you noted any changes in your eating or drinking
habits? Explain.
OBJECTIVE DATA

ƒAssess the client's temperature, pulse, respirations, and

height and weight.
 ACTUAL DIAGNOSIS
ƒIneffective Thermo regulation.
ƒFluid Volume Deficit
ƒFluid Volume Excess
ƒAltered Nutrition: Less than body requirements
ƒAltered Nutrition: More than bodyrequirements
ƒSubcutaneous fat loss Related to malnutrition
ACTUAL DIAGNOSIS
ƒIneffectiveBreastfeeding
ƒInterrupted Breastfeeding
ƒIneffective Infant Feeding Pattern
ƒImpairedSwallowing
ƒAltered Protection
ƒImpaired Tissue Integrity
ƒImpaired SkinIntegrity
Nutrition and Metabolic Pattern
Number of meals per day. Break fast: _____________Lunch_________ Dinner__________
Snacks ______________________
Food Preference:(1) Like :_________________( 2) Dislikes__________________________
Amount of fluids per day: ________________Rout (I/V) _________Oral________________
Tube feeding __________________Any dietary restriction__________________________
Any fluid restriction________________________________________
Skin
Turgor _________________Color______________Texture______________Edema_______
Hair:Texture______________________Distribution__________________________
Oral mucus membrane: _______________Gums_____________No of teeth_____________
Alignment: ___________________Dentures:________ Height_________ Weight________
Labs; HB____________ HCT_____________ WBC ______________ESR _________
RBC_____________Platelets____________PT_________ APTT _________INR ________
Albumin _____________ Na_____________ K __________Ca______
Mg___________ Others___________________
Nursing Diagnosis: __________________________________________________________
__________________________________________________________________________
 Nursing intervention to provide optimal
dietary health
ƒNurses are often the ones who spend the most time with
the patient. Therefore, their understanding of nutrition
is critical.
ƒEducate the patient that :
Modifiable risk factors such as unhealthy diet, physical
inactivity, tobacco use and harmful use of alcohol are
major causes of CVDs.(who)
 Interventions
ƒDaily measure weight.
ƒDetermine daily caloric need.
ƒTeach the patient about importance of balanced diet.
ƒMonitor intake and output daily.
ƒEducate about importance of food to prevent from
dehydration, and constipation.
 Interventions
ƒGive encouragement of individual to eat with others.
ƒ Avoid excessive use of alcohol and caffeine etc.
ƒ Give more protein and high fiber diet and avoid
excessive carbohydrate and fats.
 Exercise?
Discuss nutritional requirement for a patient with;
ƒ Diarrhea
ƒ Constipation
ƒ Immobility
ƒ Over weight
Questions?
ELIMINATION PATTERN

By: Ibne Amin

(INS ),Khyber Medical university
 Objectives
By the end of the session the students will be able to:
1. Review the basic anatomy of digestive system
2. Define elimination pattern
3. Discuss common problem of bowel elimination
4. Identify nursing care for common problem of fecal
elimination
5. Discuss common problems of urinary elimination
6. Identify nursing intervention for common urinary problems
7. Describe factors that can alter urinary function
8. Discuss nursing care for alterations in elimination pattern

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Anatomy of Digestive System

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 Anatomy of GIT.
‡Human GI system is composed of;
‡Mouth
‡Pharynx
‡Larynx
‡Esophagus
‡Stomach accessory organs.
‡Small intestine
‡Large intestine
‡Anus .

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 Elimination Pattern
Definition: The ability to get rid of wastes from
the body. OR
The expulsion of waste from body is known as
elimination.
Elimination patterns describe the regulation,
control, and removal of by -products and
wastes in the body. The term usually refers to
the movement of feces or urine and sweat
from the body.

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 Bowel Elimination
It is also known as defecation. Bowel elimination is
a natural process critical to human functioning in
which body excretes waste products of digestion.
It is a essential component of the healthy body
functioning. OR
Defecation (bowel elimination) is the act of
expelling feces (stool) from the body. To do so, all
structures of the gastrointestinal tract, especially
the components of the large intestine must
function in a coordinated manner

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 Bowel Elimination
Large intestine (colon) is about 125
-150 cm long
It has seven parts: Cecum, ascending, transverse, and
descending; sigmoid colon, rectum, and anus.

The colon forms pouches called haustra (haustrum is singular

The large intestine is a muscular tube lined with mucous

membrane

The muscles are circular and longitudinal to facilitate

peristaltic movements.

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 Types of Colon Movements
‡Haustral Churninginvolves back and forth movement
of chyme within the colon.

‡Colon Peristalsis
is relatively sluggish movement of
the chyme along the colon.

‡Mass Peristalsis
is powerful muscular movement
along the colon

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 Defecation Process
Defecation is initiated by two reflexes.
When feces enter the rectum, its distention
gives signal to mesenteric plexus to initiate
peristaltic movements in the descending,
sigmoid colon, and the rectum.
The internal sphincter in the anus relaxes and
defecation occurs by opening the external
sphincter

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 Characteristics of Feces
Feces (Healthy People):
‡ Soft, brown, moist, and firmed.
‡ Distinct odor.
Factors affecting the odor or appearance:
‡ Certain foods.
‡ Medications.
‡ Illness or infection.

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

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 Factors Promoting Elimination
‡Stress free environment
‡Ability to follow personal bowel habits, privacy
‡High fiber diet
‡Normal fluid intake (fruit juice, warm liquid)
Exercise (walking)
‡Ability to assume squatting position
‡Properly administered laxatives

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 Factors Impairing Elimination
‡Emotional anxiety
‡Failure to heed defecation reflex,
‡lack of time and privacy
‡High carbohydrate, high fat diet
‡Reduced fluid intake
‡Immobility and inactivity
‡Overuse of cathartics, narcotic analgesic
‡Inability to squat because of immobility,
musculoskeletal deformity; pain during
defecation
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 Alteration in Bowel Elimination
‡Diarrhea: Liquid watery stools..deals with the
consistency and frequency
‡Constipation: Less then 3 times/week or what ever
is less then the pt. Regular pattern of elimination
‡Incontinence: Inability to control fecal discharge
thru anal sphincter. Involuntary passage of stool
‡Fecal Impaction:Mass of hardened feces in
ƌĞĐƚƵŵ͙ƌĞĐŽŐŶŝnjĞĚďLJƐĞĞ
‡Flatulence:- Gas, Abdominal Distention & Pain
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 Assessing Elimination Status
Usual pattern:-How often, When
Changes in Bowels: Blood, Mucus
Aids to Eliminate:- Laxatives Enemas
Current Problems: Food Related, Meds
Physical, Emotional, Artificial Orifices,
Hemorrhoids (abnormally distended
veins)..Colostomy

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 Physical Assessment
Inspection- Observe contour of abdomen and
note visible peristalsis
Auscultation- Listen for bowel sounds in all
quadrants
Percussion- Resonant or tympany over hollow
ŽƌŐĂŶƐ͙ĚƵůůŶĞƐƐŽǀĞƌ
Palpation- Feel for masses, tenderness etc

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 Nursing Diagnosis
Bowl incontinence related to fecal impaction.
Constipation related to immobility.
Risk for constipation insufficient fiber intake.
Diarrhea related to spoiled food.
Risk for fluid volume deficit related to diarrhea.
Risk for impaired skin integrity related to colostomy.
Self esteem disturbances related to bowl diversion

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Nursing Interventions to Promote Normal
Bowel Elimination
‡Privacy
‡Timing- Patients should be encouraged to defecate
when the urge to defecate is recognized.
‡Nutrition and fluids- High fiber foods, 2000cc
fluids/day
‡Exercise - Ambulation helps to stimulate normal
motility, and therefore should be encouraged in post
-
surgical patients.
‡Positioning- Comfortable position needed. Squatting
position common. Assess need for elevated toilet,
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Nursing Interventions for Constipated Patients

‡Increase fluid intake. Instruct the patient to drink

fruit juices.

‡Include fiber in the diet with foods.

‡Administration of laxatives.

‡Administration of Enema
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 N. Interventions for Patients with
Diarrhea
‡Encourage intake of fluids and food.
‡Eating small amounts of bland foods.
‡Encourage the ingestion of food or fluids containing
potassium, since diarrhea can lead to great
potassium losses.
‡Avoid excessively hot or cold fluids and highly spiced
foods and high fiber foods that can aggravate
diarrhea.

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 Nursing Interventions for Fecal
Incontinence

‡Give balanced meals

‡Note time of incontinence
‡Toilet pt 30ʹ60 min before usual time of
incontinence
‡ĞŐŝŶďŽǁĞůƚƌĂŝŶŝŶŐƉƌ

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 Nursing Interventions of Fecal Impaction

‡Education/counseling/habit training
‡Diet (fiber, lactose, fructose)
‡Reduce caffeine intake
‡Anal hygiene/skin care
‡Digital removal of stool

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 N.Interventions for Flatulence

‡Decreasing flatulus
by avoiding gas
ʹproducing food, exercise, moving in
bed and ambulation

‡Glycerin Suppository

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 Plan and Implementation
‡Promotion of regular bowel habits
‡Promotion of normal defecation
‡Digital removal of stool
‡Maintenance of proper fluid/ food intake
‡Promotion of regular exercise
‡Promotion of comfort

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 Interventions
Cathartics/Laxatives- Drugs that induce emptying of the
interest. Habitual use of laxatives lead to constipation and
irreg. frequency. Prep for procedures
Enemas- Solution introduced into the lG. Interest for the
purpose of removing feces.
Suppositories- bullet shaped substance inserted into the
rectum beyond the anal sphincter where it melts to aid in
elimination.
Digital removal- with prolonged retention of feces, fecal
impaction occurs preventing passage of normal stool. Liquid
fecal seepage around hard stool can occur. Oil retention
enema is given prior to digital removal to soften stool.
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Urinary Elimination

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 Anatomy of Renal system

‡The renal system is composed of;

±2 kidneys

±2 ureters

±1 urinary bladder

±1 urethra

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 Structure of kidney
Kidneys are pairs of organ
‡ Shape: Bean shaped
‡Size: 11cm long,6 cm wide, 3
cm thick
‡ Weight: 150 g.
‡Location :The kidneys lie on
the posterior abdominal wall,
one on each side of the vertebral
column.
‡Position: It is situated at T12-
L3. (3)
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 cont͛
Longitudinal section of the kidney shows
following parts.
‡Capsule
‡Cortex.
‡Medulla
‡Hilum (3)

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 Urine
‡The formation of urine has 3 processes, filtration,
reabsorption and tubular secretion
‡Urine consists of 95% water and 5% solid substances
‡The need to urinate is usually felt at 300
-350ml of
urine in the bladder.
‡Typically 1000-1500 mL is voided daily.

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 Urination
‡Micturation, voiding, and urination all refer to the
process of emptying the urinary bladder
‡Stretch receptors - special sensory nerve endings in
the bladder wall that is stimulated when pressure is
felt from the collection of urineʹAdult: 250-450mL
of urine ʹChildren: 50-200mL of urine

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 Factors affecting voiding
‡Growth and development
‡Psychosocial factors
‡Fluid and food intake
‡Medications
‡Muscle tone and activity
‡Pathologic conditions
‡Surgical and diagnostic procedures

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 Common Urinary Elimination Problems

Urinary retention
Urinary tract infections
Urinary incontinence.

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 Altered Urinary Elimination
Frequency:is the voiding more than normal with frequent
intervals.
Nocturia: is voiding two or three time at night.
Urgency:is the feeling of person must void.
Dysuria:means voiding that is either painful or difficulty.
Enuresis:is defined as involuntary urination.
Urinary incontinence: involuntary urination. Symptom not a
disease.
Urine retention: accumulation of urine in the bladder and
become over distended
Hypospadiasis a birth (congenital) defect in which the
opening of the urethra is on the underside of the penis

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 Assessing Urinary Function

‡Determine normal voiding pattern and frequency

‡Appearance of urine
‡Recent changes
‡Past or current problems with urination (burning,
urgency,etc).
‡Presence of an ostomy
‡Factors influencing elimination pattern.

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 Assessment
‡ Nursing history:
‡Voiding pattern, description of urine for any
changing.
‡Urinary elimination problem.
‡Presence of urinary diversion.
‡Physical assessment: inspection, palpation,
percussion and auscultation.

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 Assessing Urine
‡Color: transparent.
‡Normal kidney produce urine at the rate of -60
40
ml/hr or 1500-2000 ml/day
‡Sterility: no microorganism present.
‡Glucose: not present.
‡Blood: not present.
‡Epithelial cell not present.
‡Measuring urine output.
‡Colleting urine specimen.
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 Nursing Diagnosis
‡ Altered urinary elimination related to bladder neck
obstruction.
‡Stress incontinence related to relaxation of sphincter.
‡Risk for infection related to urinary retention.
‡Self esteem disturbances related to urinary
incontinence.

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 PLANNING
‡ Maintain normal voiding pattern.
‡ Regain normal urine output.
‡ Prevent infection.
‡ Maintaining normal urinary elimination:
‡ Promote fluid intake.
‡ Assisting with toileting.
‡ Preventing urinary tract infection:
‡ Increased fluid intake.
‡ Practice frequent voiding process...
‡ Strengthening pelvic floor muscles
‡ Manual bladder compression & Kegal exercise
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 Managing Urinary Incontinence (UI)
‡Bladder training- requires that the client postpone
voiding, resist or inhibit the sensation urgency, and
void according to a timetable rather than according to
the urge to void. The goal is to lengthen the intervals
ďĞƚǁĞĞŶƵƌŝŶĂƚŝŽŶƚŽĐŽƌƌ
frequent urination
‡Habit training- also referred to as timed voiding or
scheduled toileting. There is no attempt to motivate
the client to delay voiding is the urge occurs.
‡Prompt voiding- supplements the habit training by
encouraging the client to use the toilet and reminding
the client when to void

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 Managing Urinary Incontinence (UI)
Pelvic Muscle Exercises (PME)
ZĞĨĞƌƌĞĚƚŽĂƐƉĞƌŝŶĞĂůŵ
exercises
Streghthen pubococcygeal muscles and can increase
ƚŚĞŝŶĐŽŶƚŝŶĞŶƚĨĞŵĂůĞ͛Ɛ
stream of urine

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Managing Urinary Incontinence (UI)
ͻWŽƐŝƚŝǀĞƌĞŝŶĨŽƌĐĞŵĞ
ͻDĂŝŶƚĂŝŶŝŶŐƐŬŝŶŝŶƚ
ͻƉƉůLJŝŶŐĞdžƚĞƌŶĂůƵƌ

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 Managing Urinary Retention

Urinary catheterization

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 References

1:OlowuWA, Niang A, Osafo C, Ashuntantang G, Arogundade FA, Porter J, e

al. lancet global health, 2016.
Ϯ͗ŚƚƚƉƐ͗ͬͬǁǁǁ͘ǁĞďŵĚ͘ĐŽŵͥ<ŝĚŶĞLJ^
3:http://www.newhealthadvisor.com/kidney -structure-and-function.html.
4: Porth, C., & Hannon, R. (2009).
Porth pathophysiology . Philadelphia, Pa.:
Lippincott Williams & Wilkins.Mein

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Concept of Sleep & Rest

By : Ibne Amin
Lecturer , INS
Khyber Medical University,Peshawar
 Objectives
1. Define rest and sleep pattern
2. Define terms related to rest and sleep.
3. Compare the characteristics of sleep and rest.
4. Discuss the characteristics of two kinds of sleep.
5. Enumerate the functions of sleep.
6. Discuss factors affecting sleep.
7. Identify common sleep disorders.
8. Identify conditions necessary to promote sleep.
9. Discuss nursing process for a patient to promote sleep

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 Rest and sleep pattern
Sleep is a basic human need; it is a universal biologica
process common to all people. Humans spend about
one third of their lives asleep
A sleep pattern, also referred to as sleep
-wake pattern,
is a biological rhythm that guides the body as to
when it should sleep and when it should wake . It is
one of the body's circadian rhythms and typically
follows a 24-hour cycle, controling the body's
schedule for sleeping and waking.

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 Rest and sleep pattern
Proper sleep & rest are importanat for patients and
may be interrupted because of pain, fear,stress, or
side effects of medication and necessary treatment.
An importanta nursing action is to assist the patients in
obtaining enough sleep to aid in healing and
maintaing health.
Adults need 7 hours of sleep at night

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 Rest
Rest is a condition in which the body is in a decreased
state of activity without physical, emotional stress
and freedom from anxiety. Rest is without altered
level of consciousness.OR
In medical care, rest is defined as behavior aimed at
increasing physical and mental well-being, which
usually involves stopping activity.
Rest has positive outcomes for our physical, mental, and
emotional health. By relaxing muscles and quieting the
brain, rest can help restore a sense of calm during times
of exhaustion, illness, or overexertion.

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 Sleep
An altered state ofconsciousness ŝŶǁŚŝĐŚƚŚĞ
perception of and reaction to the environment is
decreased.
OR
A physical and mental resting state in which a person
becomes relatively inactive and unaware of the
environment.
Sleep is a partial detachment from the world, where most
external stimuli are blocked from the senses.

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 Compare the characteristics of Sleep &
Rest.
Sleep Rest
1. Sleep is a body
-mind state in 1. Rest is a condition in which the
which we experience sensory body is in a decreased state of
detachment from our activity without physical,
surroundings. emotional stress and freedom
2. Sleep is associated with a typical from anxiety.
posture,such as lying down with 2. No typical posture required for
eyes closed rest
3. Sleep results in a decreased 3. In other resting conditions we
responsiveness to an external are in contact with external
stimuli stimuli
4. /ƚ͛ƐĂŶĂƌƌŽǁƚĞƌŵ͘ 4. /ƚ͛ƐĂďƌŽĂĚĞƌƚ
5. Sleep is physical 5. Rest is spiritual
6. We need 7.5 hours of sleep per 6. We need 2 hours to -25 2 min
day rest per day

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 Characteristics of Sleep
‡Sleep is a state that is characterized by changes in
brain wave activity, breathing, heart rate, body
temperature, and other physiological functions.
‡Depending on the sleep stage, different physiological
functions may be
‡more active and variable ,for example, during REM
sleep,
‡less active and more stable for example, during NREM
sleep.

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 Characteristics of Sleep
‡Sleep is a period of reduced activity.
‡Sleep is associated with a typical posture, such as
lying down with eyes closed in humans.
‡Sleep results in a decreased responsiveness to
external stimuli.
‡Sleep is a state that is relatively easy to reverse
‡Sleep consist of two main phases that are
±Non Rapid Movement (NREM)
±Rapid Eye Movement(REM)

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 Stages of Sleep
1. Non Rapid Movement (NREM)
About 75% to 80% of sleep during a night is NREM
sleep. NREM sleep is divided into four stages, each
associated with distinct brain activity and physiology.
NREMʹ Non rapid eye moment
Stage-I
Stage-II
Stage-III
Stage-IV
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 1. Characteristics of NREM
Stage I
Stage I is the stage very
of light sleepand lasts only a few
minutes. During this stage, the person feels drowsy and
relaxed, the eyes roll from side to side, and the heart and
respiratory rates drop slightly. The sleeper can be readily
awakened and may deny that he or she was sleeping.
‡ Relax and drowsy
‡ Profound and restfullness
‡ Floating sensation
‡ Eyes roll from sisde to side
‡ Usually last only a few minutes

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 Characteristics of NREM
Stage II
Stage II is the stage light
of sleepduring which body
processes continue to slow down. The eyes are generally
still, the heart and respiratory rates decrease slightly, and
body temperature falls. Stage II lasts only about 10 to 15
minutes but constitutes 44% to 55% of total sleep
(Choudhary & Choudhary, 2009).
An individual in stage II requires more intense stimuli than
in stage I to awaken such as touching or shaking.
‡Light sleep
‡Easily aroused

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

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 1. Characteristics of NREM
STAGE -this
4 is the deepest sleep or delta sleep. It is the stage
where the heart rate and respiratory rate drop -30%
20 below
those exhibited during waking hours. This stage is thought to
restore the body physically. Some dreaming may occur here.
This stage may be absent in the elderly.
‡ Stage lasts approximately 15 to 30 minutes.
‡ It is the deepest stage of sleep.
‡ If sleep loss has occurred, sleeper spends considerable
portion of night in this stage.
‡ Vital signs are significantly lower than during waking hours.
‡ Further slowing of EEG
‡ Sleep walking and enuresis (bed -wetting) sometimes occur.
‡ t is very difficult to arouse sleeper

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 1. Characteristics of NREM
Stages III & stage IV
Stages III and IVare the deepest stages of sleep, differing only
in the percentage of delta waves recorded during a - 30
second period. During deep sleep or delta sleep,the
ƐůĞĞƉĞƌ͛ƐŚĞĂƌƚĂŶĚƌĞƐƉŝƌĂ
below those exhibited during waking hours.
The sleeper is difficult to arouse. The person is not disturbed
by sensory stimuli, the skeletal muscles are very relaxed,
reflexes are diminished, and snoring is most likely to occur.
Even swallowing and saliva production are reduced during
delta sleep(Choudhary & Choudhary, 2009).
These stages are essential for restoring energy and releasing
important growth hormones

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 2.Characteristics of REM
This sleep type usually recurs about every 90 minutes
and lasts 5 to 30 minutes.
Othername: PARADOXICAL Sleep. The EEG pattern
ƌĞƐĞŵďůĞƐƚŚĂƚŽĨƚŚĞ͞
restful as NREM sleep.
Most dreams take place during this period and the
dreams are usually remembered or consolidated to
memory. The brain is highly active with metabolic
rate increasing as much as 20%
.

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 2. Characteristics of REM
The sleeper may be very difficult to arouse.There are
rapid conjugate eye movements, muscle tone is
depressed, but gastric secretions increase, HR and R
are increased and IRREGULAR.
This sleep period becomes longer as the night
progresses

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 NREM VS REM Sleep
NREM REM
‡Slow eye movement ‡Rapid eye movement
‡Restful sleep ‡Not restful
‡Decrease metabolism ‡Increased metabolism
‡Vital sign low ‡Vital signs irregular
‡Muscle tone maintained ‡Muscle tone depressed
‡No vivid draems ‡Dreams occur

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 Sleep Cycles
During a sleep cycle, people typically pass through
NREM and REM sleep, the complete cycle usually
lasting about 90 to 110 minutes in adults.
In the first sleep cycle, a sleeper usually passes through
all of the first three NREM stages in a total of about
20 to 30 minutes.
Then, stage IVmay last about 30 minutes. After stage IV
NREM, the sleep passes back through stages III and
over about 20 minutes. Thereafter, the first REM
stage occurs, lasting about 10 minutes, completing
the first sleep cycle.
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 Sleep Cycles
It is not unusual for the first REM period to be very
brief or even skipped entirely. The healthy adult
sleeper usually experiences four to six cycles of sleep
during 7 to 8 hours .
The sleeper who is awakened during any stage must
begin a new at stage I NREM sleep and proceed
through all stages to REM sleep.

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Sleep Cycle

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 Functions of Sleep
The effects of sleep on the body are not completely
understood.
Sleep exertsphysiologicaleffects on both the nervous
system and other body structures.
The role of sleep in
psychologicalwell-being is best noticed
by the deterioration in mental functioning related to
sleep loss.
Persons with inadequate amounts of sleep tend to become
emotionally irritable, have poor concentration, and
experience difficulty making decisions.(Regulation of
emotion)

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 Functions of Sleep
‡Restore biological processes (NREM)
‡Preserve cardiac functions
‡Human growth harmone released
‡Proteins synthesis and cell division
‡Body conserve energy during sleep
‡Thermoregulation
‡REM sleep is necassry for brain tissue restoration and
cognitive functions
‡Loss of REM sleep leads to feeling of confusion and
suspecion

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 Functions of Sleep
Prolong sleep loss leads to alterations in mood,
memmory and motor performance
Disturb REM sleep may affect on body such as,
‡Risk for obesity
‡Memory problem
‡Easily gets depression
‡Disturb metabolism

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 Factors Affecting sleep
Both the quality and the quantity of sleep are affected
by a number of factors. Factors that affects sleeps
are:
‡Age ‡Diet
‡Illness ‡Smoking
‡Environment ‡Motivation
‡Lifestyle ‡Medications
‡Emotional stress
‡Stimulants and Alcohol
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 Factors Affecting sleep
1. Age
Newborn: 16-18 hours /day
Infants: 12-14 hours
Toddlers: 10 -12 hours
Preschool: 11 -12 hours
School-Age: 8- 12 hours
Adolescents: -810 hours
Adult: 6-8 hours
Elders: 6 hours
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 Factors Affecting sleep
‡Certain endocrine disturbances can also affect sleep.
Hyperthyrodism lengthens presleep time making it
difficult for a client to fall asleep.Hypothyroidism,
conversely, decreases stage IV sleep.
‡Elevated body temperatures can cause some reduction in
delta sleep and REM sleep.
‡The need to urinate during the night also disrupts sleep,
and people who awaken at night to urinate sometimes
have difficulty getting back to sleep.

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 Factors Affecting sleep
2. Illness
Illness that causes pain or physical distress (e.g., arthritis,
back pain & low level of estrogen) can result in sleep
problems. People who are ill require more sleep than
normal, and the normal rhythm of sleep and wakefulness
is often disturbed.
‡ZĞƐƉŝƌĂƚŽƌLJĐŽŶĚŝƚŝŽŶƐĐĂŶ
‡People who have gastric or duodenal ulcers may find
their sleep disturbed because of pain, often a result of
the increased gastric secretions that occur during REM
sleep.

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 Factors Affecting sleep
3. Environment
Environment can promote or hinder sleep. The person must
be able to achieve a state of relaxation prior to entering a
period of sleep.
Any change Ͷfor example, noise in the environmentͶ can
inhibit sleep.The absence of usual stimuli or the presence
of unfamiliar stimuli can prevent people from sleeping.
Hospital environments can be quite noisy, and special
care needs to be taken to reduce noise in the hallways
and nursing care units.

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 Factors Affecting sleep
/ŶĨĂĐƚ͕ƐŽŵĞŚŽƐƉŝƚĂůƐŚĂǀ
afternoon on nursing units where the lights are lowered
and activity and noise are purposefully decreased so
clients can rest or nap.Discomfort from environmental
temperature (e.g., too hot or cold) and lack of ventilation
can affect sleep.
Light levels can be another factor. A person accustomed to
darkness while sleeping may find it difficult to sleep in
the light. Another influence includes the comfort and size
of the bed.
ƉĞƌƐŽŶ͛ƐƉĂƌƚŶĞƌǁŚŽŚĂƐĚŝĨĨĞƌĞ
difficulties may become a problem for the person also.
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 Factors Affecting sleep
4.Lifestyle
Following an irregular morning and night time schedule can
affect sleep. Moderate exercise in the morning or early
afternoon usually is conducive to sleep, but exercise late
in the day can delay sleep.
dŚĞƉĞƌƐŽŶ͛ƐĂďŝůŝƚLJƚŽƌĞů
factor affecting the ability to fall asleep. It is best,
therefore, to avoid doing homework or office work
before or after getting into bed.

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 Factors Affecting sleep
Night shift workers frequently obtain less sleep than other
workers and have difficulty falling asleep after getting off
work. Wearing dark wrap -around sunglasses during the
drive home and light -blocking shades can minimize the
alerting effects of exposure to daylight, thus making it
easier to fall asleep when body temperature is rising.

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 Factors Affecting sleep
5. Emotional Stress
Stress is considered by most sleep experts to be the numbe
one cause of short-term sleeping difficulties (National
Sleep Foundation).
A person preoccupied with personal problems (e.g., school -
or job-related pressures, family or marriage problems)
may be unable to relax sufficiently to get to sleep.
Anxiety increases the norepinephrine blood levels through stimulation
of the sympathetic nervous system. This chemical change results in
less deep sleep and REM sleep and more stage changes and
awakenings.

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 Factors Affecting sleep
6. Stimulants and Alcohol
Caffeine-containing beverages act as stimulants of the
central nervous system (CNS). Drinking beverages
containing caffeine in the afternoon or evening may
interfere with sleep. People who drink an excessive
amount of alcohol often find their sleep disturbed.
Alcohol disrupts REM sleep, although it may hasten the
onset of sleep. The alcohol
-tolerant person may be
unable to sleep well and become irritable as a result.

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 Factors Affecting sleep
7. Diet
Weight gain has been associated with reduced total sleep
time as well as broken sleep and earlier awakening.
Weight loss, on the other hand, seems to be associated
with an increase in total sleep time and less broken
sleep.
Dietary L-tryptophanͶfound, for example, in cheese and
milkͶmay induce sleep, a fact that might explain why
warm milk helps some people get to sleep.

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 Factors Affecting sleep
8. Smoking
Nicotine has a stimulating effect on the body, and smokers
often have more difficulty falling asleep than
nonsmokers. Smokers are usually easily aroused and
often describe themselves as light sleepers.
By refraining from smoking after the evening meal, the
person usually sleeps better; moreover, many former
smokers report that their sleeping patterns improved
once they stopped smoking

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 Factors Affecting sleep
9. Motivation
Motivation can increase alertness in some situations
(e.g., a tired person can probably stay alert while
attending an interesting concert or surfing the web late
at night).
Motivation alone, however,is usually not sufficient to
overcome the normal circadian drive to sleep during
the night.Nor is motivation sufficient to overcome
sleepiness due to insufficient sleep.Boredom alone is
not sufficient to cause sleepiness, but when insufficient
sleep combines with boredom, sleep is likely to occur.

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 Factors Affecting sleep
10. Medications
Some medications affect the quality of sleep. Most
hypnotics can interfere with deep sleep and suppress
REM sleep.
‡Beta-blockers have been known to cause insomnia and
nightmares.
‡Narcotics, such as morphine, are known to suppress REM
sleep and to cause frequent awakenings and drowsiness.
‡Tranquilizers interfere with REM sleep.
‡Although antidepressants suppress REM sleep, this effect i
considered a therapeutic action
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 Common Sleep Disorders.
A knowledge of common sleep disorders can help nurses assess
the sleep complaints of their clients and, when appropriate,
make a referral to a specialist in sleep disorders medicine.
Sleep disorders are typically categorized for the purpose of
research as
‡ Dysomnias,
‡ Parasomnias, and
‡ Disorders associated with medical or psychiatric illness,
Primary disorders can be divided into parasomnias
and dyssomnias.
Parasomnia sleep disorders cause abnormal activities during sleep, such
sleep terrors or sleep walking. Dyssomnia sleep disorders cause trouble
falling asleep or staying asleep.

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 Common Sleep Disorders
1. Insomnia
Insomnia is described as the inability to fall asleep or
remain asleep. Persons with insomnia awaken not feeling
rested.
Acute insomnialasts one to several nights and is often
caused by personal stressors or worry.
Chronic insmnia: If the insomnia persists for longer than a
month, it is considered chronic insomnia.
More often, people experience chronic -intermittent
insomnia, which means difficulty sleeping for a few
nights, followed by a few nights of adequate sleep

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 Common Sleep Disorders
The two main risk factors of insomnia are 1) Older age
and 2) Female gender (National Sleep Foundation).

Women suffer sleep loss in connection with hormonal

changes (e.g., menstruation, pregnancy, and
menopause). The incidence of insomnia increases
with age, but it is thought that this is caused by some
other medical condition.

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 Common Sleep Disorders
Treatment for insomnia frequently requires the client to develop
new behavior patterns that induce sleep and maintain sleep.
Examples of behavioral treatments include the following
‡ Stimulus control: creating a sleep environment that promotes
sleep
‡ Cognitive therapy :learning to develop positive thoughts and
beliefs about sleep
‡ Sleep restriction:following a program that limits time in bed
in order to get to sleep and stay asleep throughout the nigh.
Similarly,the long-term efficacy of hypnotic medications is questionable.
Such medications do not deal with the cause of the problem, and their
prolonged use can create drug dependencies.

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 Common Sleep Disorders
2. Excessive Daytime Sleepines
Clients may experience excessive day time sleepiness as a resu
of hypersomnia , narcolepsy, sleep apnea, and insufficient
sleep.
Hypersomnia
Hypersomnia refers to conditions where the affected individual
obtains sufficient sleep at night but still cannot stay awake
during the day. Hypersomnia can be caused by medical
conditions, for example, CNS damage and certain kidney, live
or metabolic disorders, such as diabetic acidosis and
hypothyroidism.Rarely does hypersomnia have a psychologica
origin

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 Common Sleep Disorders
Narcolepsy(Sleeping at the wrong time) or falling asleep
uncontrollably at inappropriate time
Narcolepsy is a disorder excessive
of daytime sleepiness
caused
by the lack of the chemical hypocretin in the area of the CNS
that regulates sleep. Clients with narcolepsy have sleep
attacks or excessive day time sleepiness, and their sleep at
night usually begins with a sleep
-onset REM period
(dreamingsleep occurs within the first 15 minutes of falling
asleep ).
‡ Sleep intrudes into wakefulness, causing clients to fall asleep
almost instantly
‡ Sleep is brief but refreshing
‡ May also have sleep paralysis, sudden loss of strength, and
hallucinations as fall asleep or awaken.

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 Common Sleep Disorders
Sleep Apnea(inability to sleep & breath at the same time)
Sleep apnea is characterized by frequent short breathing
pauses during sleep. Although all individuals have
occasional periods of apnea during sleep, more than five
apneic episodes or five breathing pauses longer than 10
seconds/hour is considered abnormal and should be
evaluated by a sleep medicine specialist.
Symptoms suggestive of sleep apnea include loud snoring, frequent
nocturnal awakenings, excessive daytime sleepiness, difficulties
falling asleep at night, morning headaches, memory and cognitive
problems, and irritability.

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 Common Sleep Disorders
Although sleep apnea is most frequently diagnosed in men
and postmenopausal women, it may occur during
childhood.
Three common types of sleep apnea are
‡Obstructive Apnea,
‡Central Apnea, And
‡ Mixed Apnea.

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 Common Sleep Disordersa
Obstructive apneaoccurs when the structures of the
pharynx or oral cavity block the flow of air.
The person continues to try to breathe; that is, the chest
and abdominal muscles move. The movements of the
diaphragm become stronger and stronger until the
obstruction is removed. Enlarged tonsils and adenoids,
a deviated nasal septum, nasal polyps, and obesity
predispose the client to obstructive apnea.
An episode of obstructive sleep apnea usually begins with snoring;
thereafter, breathing ceases, followed by marked snorting as
breathing resumes.
Toward the end of each apneic episode, increased carbon dioxide
levels in the blood cause the client to wake.

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 Common Sleep Disordersa
Central apneais thought to involve a defect in the
respiratory center of the brain.All actions involved in
breathing, such as chest movement and airflow, cease.
Clients who have brainstem injuries and muscular
dystrophy, for example, often have central sleep apnea.
At this time, there is no available treatment.
Mixed apneais a combination of central apnea and
obstructive apnea.

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 Common Sleep Disordersa
3. Insufficient Sleep(Disturbed Sleep or Sleep Deprivation)
Healthy individuals who obtain less seep than they need
will experience sleepiness and fatigue during the day
time hours. Depending on the severity and chronicity of
this voluntary, unintentional sleep deprivation,
individuals may develop attention and concentration
deficits,reduced vigilance,distractibility, reduced
motivation, fatigue, malaise, and occasionally diplopia
and dry mouth.

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 Common Sleep Disorders
Parasomnia
A parasomnia is behavior that may interfere with sleep
and may even occur during sleep. The
InternationalClassification of Sleep Disorders
subdivides parasomnias into
‡Arousal disorders (e.g., sleepwalking, sleep terrors),
‡Seep/wake transition disorders (e.g., sleeptalking),
‡Parasomnias associated with REM sleep (e.g.,
nightmares), and others (e.g., bruxism).

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 Parasomnias
Bruxism.
Usually occurring during stage II NREM sleep, this clenchin
and grinding of the teeth can eventually erode dental
crowns, cause teeth to come loose, and lead to
deterioration of the temporomandibular (TMJ) joint,
called TMJ syndrome.
Enuresis.
Bed-wetting during sleep can occur in children over 3 years
old. More males than females are affected. It often
occurs 1 to 2 hours after falling asleep, when rousing
from NREM stages III and IV.
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 Parasomnias
Periodic limb movement disorder (PLMD).
In this condition, the legs jerk twice or three times per minute
during sleep. It is most common among older adults. This
kicking motion can wake the client and result in poor sleep.
Sleeptalking.
Talking during sleep occurs during NREM sleep before REM
sleep. It rarely presents a problem to the person unless it
becomes troublesome to others.
Sleepwalking.
Sleepwalking (somnambulism) occurs during stages III and IV
of NREM sleep. It is episodic and usually occurs 1 to 2 hou
after falling asleep. Sleepwalkers tend not to notice dangers
(e.g., stairs) and often need to be protected from injury.

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 Disorders due to other medical
conditions
These disorders are associated with Medical or
Psychiatric or other illness. Usually the disorders that
cause sleep disturbance includes:
‡ Depression
‡ Alcolism
‡ Thyroid dysfunction
‡ Peptic ulcer
‡ COPD

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 Promoting Sleep
SLEEP PATTERN
‡ If you have difficulty falling asleep or staying asleep, it is important
to establish a regular bedtime and wake -up time for all days of the
week to enhance your biological rhythm.
‡ A short daytime nap (e.g., 15 to 30 minutes), particularly among
older adults, can be restorative and not interfere with nighttime
sleep. A younger person with insomnia should not nap.
‡ Establish a regular, relaxing bedtime routine before sleep such as
reading, listening to soft music, taking a warm bath, or doing some
other quiet activity you enjoy.
‡ Avoid dealing with office work or family problems before bedtime.
‡ Get adequate exercise during the day to reduce stress.
‡ When you are unable to sleep, get out of bed, go into another
room, and pursue some relaxing activity until you feel drows

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 Promoting Sleep
ENVIRONMENT
‡ Create a sleep
-conducive environment that is dark,
quiet, comfortable, and cool.
‡ Keep noise to a minimum; block out extraneous
noise as necessary with noise from a fan, air
conditioner, or noise machine.
‡Music is not recommended as studies have shown
that music will promote wakefulness (it is interesting
and people will pay attention to it).
‡ Sleep on a comfortable mattress and pillows

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 Promoting Sleep
DIET
‡Avoid heavy meals 2 to 3 hours before bedtime.
‡ Avoid alcohol and caffeine
-containing foods and
beverages (e.g., coffee, tea, chocolate) at least 4
hours before bedtime. Caffeine can interfere with
sleep. Both caffeine and alcohol act as diuretics,
creating the need to void during sleep time.
‡ If a bedtime snack is necessary, consume only light
carbohydrates or a milk drink. Heavy or spicy foods
can cause gastrointestinal upsets that disturb sleep

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 Promoting Sleep
MEDICATIONS
‡Use sleeping medications only as a last resort. Use
OTC medications sparingly because many contain
antihistamines that cause daytime drowsiness.
‡Take analgesics before bedtime to relieve aches and
pains.
‡Consult with your health care provider about
adjusting other medications that may cause
insomnia.

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Nursing Process for a Patient to
Promote Sleep

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 Assessment of Sleep
ƐƐĞƐƐŵĞŶƚŽĨĂĐůŝĞŶƚ
‡Sleep history
‡Physical examination
‡Sleep diary

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 Sleep Rest Pattern
‡EŽŽĨŚŽƵƌ͛ƐƐůĞĞƉͬϮϰ
Home______________ Hospital __________
Naps
‡Any problem to fall/stay a sleep___________
‡Use of tranquillizers___________

‡Any home remedy to induce

sleep___________
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 Sleep RestPattern
‡Evidence of lack of sleep_____
‡Quality of sleep______

‡Nursing diagnosis

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

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 Sleep History
‡What is the usual sleeping pattern,
specifically:
‡sleeping and waking times
‡hours of undisturbed sleep, etc.
‡Bedtime rituals
‡Use of sleep medications
‡Sleep environment
‡Changes in sleep pattern

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

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 NursingDiagnosis
‡Readiness for enhanced sleep
‡Insomnia related to anxiety
‡Insomnia related to the disruption in the amount
and quality of sleep
‡Sleep deprivation related to jet lag
‡Sleep deprivation related to nocturnal work hours
‡Sleep deprivation related to prolonged periods of
time without sleep

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 Conti..
‡Impaired sleep related to obstructive sleep apnea
‡At risk for injury and accidents relating to
somnambulism
‡Impaired gas exchange related to central or
obstructive sleep apnea
‡At risk for disturbed sleep secondary to alcohol
use
‡Insomnia related to unrelenting pain and the lack
of comfort

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 Intervention
‡The promotion of sleep and adequate rest depends on
correcting any underlying problems, including pain and
alcohol use, and then planning activities and routines
that will enhance the duration and the quality of sleep.
‡Some of these sleep promotion interventions and
schedules include:
‡Establishing and adhering to a regular sleep time and
wake time for the client based on their patterns and
needs
‡Limiting the duration and frequency of day time naps
‡The promotion of daily exercise
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 Conti...
‡The avoidance of alcohol, caffeine, heavy
meals and exercise at least a couple of hours
before bedtime
‡The promotion of comfort using techniques
such as white noise, dim lighting, pain
management, stress reduction techniques,
massage and the elimination of
environmental noise

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 Conti...
‡Close window curtains if street lights shine through
‡Close curtains between clients in semiprivate and larger
rooms
‡Reduce or eliminate overhead lighting: provide night
light at the bedside or in the bathroom
‡ůŽƐĞƚŚĞĚŽŽƌŽĨƚŚĞĐůŝ
‡Perform only essential noisy activities during sleeping
hours

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 Reducing environmental distractions
in Hospitals
‡Close window curtains if street lights shine through
‡Close curtains between clients in semiprivate and larger
rooms
‡Reduce or eliminate overhead lighting: provide night
light at the bedside or in the bathroom
‡ůŽƐĞƚŚĞĚŽŽƌŽĨƚŚĞĐůŝ
‡Perform only essential noisy activities during sleeping
hours

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 Conti...

‡Ensure that all carts wheels are well oiled

‡Wear rubber soled shoes
‡Keep required staff conversations at low
levels: conduct nursing reports or other
discussions in a separate area away from
clients rooms

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 Teaching to promote rest &sleep
‡Establish regular betimes & wake up
‡Eliminate lengthy naps
‡Exercise just not 2 hrs before bedtime
‡Take analgesics before bedtime if needed
‡Decrease fluid intake-42 hrs before bed
‡Use sleeping meds as last resort
‡Avoid heavy meals 3 hrs before bedtime
‡Avoid alcohol & caffeine at least 4 hrs before bedtime

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 References

‡<ŽnjŝĞƌΘƌď͛Ɛ&ƵŶĚĂŵĞŶƚ th

edition.
‡WŽƚƚĞƌĂŶĚWĞƌƌLJ;ϮϬϬϱͿ
published by most by an imprint of Elsevier, 6th
edition. New Delhi. Page no 1068
ʹ1071
‡www.google.com

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Human Responses to Illness

Faculty: Ibne Amin

INS, Khyber Medical University,
Peshawar,
 Definition of Health

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

Second definition ofHealth Potter & Perry (2014)

ĚĞĨŝŶĞŚĞĂůƚŚĂƐĂ͞ĚLJŶ
individual adapts to changes in internal and external
environments to maintain a state of well
-ďĞŝŶŐ͘͟

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 Wellness

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

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Dimensions of Wellness

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 Dimensions of Wellness

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

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 Dimensions of Wellness

Social Potential:
ďůĞƚŽŝŶƚĞƌĂĐƚƐƵĐĐĞƐƐĨ
environment, to develop and maintain intimacy with
others, to develop respect and tolerance about
different opinions and believes.

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 Dimensions of Wellness

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

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

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 Dimensions of Wellness

Environmental Potential:
Ability to promote health measures to enhance
standard of living and quality of life in community
Spiritual potential:
Belief in some forces or higher power, meaning and
purpose of life (morals, values, ethics)

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 Dimensions of Wellness

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

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 Concepts of illness and disease

Disease
Disease can be described as an alteration in body functions
resulting in a reduction of capacities or shortening of the
normal lifespan. OR
A diseaseis a pathological condition that impairs normal body structure and
functions. ...Illnessis a broad term that is used to describe a person who is in a
poor state ofhealth. Illnessis not always due todisease.
Illness: the unique response of a person to a disease
It is an abnormal, highly personal and subjective feeling in which
ŝŶĚŝǀŝĚƵĂů͛ƐƉŚLJƐŝĐĂů͕ĞŵŽƚŝ
developmental or spiritual functioning is thought to be
diminished or impaired

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 Illness

ͻ͞/ůůŶĞƐƐŝƐĂĐŽŶĚŝƚŝŽŶ
from a normal health state which is manifested by
ƉŚLJƐŝĐĂůΘƉƐLJĐŚŽůŽŐŝĐĂů ʹKozier.

ͻ͞/ůůŶĞƐƐŝƐĂƐƚĂƚĞŝŶ
intellectual, emotional, social or spiritual functioning
is diminished or impaired in comparison with the
ƉƌĞǀŝŽƵƐĞdžƉĞƌŝĞŶĐĞ͘͟
Potter & Perry.

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 Variables Affecting Illness Behaviour

1. Internal Variables.
2. External Variables.

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 Variables Affecting Illness Behaviour

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

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 Variables Affecting Illness Behaviour

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

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 Types of Illnesses
Acute Illness:Generally has a rapid onset of symptoms and
lasts only for a relatively short time
Examples: Appendicitis, Pneumonia, Diarrhea, Common Cold

Chronic Illness:A broad term that encompasses many

.
different physical and mental alterations
‡ It is a permanent change
‡ It causes/is caused by irreversible alterations in normal A & P
‡ It requires special patient education for rehabilitation
‡ It requires a long period of care or support

Examples: Diabetes Mellitus, COPD, Arthritis, CRF etc

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 Types of Illnesses

Acute illness
ʹShortduration
ʹMostly severe
ʹStarts abruptly and subsides in relatively short period (less
than 6 months)
Chronicillness
ʹPersist for more than six months
ʹMay affect functioning of body in any dimension
ʹUp to the level ofdisability
ʹMajor health problem
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 Illness Behaviour

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

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 Stages of Illness Behavior

Edward suchman (1972)

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

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 Stages of Illness Behavior

STAGE ʹ I SYMPTOM EXPERIENCE (manifestation /Signs)

‡In the first stage, person feels that something is
wrong but he is not able to diagnose the problem.
‡Perception of symptoms includes awareness of
physical change like pain, rashes, lump. At the end o
this stage , he is able to make the decision that it is a
symptom of an illness.
‡Awareness of physical changes.
‡Pain, rashes and lump etc

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 Stages of Illness Behavior
STAGE II
ʹ ASSUMPTION OF SICK ROLE
(Disruption of normal social roles, rights, obligation)
If the symptoms persist, then the client will assume sick role &
seek confirmation from family & others that they are indeed
sick. Then he gets excuse from normal duties & role
expectations.
Assumption of sick role results in emotional changes such as
withdrawal, depression, physical changes. The person may
deny & delay the contact with health care system.
‡ Accept sick role and seek confirmation
‡ Self treatment
‡ Excuses
‡ Emotional responses
‡ Illness persist seek professional help

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 Stages of Illness Behavior

STAGE III
ʹ MEDICAL CARE CONTACT
At this stage, the client acknowledges the illness & seeks
ĞdžƉůĂŶĂƚŝŽŶŽĨĐĂƵƐĞƐ͕ĚƵƌ
complications. Health professional may determine
whether the client is ill or not.
After knowing about illness some client seek medical
treatment , but sometimes, they start denying the
symptoms.
‡ Seek professional advice
‡ Accept or deny diagnosis
‡ Follow the treatment plan

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 Stages of Illness Behavior

STAGE IV
ʹDEPENDENT STAGE
(Increased attention and escape for work responsibilities)
After accepting the diagnosis, client becomes
dependent upon health care professionals to get
treatment.
Here, the client accepts the care, sympathy, protection
from the demands & stress of life.
‡ Dependent for professional help.
‡ Accept their dependence on the primary care provider.

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 Stages of Illness Behavior

STAGE V
ʹRECOVERY & REHABILITATION
(Varies depending on the type of illness)
This is the stage when the symptoms of illness get
subsiding. The person starts regaining original health
status.
In case of chronic illness, final stage involves an adjustmen
to a prolonged reduction in health & functioning.
Relinquish the dependent role
Resume former roles and responsibilities.
Acute illness (short term)
ʹrecovery fast
Chronic illness (Long term)ʹrecovery
s difficult

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 Emotional Responses To Illness

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

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 Impact Of Illness
1.Impact of illness on client.
2.Impact of illness on client & family.

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 Support During Illness

‡Family Support

‡Health Care Givers Support

‡Complementary and Alternative Medicine

‡Faith Healing

‡Homeopathy

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 Models of Health and Illness

‡The Agent-Host-Environment Model

‡The Healthʹ
Illness Continuum

‡The High-Level Wellness Model

‡The HealthBelief model

‡The Health Promotion Model

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 The Agent-Host-Environment Model

Agent-Host-Environment Model (Leavell and Clark)

Agent: Agent is environmental factor or stressor,

bacteria, virus, chemical substance
Host: Host is living organism cable of being affected
by the agent
Environment:Environment is factors that are
external to host that make illness more likely i.e:
Lack of Sleep. Cold Temperature

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 The Healthʹ
Illness Continuum

The Healthʹ
Illness Continuum

DĞĂƐƵƌĞƐĂƉĞƌƐŽŶ͛ƐůĞǀĞů
Views health as a constantly changing state with -high
level wellness and death on opposite sides of a
continuum
Illustrates the dynamic (ever
-changing) state of health

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 The High-Level Wellness Model (Dunn)
‡ Encourages the nurse to care for the total person
‡ /ŶǀŽůǀĞƐĨƵŶĐƚŝŽŶŝŶŐƚŽŽŶĞ͛Ɛ
maintaining balance and a purposeful direction
‡ Regards wellness as an active state, oriented toward maximizing
the potential of the individual, regardless of his or her state of
health
‡ Incorporates the processes of being, belonging, becoming, and
befitting

ĐƚŝǀĞ^ƚĂƚĞ͗DŽƌĞƚŚĂŶŐŽŽĚ
potential. More total person focus encompasses all of the
dimensions Being: Recognizing self as separate and individual
Belonging: Being part of a whole becoming: Growing and
Developing Befitting: Making personal choices to befit the self of
the future

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 The High-Level Wellness Model (Dunn)

Dunn(1959) described a health grid in which a health

axis and an environmental axis intersect.The Health
axis extends from peak wellness to death, & the
environmental axis extends from very favourable to
very unfavourable.The intersection of two axis forms
four quadrants of health and wellness;
1:High level wellness in a favourable environment
2:Emergent high level wellness in an unfavorable environment
3:Protected Poor Health in a favorable environment
4:Poor health in an unfavorable environment

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 The Health Belief Model (Rosenstock)
‡ Concerned with what people perceive to be true about
themselves in relation to their health

‡ Modifying factors for health include demographic,

sociopsychological, and structural variables

‡ Based on three components of individual perceptions of

threat of a disease
±Perceived susceptibility to a disease
±Perceived seriousness of a disease
±Perceived benefits of action

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 Health Promotion Model (Pender)

/ůůƵƐƚƌĂƚĞƐƚŚĞ͞ŵƵůƚŝĚŝŵĞŶƐ
ǁŝƚŚƚŚĞŝƌĞŶǀŝƌŽŶŵĞŶƚĂƐƚŚ
Incorporates individual characteristics and experiences and
behavior-specific knowledge and beliefs, to motivate health
-
promoting behavior
Personal, biologic, psychological, and sociocultural factors are
predicative of a certain health
-related habit

Health-related behavior is the outcome of the model and is

directed toward attaining positive health outcomes and
experiences throughout the lifespan

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 Health Promotion Model (Pender)

Example: Used to predict how a person is likely to

incorporate health promotion behaviors into their
lifestyle.
Smoking: If parents smoke children more likely to
smoke
Primary preventionͶe.g., Diet, Exercise

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 Level of prevention

‡Primary prevention
Ͷe.g., Diet, Exercise,
Immunizations

‡Secondary prevention
Ͷe.g., Screenings,
Mammograms, Family Counseling

‡Tertiary preventionͶe.g., Medications, Surgical

Treatment, Rehabilitation

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 References
‡<ŽnjŝĞƌΘƌď͛Ɛ&ƵŶĚĂŵĞŶƚ th

edition.
‡DŝĐŚĂĞůĞƚƚŵĂŶ&Z^
‡dŚŽŵĂƐ&ƵůůĞƌWŚͬ͘DWZ
1955.
‡John Jackson M.D nursing research th6edition.
͞ŽĨ
Manual

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Concept of Sexuality

By: Zafar Iqbal/IbneAmin

KhyberMedical university
 Introduction
‡Sexuality has been a consistent focus of curiosity,
interest, and analysis to
humankind
‡Sexuality encompasses all those thoughts, feelings,
and behaviors connected with sexual gratification
and reproduction, including the attraction of one
person toanother.
‡It is a key factor in our principal relationships and the
formation of ourfamilies.
‡It is also a common source of problems.
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 Objectives
At the end of this unit, learners will be able to:
‡Reviewthe Anatomy and physiology of the male and
female reproductive system
‡Describenormal sexual pattern
‡Relatesexuality to all stages of life cycle
‡Identify factors that effects sexual functioning
‡Describecommon risks and alteration in sexuality
‡Understandthe nursing process as it relate to sexual
functioning
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 Male Reproductive System
Male reproductive system consist
of:
‡ External organs & Internal
organs

ͻAn adult male manufactures over

100 million sperm cells each
day.

ͻTestosterone, is a hormone that is

responsible for the development of
the secondary sex characteristics.
of men such as the beard, deep
voice, and masculine body shape.
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 Female Reproductive System
Female reproductive system consist
of:
‡Externalorgans& Internal organs
‡Estrogenis responsible for the
development of the secondary
sexual characteristics of a mature
woman.
‡Estrogencontinues to be
secreted throughout the
reproductive age of the female,
regulatesmenstrual period in
female, eggs production occur
prior to birth.
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 Why to Study
‡Reason for studying human sexuality is that we may
face various personal and social problems involving
sexuality, such as, sexually transmitted diseases,
unwanted pregnancies, and sexual harassment

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 Sexuality pattern
‡Sexualityis a state or quality of being sexual
including the collective characteristics that
distinguish male and female. Itcomprisesof:
‡ Sexual identity
‡Sex role
‡Sexualperformance and
‡Social norms.

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 Sexual orGender identity
‡Anatomicalstate of being male and female, results
from genetic and hormonal influence

‡It is sense of one's self as male or female

‡Characteristic develop 8 month to 3 years of life

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 Sex role:

‡This is expression of one's own gender through

behavior, feeling, attitude.

‡Culturally defined as feminine and masculine

role.

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 Sexual orientation:
It is a feeling of sexual
attraction towardssexual
partner
‡Heterosexual : "romantic or sexual attraction to
ƉĞƌƐŽŶƐŽĨƚŚĞŽƉƉŽƐŝƚĞ
‡Bisexual: is sexual orientation involving physical or
romantic attraction to both males and females.
‡Homosexual : an enduring pattern to experience
sexual, or romantic attractions to people of the same
sex

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

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 Sexual Reproductive pattern
‡Sexual reproduction is a union that results in
increasing genetic diversity of the
offspring.

‡Reproduction is only one component of sexuality

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 Normal Sexual pattern

Four stages of sexual responsiveness

resolution excitement

Orgasm platuae

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 Normal Sexual pattern
‡ Excitement Phase : is the first stage of the human sexual
response cycle. It occurs as the result of any physical or
mental stimulation that leads to sexual arousal
‡ PlatuaePhase: is the period of sexual excitement prior to
orgasm.
‡ Orgasm Phase : is the conclusion of the plateau phase of the
sexual response cycle. It is accompanied by quick cycles of
muscle contraction in the lower pelvic muscles, which
surround both the anus and the primary sexual organs.
Resolution Phase : occurs after orgasm and allows the muscles
to relax, blood pressure to drop and the body to slow down
from its excited state.
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 Abnormal Sexuality
‡ Sexual behavior that is destructive to oneself or others, that is
markedly constricted, that cannot be directed toward a
partner, that excludes stimulation of the primary sex organs,
and that is inappropriately associated with guilt or anxiety.

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

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 Sexuality to all stages of life cycle
‡ Adolescenceis a phase of transition during which major
developments of sexuality takes place. Puberty is reached
during adolescence, which is a major landmark in the
development of sexuality.
‡ Adolescent sexuality development can be better explained
with the bio-psycho-social model.
‡ Biological factors, psychological factors, as well as social
factors have equal importance in determining, the
development of sexuality in adolescents
‡ Other than the biological, psychological, and social factors,
many more factors such as political, legal, philosophical,
spiritual, ethical, and moral values significantly influence the
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 Sexuality to all stages of life cycle
‡ Sigmund Freud had proposed his theory of psychosexual
development, where he described about ʹoral phase, anal
phase, phallic phase, latency phase, and genital phase as the
landmark steps of psycho-sexualdevelopment.
‡ Duringthese phases, different body parts behave as most
erotogenic and the individual attempts to explore or stimulate
these erotogenic zones in order to get
gratification
‡ He emphasized that a child's personality is formed by the
ways which his parents managed his sexual and aggressive
drives.

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 &ƌĞƵĚ͛ƐWƐLJĐŚŽƐ
Stage: Focus:
Oral (0
-18 months) Pleasure centers on the mouth
-sucking,
chewing, biting
Pleasure focuses on bowel and bladder
Anal (18
-36 months)
elimination; coping with demands for
control
Phallic (3
-6 years)
Pleasure zone is the genitals; coping with
incestuous sexual feelings
Latency (6 to puberty) Dormant sexual feeling

Genital (puberty on) Maturation of sexual interest.

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 Sexuality to all stages of life cycle
‡ Sexuality is a normative and physiological component of adolescent
development and usually this group engage in risky sexual practices such
as early sexual intercourse, multiple sexual partners, unprotected sexual
intercourse, and casual sex
‡ Adulthood, is a time of exploration, experimentation, and instability in
many areas of life, particularly in relation to sexual
behavior.
‡ Adolescentsand youth are one of the populations most impacted by
sexually transmitted infections (STIs), including human immunodeficiency
virus (HIV) and papillomavirus (HPV)
‡ Sociocultural differences are determinant of sexual behaviors, influencing
the age of first intercourse, number of partners, coercive sexual culture
and it can affect the probability of being engaged in risky sex

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 Sexuality to all stages of life cycle
‡ Sexuality in older ageconcerns thesexual drive,sexual activity, interests,
orientation, intimacy, self-esteem, behaviors,and the social perceptions
concerning sexuality in older age.
‡ Older people engage in a variety of sexual acts from time to time for a
variety of reasons.
‡ Desirefor intimacy does not disappear with age, yet there are many
restrictions placed on the elderly preventing sexual expressions and
discouraging the fulfillment of sexual needs
.
‡ Sexuality in older age is often considered taboo
a yet it is considered to be
quite a healthy practice; however, this stigma can affect how older
individuals experience their sexuality.
‡ While the human bodyhas some limits on the maximum age
for reproduction,sexual activity can be performed or experienced well
into the later years of life
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 Factors AffectingSexuality
‡ Quality ofrelationship
‡ Cognitionand perception
‡ Culture, value and believe
‡ Self concept
‡ Previousexperience
‡ Environment
‡ Pregnancy
‡ Illness and diseases
‡ life circumstances
‡ Personality traits
‡ Biologicalmakeup
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 Risks and Alteration in Sexuality

‡General health status (Chronic diseases)

‡Sexual abuse

‡Sexual dysfunction

‡Impotence and ejaculatory dysfunction

‡Dyspareunia

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

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

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 Nursing CareProcess
Nursing Diagnosis
‡Ineffectivesexuality pattern.

‡Sexual dysfunction

‡Rape trauma syndrome

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 Nursing CareProcess
Nursing Diagnosis
‡Ineffectivesexuality pattern.

‡Sexual dysfunction

‡Rape trauma syndrome

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 Nursing CareProcess
Goal:

‡The person will resume previous sexual activity

‡The person will have alternative sexual activity

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 Nursing CareProcess
Nursing Interventions :

‡Establishtrusting relationship
‡Maintain privacy
‡Activelistening
‡Clarifythe patient that sexuality does not mean only
intercourse
‡Discussalternative methods

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 References
‡ Craven, R. F., & Hirnle, C. J. (2006).
Fundamentals of nursing: Human
health and function
. (5th.ed.)p.1176-1262 New York: Lippincott.

‡ Cox, H. C. et. al.(2002).

Clinical application of nursing diagnosis.
Philadelphia: Lippincott

‡ Estes,M. E. Z. (2000) nd ed.).

Health assessment & Physical examination (2
Delmar.

‡ Katz, A. (2000). Birds do it, Bees do it, Lets talk about

AWHONN
it. lifelines,
4(5) 40-41

‡ Harkreader, H. & Hogan, M. A. (2004)Fundamental of nursing

: caring and
clinical Judgment(2nd ed.). Sunders

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Loss, Death, and Grieving

By : Ibne Amin
Lecturer , INS
Khyber Medical University,Peshawar
 Objectives

1. Assess the physiologic signs of death.

2. Identify beliefs and attitude about death in relation to age.
3. Discuss the various ways of helping the dying patient meet
his/her physiological, spiritual and emotional needs.
4. Discuss care of the body after death.
5. Discuss the legal implications of death.
ϲ͘ĞƐĐƌŝďĞŚŽǁĂŶƵƌƐĞŵĞ
comfort.
7. Discuss important factors in caring for the body after death.
8. List changes that occur in the body after death.

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 Objectives

9. Define terms related to loss and grieving.

10. Discuss Kubler
-ZŽƐƐ͛ƚŚĞŽƌLJƚŽĂƐƐ
behaviors.
11. Identify common manifestations of grief
12. Discuss the effects of multiple losses on the grief
process
13. Apply the nursing process to grieving clients.

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 Introduction

Birth and death are two aspects of life, which will happen
to everyone.

Dying and death are painful and personal experiences fo

those that are dying and their loved ones caring for
them.

Death affects each person involved in multiple ways,

including physically, psychologically, emotionally,
spiritually, and financially.

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 Definition

ĞĂƚŚŝƐĚĞĨŝŶĞĚĂƐ͞dŚĞŝƌƌĞ
functions especially as indicated by permanent stoppage of
ƚŚĞŚĞĂƌƚ͕ƌĞƐƉŝƌĂƚŝŽŶ͕ĂŶĚ

Death is the cessation or permanent termination of all the

biological functions that sustain a living organism.

LJŝŶŐŵĞĂŶƐ͞ĂƉƉƌŽĂĐŚŝŶŐĚĞĂƚ

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 Physiologic signs of death

The four main characteristic changes are ;

‡ Loss of muscle tone
‡ Slowing of the circulation
‡ Changes in the vital signs
‡ Sensory impairment.
The following guidelines for physicians as indications of death.
1. Total lack of response to external stimuli
2. No musscular movement(esp breathing)
3. No reflexes
4. Flat encephalogram.

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 Beliefs and attitudes about death in
relation to age relation to age
‡Infancy to 5 years;Does not understand concept of
death,belives death is reversible, temporary departure or
sleep.
‡5 to 9 years;Understand death is final, believes own
death can be avoided, believes wishes and unrelelated
actions can be responsible for death.
‡9 to 12 years;Begin to understand own mortality,
expressed in after life and fear of death.

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 ŽŶƚŝ͙͘

‡ 12 to 18 years;May still hold concept from previous

ĚĞǀĞůŽƉŵĞŶƚĂůƐƚĂŐĞƐ͕ŵĂLJƐĞ
of death but be emotionally unable to accept it.
‡ 18 to 45 years
; Has attitude towards death influenced by
religious and cultural beliefs.
‡ 45 to 65 years;Accepts own mortality. encounters death of
parents and some peers experiences.
‡ 65 years +;Fears prolonged illness, sees death as having
multiple meanings,(eg,freedom from pain, reunion with
already deceased family

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 Dying Patients
We may help the dying patient meet his/her

‡Physiological Needs
‡Spiritual Needs
‡Emotional Needs

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 Meeting physiologic needs of the dying
patient.
‡Providing personal hygiene measures
‡Controlling pain
‡Relieving respiratory difficulties
‡Assisting with movement,nutrition,hydration and
elimination.
‡Providing comfort to the patient and relieving pain.

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 Spiritual support

‡Identify patient spiritual needs

‡Respect the beliefs of patients
‡Be willing to listen and discuss issues of spirituality.
‡Demonstrate empathy
‡Provide a supportive presence
‡Refer to community resources or spiritual leaders
‡Acknowledge and provide for the rituals

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 Emotional support

‡Compassion (desire to help)

‡Responsiveness to emotional needs
‡Maintain a positive attitude
‡Expressing empathy
‡Attending wishes
‡Being present.

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 Physical Changes After Death

±Pupils- Fixed and dilated

±Algor Mortis- Rapid cooling of the body
±Rigor Mortis- Stiffening of the body, develops-42
hours after death
±Livor Mortis- Purple discoloration of skin in
dependent areas

Educational Platform
 Care After Death

‡ Death declaration/ Death certificate by physician.

‡ Autopsy(written permission)
‡ Customs & principles are kept in mind.
‡ Positioning- body straitened & arms laid at the side.
‡ Eyes are closed as in sleep.
‡ Dentures are removed & prop chin in position with
bandaging.
‡ Remove all appliances used for patient care(-e.gcatheter
tubing's etc..)

Educational Platform
 Care After Death
‡ Remove all the appliances used for patient care. (e.g. Catheter,
tubing's, I,V.sets, etc)
‡ Remove ornaments and list them to relatives.
‡ All orifices are to be plugged with cotton to prevent escape of body
discharges.
‡ Prevention of spread of diseases (i.e sealing body)
‡ Send body clean and neatly dressed.
‡ An identification tag
‡ If relatives are present then body is handed over them with proper
written legal authority permission.
‡ Maintain record of death and inform to authority for register of
deaths. for body.

Educational Platform
 Legal aspects of death

Federal and state law require that institutions develop policies

and procedures for certain events that occur after death.

1.Requesting organ or tissue donation

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

Educational Platform
 Legal aspects of death
Death must be certified by a physician
In unusual death,an autopsy(postmortem examination)may be
required.
Request family member consent and signature for autopsy.
Several reasons for a death becoming a case for the coroner:
±ĞĂƚŚďLJƐƵƐƉŝĐŝŽƵƐŵĞĂŶƐ
±Death resulting from an accident
±Client has been hospitalized for less than 24 hours
‡ LJŝŶŐWĞƌƐŽŶƐ͛ŝůůŽĨZŝŐŚƚƐ
‡ Passive euthanasia
‡ California Law (1976)
- ͞ZŝŐŚƚƚŽŝĞ͟ďŝůů
‡ California Natural Death Act

Educational Platform
 Loss

Loss occurs when a valued person, object, or situation is

changed.
OR
Loss can be defined as the undesired change or removal o
a valued object ,person or situation

Loss is a universal experience that occurs throughout the

lifespan.

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 Types of loss

1. Actual Losscan be recognized by others including

the person sustaining the loss, ex: a person losing a
limb, spouse, valued object, job etc.
2.Perceived lossfelt by the person but is intangible to
others loss of your youth, financial dependence, loss
of confidence or prestige.
3. Anticipated lossthe person displays loss and grief
behaviors for loss that has yet to take place. EX:
families with terminally ill patients and serves to
lessen the impact of actual loss
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 Grief

Grief is an emotional response to a loss.

Grief is a form of sorrow involving feelings, thoughts and
behaviors caused by bereavement.
Grief is the physical ,psychological and spiritual responses to
loss.
'ƌŝĞĨŝƐĂ͞ƐĞƚŽĨĐŽŐŶŝƚŝǀĞ͕
follow the death of a loved one.
The grief process involves a sequence of affective, cognitive and
psychological states as a person responds to and finally accepts a
loss.
It is a normal, natural, necessary, and adaptive response to a loss.

Educational Platform
 Loss & Grieving

‡ LOSS Something of value is gone

‡GRIEF Total response to emotional experience
related to loss
‡BEREAVEMENTSubjective response to by lovedones
‡MOURNING Behavioral response

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 Functions of Grief

‡To make the outer reality of the loss in to an internally

accepted reality
‡To lessen the emotional attachment to the lost person or
object
‡To make it possible for the bereaved person to become
attached to other people or objects

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 Types Of Grief

1. ANTICIPATORY GRIEF
2. NORMAL OR COMMON GRIEF
3. COMPLICATED GRIEF
4. DISENFRANCHISED GRIEF

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 Common Grief Reactions

A grief reaction is a set of psychological and somatic (body)

symptoms that results from extreme sorrow or loss.
These reactions fall into four different categories:
I. Thought Patterns
II. Physical Sensations
III. Emotions
IV. Behaviours.

Educational Platform
Common Clinical Manifestion of Grief
‡Shock and disbelief
‡Sadness
‡Guilt
‡Anger
‡Fear
‡Disorganised behavior
‡Physical symptom
‡Anorexia , GI issues, SOB etc.

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 Stages Of Grief
Kubler-Ross, in extensive research with terminally ill patients,
identified five stages of feelings and behaviours that
individuals experience in response to a real, perceived or
anticipated loss.

‡ Kubler-Ross Stages of Grieving (1969)

±Denial
±Anger
±Bargaining
±Depression
±Acceptance

Educational Platform
 Kubler-Ross Stages of Grieving

1. Denial and Isolation

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

Educational Platform
 Kubler-Ross Stages of Grieving

2.Anger
‡Anger can manifest in different ways. People dealing
with emotional upset can be angry with themselves,
and/or with others, especially those close to them.
͞tŚLJŵĞ͍͟ĂŶĚ/ƚ͛ƐŶŽƚĨ
expressed during anger stage

Educational Platform
 Kubler-Ross Stages of Grieving

3. Bargaining
Traditionally the bargaining stage for people facing
death can involve attempting to bargain with
whatever God the person believes in. For example
"Can we still be friends?.." when facing a break
-up.
Bargaining rarely provides a sustainable solution,
especially if it's a matter of life or death.

Educational Platform
 Kubler-Ross Stages of Grieving

4. Depression
‡During this stage, the full impact of the loss is
experienced. The sense of loss is intense and feeling
of sadness and depression prevail. This is a time of
quiet desperation and disengagement from all
association with the lost entity.

Educational Platform
 Kubler-Ross Stages of Grieving

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

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 Nursing Implications

‡Nursing care involves providing comfort ,maintaining

safety ,addressing physical and emotional needs
,and teaching coping strategies to terminally ill
patients and their families .
‡More than ever ,the nurse must explain what is
happening to the patient and the family and be a
confident who listens to them talk about dying.

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 Nursing Implications

‡Hospice care , attention to family and individual

psychosocial issues ,and symptom and pain
management are all part of the nurse's
responsibilities.
‡The nurse must also be concerned with ethical
considerations and quality
-of-life issues that affect
dying people

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 Nursing Implications

‡Of utmost importance to the patient is assistance

with the transition from living to dying,
maintaining and sustaining relationships, finishing
well with the family, and accomplishing what
needs to be said and done.
‡In the hospital, in long
-term care facilities, and in
home settings, the nurse explores choices and
end-of-life decisions with the patient and family.

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 Nursing Implications

‡Referrals to home care and hospice services, as well

as specific referrals appropriate for the management
of the situation, are initiated.
‡The nurse is also an advocate for the dying person
and works to uphold that person's rights. The use of
living wills and advance directives allows the patient
to exercise the right to have a"good death or to die
with dignity.

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 References

‡<ŽnjŝĞƌΘƌď͛Ɛ&ƵŶĚĂŵĞŶƚ th

edition.
‡WŽƚƚĞƌĂŶĚWĞƌƌLJ;ϮϬϬϱͿ
published by most by an imprint of Elsevier, 6th
edition. New Delhi. Page no 1068
ʹ1071
‡www.google.com

Educational Platform
Educational Platform
 Stress and coping

By: Ibne Amin/Zafar Iqbal

(INS ),Khyber Medical university
 Objectives

At the end of this unit learners will be able to:

1.Discussthe stress andcoping
2. Identifydifferent stressors and different types of
stress
3. Listthe different Symptoms of Stress.
4. Identifydifferent techniques of stress management.
 Stress
Stress is a person response to stressor such as an
environmental condition or a stimulus.
OR
Mind and body response or reaction to a real or
imagined threat, event or change.
OR
Stress is condition in which the person experience
changes in the normal balance state.
 Stress
¾Stressor-----as any event or stimulus that cause the
individual to experience stress.
¾Coping strategies , coping response, coping
mechanism-----person response to stress
 Stress
Stress can result from both positive and negative
experiences........
Examples ;
‡ A bride preparing for her wedding
‡A graduate preparing to start new job
‡A husband concern about caring of his wife and
family
‡Diagnosis of cancer
‡Lossing of special object ,person or any other
things all experiences stress reactions.
 Stress Coping

"The cognitive and behavioral efforts to manage

specific internal demandsinfection
( ,feeling of
depression)or external demandsmove ( to another city
,death in family )that are appraised as exceeding the
resources of a person".
Folkman and Lazarus(1991)

OR
When a person faces stressors ,then the responses
of the person are reffered as coping strategies
,coping responses or coping mechanisms.
 Indicators of stress
1. Physiological indicators
2. Psychological indicators
 Stress indicators
1. Physiological indicators
‡The physiological sign & symptoms of stress
result from the activation of sympathetic and
neuroendocrine systems of the body
‡Clinical manifestations lists physiological
indicators of stress
 Clinical Manifestation Of Stress
‡Pupils dilates
‡Sweat production
‡Heart rate increase
‡Cardiac output increase
‡Skin is pailedbecause
( of constriction of peripheral blood vessels)

‡Sodium and water retention increase which

increase blood volume
 Clinical Manifestation Of
Stress/Physiological indicators
‡Rate and depth of respiration increase
(because of dilation of bronchioles)
‡Urinary output decrease
‡Mouth may be dry
‡Paristalsis of intestine decrease
‡Muscles tension increase
 Psychological Indicators
‡Anxiety
‡ Fear
‡Anger
‡Depression
‡Uncounsious Ego Mechanism
 Psychological Indicators
1. Anxiety: Common reaction to stress
‡A state of mental uneasiness ,apprehension, or a
feeling of helplessness related to an impending or
anticipated unidentified threat to self or significant
relationships.
Four levels of anxiety
± Mild Anxiety
± Moderate Anxiety
± Severe Anxiety
± Panic
 Psychological Indicators
2. FEAR
An emotion or feeling of apprehension aroused
by impending or seeming danger ,pain or
another percieved threat
 Psychological Indicators
Anxiety and Fear differ in four ways
1. The source of anxiety may not be identified
2. Anxiety is related to mainly future, to an anticipated
event ,fear is related to past ,present and future
3. Anxiety is Vague, whereas fear is definite
4. Anxiety results from psychological or emotional
conflicts ,fear results from a specific physical or
psychological entity.
 Psychological Indicators
3.Anger
An emotional state consisting of a subjective
feeling of animosity or strong displeasure
 Psychological Indicators
4. Depression
‡A common reaction to events that seem
overwhelming or negative
‡An extreme feeling of saidness ,dispair ,dejection
,lack of worth ,or emptiness
 Psychological Indicators
5. Unconscious Ego Mechanisms
Unconscious psychological adaptive mechanism
or mental mechanisms that develop as the
personality attempts to defend itself ,establish
compromises among conflicting impulses and
calm inner tentions
 Coping Pattern
‡The cognitive and behavioral efforts to
manage specific external or internal demands
that are appraised as exceeding the resources
of the person
OR
‡A natural or learned way of responding to a
changing environment or specific problem or
situation
 Types of coping
1. Problem- focused coping
2. Emotion-Focused coping
3. Long term coping strategies
4. Short term coping strategies
5. Adoptive coping
6. Maladaptive coping
7. Care-giver burden
 Types of coping
1. Problem- focused coping
Refers to efforts to improve a situation by making
changes or talking actions(Lozarus 2006)

2. Emotion-focused coping
‡Include thoughts and actions that relieve
emotional destress
‡Doesn't improve the situation but the person
often feels better (Lozarus 2006)
 Types of coping
3. Long term coping strategies
‡Can be constructive and practical
‡In certain situations talking with others and trying to
find out more about the situation are long term
strategies
‡Other long term Coping strategies include
‡Lifestyle pattern
e.g. Eating a healthy diet
Exersicing regularly
Decision making
 Types of coping
4. Short term coping strategies
‡Can reduce stress to a tolerable limit temporarily
but are ineffective ways to permennently deal
with reality.
‡These may even have destructive or detrimental
effect on the person
‡Examples;
‡Using Alcohol
‡Using drugs
 Types of coping
5. Adaptive coping
‡Helps the person to deal effectively with stressful
events and minimizes distress associated with them
‡Effective coping result in adaptations
6. Maladaptive coping
‡Can cause unnessasary distress for the person and
others associated with the person or stressfull events
‡Ineffective coping result In maladaptation
 Types of coping
7. care giver Burden
‡Reaction to a long term stress is seen in family
members who undertake the Care of a person in the
home for long time period
‡Produces responses such as chronic fatigue , sleepin
difficulties and high blood pressure
 Factors affecting copping pattern
during hospitalization
‡Many factors can affect the copping pattern of
patient,family members and nurses in
hospital.
‡Following are the main factors which affect
the copping pattern during hospitalization.
 ŽŶƚŝ͙
Anxiety:Anxiety is an emotion characterized by feelings of
tension, worried thoughts and physical changes like increased
blood pressure.
Anxiety in hospital:Depression and anxiety arecommon in
hospitalizedpatients especially those waiting for surgery
and
with chronic or hard-to-treat conditions. Psychological
disorders are not only related to a poor adjustment to
hospitalization distress,
but is associated with adverse events
and unsatisfactory outcomes.
‡Hospitalization exacerbates patients' emotions, and
increases feelings of depression and anxiety.
‡By this way copping is affected by admitted into hospital.
 Conti ..
‡Fear:More prosaic issues might result in the fear of
hospitals, such as smells,
sick roommates, and a
complete lack of privacy. Media reports surrounding
medical mishaps often result in fear among patients.
‡The fear from doctor or nurse during the
intervention steps by applying nursing processs
affect the copping
 ŽŶƚŝ͙
‡ Example of fear.The most common examples of fear
a nurseencounter are patient in the community, a patient
may also have fear during diagnostic testing in an outpatient
ƐĞƚƚŝŶŐ͕ŽƌĚƵƌŝŶŐŚŽƐƉŝƚĂůŝ
when patients are experiencing fear and must find ways to
help them in a respectful way to face these feelings. The
nurse must also learn to distinguish when fear becomes
ƉĞƌƐŝƐƚĞŶƚĂŶĚƉĞƌǀĂƐŝǀĞƚŚĂ
to perform his or her activities of daily living. Referral to a
reliable support system and programs increase the chances o
successfully managing, treating, and overcoming phobias and
other fears.
 ŽŶƚŝ͙
‡Possibility of fear for nurse: the possibility of harming
SDWLHQWLVWKHLUELJJHVW
‡For family:
Family member of the patient are also at fear
there may be chance of paralysis or even death may
patient .
 ŽŶƚŝ͙
Sleep:Unfortunately, the hospital environment often
is
poorly conducive to sleep .
Pain, anxiety, medication effects, medical
interventions, environmental noise and light, and the
acute illness itself all contribute to decreased quality
and quantity of sleep in hospitalized patients.then
the patient cannot mannage such stress .
‡ Sleep loss in the hospital is associated with worse health outcomes
including cardio
-metabolic derangements and increased risk of
delirium
 Conti.
‡Isolation from parents: to separate the child frome parents
and admitted them into hospital it will affected the copping
of the childs mostly .it this stages child are totally
dependent to their parents .
‡Change in nutrition
‡The following factors can also contribute to malnutrition:
‡teeth that are in poor condition, or dentures that do not fit
properly, which can make eating difficult or painful.
‡a physical disability or other impairment that makes it
difficult to move around, cook or shop for food.
‡living alone and being
‡These all are including in changing the copping of clints.
 ŽŶƚŝ͙
‡Economic:the lower economy level and poverty can affect
copping of patient and their familysome
. time when
patient require surgery of heart and other serious surgery
but they cannot afford and sustain their cost that s way the
copping pattern is affected .
‡Social culturethe
: Clint of various culture are admitted into
hospital .
‡They affect decisions about a patient's treatment and who
makes the decisions. Cultural differences
create problems
in communication, rapport, physical examination and
treatment compliance and follow through. The special
meaning of medicines and diet requires particular
attention.
 Nursing Management of stress
Assessing
Nursing assessment of clients stress and coping
pattern includes;Nursing History & Physical
Examination. During Nursing History the nurse
have to poses questions ,,i.e Client perceived
stressors or stressful incidents
Manifestations of stress
Past coping strategies
Present coping strategies
 Nursing Management of stress
During physical examination the Nurse observe; for
‡Verbal and cognitive manifestations
‡Indicators of stress such as,Nail
biting,Nervousness,Weight changes
‡Stress related health problems such as,
Hypertension
Hyperthyroidism
Dyspnea
 Nursing Management of stress
2.Nursing diagnosis
‡Anxiety related to unconscious conflict's about
essential goals and values of life , threat to self
concept , positive or negative self talk ,or
physiological factors (E.g hyperthyroidism
,dysrhythmias ,dyspnea )
 Conti..
Planning
‡The overall clients goals for individual experiencing
stress related responses are;
‡Decrease or resolve anxiety
‡Increase abality to manage or cope with stressful
events or circumstances
‡Improve role performance
 Nursing Management of stress
Implementation
‡Although stress is a part of daily life ,it is also
highly individualize
‡Some methods help to reduce stress will be
effective for one person
‡Other methods are appropriate for a different
person
‡A Nurse who is sensitive to clients needs and
reactions can choose those methods of
interventions that will be most effective for each
individuals
 Nursing Management of stress
‡Several health promotion strategies are often
appropriate as interventions for clients with stress
related Nursing daignosis
‡Among these are;
‡Physical exercise (relief mention,feeling of well being
relaxation)
 Nursing Management of stress
Optimal Nutrition (balanced diet)
‡Adequate rest and sleep (sleep restore bodies energ
levels and is essential aspect of stress management
‡Time management (people who manage their time
effectively usually experience less stress because
they feel more in control of their circumstances)
 Nursing Management of stress
Evaluation
‡How does the cleint perceive the problems?
‡Is there an underlying problem not identified?
‡Have new stressors occur that interfare with
successful Coping?
‡Were existing coping strategies sufficient to meet
intended outcomes?
 Nursing Management of stress
‡How does the client perceive the effctiveness of new
coping strategies?
‡Did the client implement new coping strategies
properly?
‡Did the client access and use available resources?
‡Have family members and significant others provided
effective support?
 Stress Management for Nurses
‡Nurses like client's are susceptible to experiencing
anxiety and stress
‡Nursing practice involves many stressors I.e;
‡Increasing severity of client illness
‡Adjusting to various work shifts
‡Inadequate support from supervisors
‡Caring for dying client etc
Although most Nurses cope effectively with physical and
emotional demands of nursing But some Nurses
become overwhelmed and develop Burnout
 Stress Management for Nurses
BURNOUT
‡A complex syndrome of behavior
‡The Nurses with Burnout manifests physical and
emotional depletion
‡A negative attitude and self concept
‡Feeling of helplessness and hopelessness
 Stress Management for Nurses
STEPS TO REDUCE STRESS FOR NURSES
Plan daily relaxation programs to reduce tention ( novels
I.e read
,listen to music or other favorite activities)
Establish regular exercise program
Learn to accept failure's
‡Seek counseling if indicated

‡Support each others as a team

‡Take time to relax

‡Eat properly
‡Lern something New
 References

‡<ŽnjŝĞƌΘƌď͛Ɛ&ƵŶĚĂŵĞŶƚ th

edition.
‡WŽƚƚĞƌĂŶĚWĞƌƌLJ;ϮϬϬϱͿ
published by most by an imprint of Elsevier, 6th
edition. New Delhi. Page no 1068
ʹ1071
‡www.google.com
 Parentral Medication

By : Ibne Amin
Lecturer INS
Khyber Medical University,Peshawar
 Parentral Medication

Para: outside enteron: intestine (i.e. beside the intestine)

These are the preparations which are given other than
oral routes.
Parenteral administration is injection or infusion by
means of a needle or catheter inserted into the body.
Parenterals are sterile solutions or suspension of drug
in aqueous or oily vehicle.
Parenteral drugs are administered directly in to the
veins, muscles or under the skin , or more specialized
tissues such as spinal cord.
 Parenteral Routes
Parenteral administration involves injecting a
medication into body tissues. The following are the
four major sites of injection:
1. Intradermal (ID): Injection into the dermis just under
the epidermis.
2. Subcutaneous (SC): Injection into tissues just below
the dermis of the skin.
3. Intramuscular (IM): Injection into a muscle.
4. Intravenous (IV): Injection into a vein.
Parenteral Routes
 Parenteral Routes
Some medications are administered into body cavities.These
additional routes include
5. Intra-arterial
6. Intracardiac
7. Intrathecal
8. Intracisternal
9. Peridural
10.Intraarticular
11.Intracerebral
12. Intrapleural
13. Intraosseous
14. Intraperitoneal
 Intradermal Injections
An intradermal (ID) injection is the administration of a drug
into the dermal layer of the skin just beneath the
epidermis. Usually only a small amount of liquid is used,
for example 0.1ml. This method of administration is
frequently used for allergy testing and tuberculosis(TB)
screening.
‡Use a tuberculin or small hypodermic syringe for skin
testing.
‡The angle of insertion for an intradermal injection is 5 to
ϭϱĚĞŐƌĞĞƐ;^LJƌŝŶŐĞŝƐƉŽƐ -ϭϱȗĂŶŐůĞ͘
‡Needle used is a short (3/8 inch) length, gauge-27G).
(25
‡Create small bubble like.
 Intradermal Injections
It is an injection given into the dermal layer(the top few layers of th
skin. ) of the skin for some purposes :
ʹLocal Anesthesia
ʹDiagnostic Tests
ʹImmunizations (BCG vaccine)

After injecting the medication, a small bleb resembling a mosquito bite

appears on the surfaceoftheskin
 Intradermal Injection Procedure
Check the 5 Right then :
1.Wash hand and Take equipment to the patient's side.
2.Explain procedure to patient.
3.Locate the site of injection, and Cleanse the skin with a spirit swab, allow
the area to dry.
ϰ͘ZĞŵŽǀĞŶĞĞĚůĞĐĂƉĂŶĚŚŽůĚƐƐLJƌŝ -ϭϱȗĂŶŐůĞĨƌŽŵ
up and Inject the solution.
5.Remove the needle quickly but gently at the same angle used for injection.
6.Wipe with dry cotton ball but do not press or massage the injection site.
7.Chart the data and time of the administration of the drug.
8.Take care of the equipment & return to their places.
 Subcutaneous Injections

The injection of the drug under the skin into the fatty layer,
but not into the muscle. Absorption of the drug is rapid.
Eg; insulin
The subcutaneous injection sites include
‡ The outer posterior aspect of the upper arms
‡ The abdomen
‡ The anterior aspects of the thighs
‡ The scapular areas of the upper back
‡ The upper ventral or dorsal gluteal areas.
 Subcutaneous Injections
Subcutaneous(SC; SQ ;Sub Q):
‡The injection is given under the skin
‡Need to be isotonic
‡Upto 2 ml is given
‡Using ½ to 1 inch 23 gauge needle or smaller needle

‡Given:
» Vaccines
» Insulin
» Scopolamine
» Epinephrine
 Subcutaneous Injections

Kinds of drugs commonly administered:

1. Vaccines
2. Preoperative medications
3. Narcotics
4. Nnsulin
5. Heparin
ͻKŶůLJƐŵĂůůǀŽůƵŵĞƐ;Ϭ͘ϱƚ
given subcutaneously.
ͻdŚĞĂŶŐůĞŽĨŝŶƐĞƌƚŝŽŶĨŽ
or 45 degrees.
 Subcutaneous Injection Procedure
Check the 5 Right then : 1.Wash hand and Take equipment to the patient's
side.
2.Explain procedure to patient.
3.Locate the site of injection, and Cleanse the skin with a spirit swab, allow
the area to dry.
ϰ͘ZĞŵŽǀĞŶĞĞĚůĞĐĂƉĂŶĚŚŽůĚƐƐLJƌŝ
5.Draw back the plunger to check you are or aren't in the blood vessel (Blood
return should not be seen) then inject the solution.
6.Remove the needle quickly but gently at the same angle used for injection
and massage the area with alcohol swab .
7.Chart the data and time of the administration of the drug.
8.Take care of the equipment & return to their places.
 Intramuscular Injection

Drugs are injected deeply into muscle tissue. If the drug is

in aqueous (water) solution, absorption is rapid.
However, if the drug is in an oily liquid or in the form of a
suspension, it can prolong the release of the drug.
It is injecting of drug into a body's system via the muscles .
Used to administer :
Some antibiotics
Vitamins or iron
Some Vaccines (DTP)
± Needle used is (1
-1.5 inch)length, gauge(19
-22G).
± Volume usually -5
2 ml are injected.
± /ŶũĞĐƚƚŚĞŶĞĞĚůĞĂƚĂŶĂŶŐůĞŽĨϵϬȗ
 Intramuscular Injection

‡Striated muscle fibre

‡0.5 to 2 ml sometimes upto 4 ml
‡1 to 1.5 inch & 19 to 22 gauge needle is used
‡Preferably isotonic
Principle sites: Given:
‡ Solutions
‡Gluteal (buttocks)(Ventrogluteal , Dorsoglutea) ‡ Emulsions
‡ Oils
‡Deltoid (upper arms) ‡ Suspension

‡Vastus lateralis (lateral thigh)

‡Rectus Femoris
Care must be taken with deep IM injections
to avoid hitting a vein, artery, or nerve
 Intramuscular Injection Procedure
Check the 5 Right then :
1.Wash hand and Take equipment to the patient's side.
2.Explain procedure to patient.
3.Locate the site of injection, and Cleanse the skin with a spirit swab, allow
the area to dry.
ϰ͘ZĞŵŽǀĞŶĞĞĚůĞĐĂƉĂŶĚŚŽůĚƐƐLJƌŝ
5.Draw back the plunger to check you are or aren't in the blood vessel (Blood
return should not be seen) then inject the solution.
6.Remove the needle quickly but gently at the same angle used for injection
and massage the area with alcohol swab.
7.Chart the data and time of the administration of the drug.
8.Take care of the equipment & return to their places.
 Intravenous Injections

‡Fast-acting route because the drug goes directly into the

bloodstream
‡Often used in the emergency department and in critical
care areas
‡Commonly used
± For fluid and electrolyte replacement
± To provide necessary nutrition to the patient who is critically ill
‡Needle used is (1
-1.5 inch)length, gauge(16
-20 G).
‡Intravenous (IV) injections are administered at an angle
ŽĨϭϱȗ-ϮϬȗ
 Intravenous Injections

For adults, the veins on the arm are:

±Basilic vein
±Median cubital vein
±Dorsal veins Given:
±Median vein Aqueous solutions
Hydro alcoholicsolutions
±Radial vein
Emulsions
±Cephalic vein Liposome
On the foot, the veins are;
±Great saphenous vein
±Dorsal plexus
 Intravenous Injection Procedure
Check the 5 Right then :
1.Wash hand and Take equipment to the patient's side.
2.Explain procedure to patient. Expose the arm and apply tourniquet
3.Ask pt. To open and close his fist.
4.Palpate the vein and clean with alcohol swab the site of the injection
ϱ͘ZĞŵŽǀĞŶĞĞĚůĞĐĂƉĂŶĚŚŽůĚƐƐLJƌŝ -ϮϬȗĂŶŐůĞ͘
6.Puncture the vein and draw back (Blood return should be seen(.
7.Once you know that you are in the vein, release the tourniquet and gently
lower the angle of the needle then inject the solution very slowly.
8.Remove the needle quickly but gently at the same angle used for injection
and apply pressure over the area to prevent bleeding..
9.Chart the data and time of the administration of the drug.
10.Take care of the equipment & return to their places
 Complications During IV Therapy

‡ Infiltration escape of fluid into subcutaneous tissue due to

dislodgement of the needle causing swelling and pain. Gross
infiltration may result in nerve compression injury which can result in permanent
loss of function of extremity or in case of irritating medications (vesicant),
significant tissue loss, permanent disfigurement or loss of function may result.
‡ Phlebitis is the inflammation of the vein. This may result
from mechanical trauma due to the insertion too big a
needle (for small vein) or leaving a device in place for a long
time. Chemical trauma result s from irritation from solutions or infusing too
rapidly. This manifests as pain or burning sensation along the vein. On observation
there may be redness, increased temperature over the course of thevein. The site
should be changed and warm compress should be applied.
 Complications During IV Therapy

ͻ
Circulatory Overload
; the intravascular fluid
compartment contains more fluid than normal. This
occurs when infusion is too rapid or excess volume is
infused. This manifests as dyspnoea, cough, frothy
sputumandgurglingsoundsonaspiration.

ͻ
Embolism;obstruction of the blood vessels by travelling
air emboli or clot of the blood. Itisfata
 General requirements of parenteral
preparations
‡Stability
‡Sterility
‡Free from Pyrogens
‡Free from foreign particles
‡Isotonicity
‡Specific gravity
‡Chemical purity
 Equipment
To administer parenteral medications, nurses
use syringes and needles to withdraw
medication from ampules and vials.
 Equipments

Needles Available in different gauges

ʹthe smaller the
number, the larger the gauge (inside diameter)
Lengthʹlong enough to penetrate the appropriate layers of
tissue
Syringes
‡Barrel
‡Plunger
‡With or without needle
‡Calibrated in milliliters or units
 Needles

A needle has three parts,the hub , the shaft & the bevel.
 Needles

Most needles are made of stainless steel, and all are

disposable.
A needle has three parts:
1.The hub, which fits onto the tip of a syringe
2. The shaft, which connects to the hub
3. The bevel, the tip of the needle

The hollow bore of the needle shaft is known as the lumen.

 Needle Size
-is Designated By Length And Gauge

Thelength of a needleis measured in inches from the

juncture of the hub and the shaft to the tip of the
point. Needle lengths range from 3/8 inch to 3 1/2
inches; some special use needles are even longer.

Thegauge of a needle, used to designate the size of

the lumen, ranges from 27 (the finest) to 13 (the
largest).
The smaller the number, the larger the gauge (inside
diameter).
 Needle Size
-is Designated By Length And Gauge

Smaller the number, the larger the Guage,the inside diameter.

 ŽŶƚŝ͙

‡The gauge varies from 18 to 30.Use longer needles

for IM injections and a shorter needle for
subcutaneous injections.
 Preventing needle stick injuries
‡One of the most potentially hazardous procedures that
health care personnel face is using and disposing of
needles and sharps.
‡ Needlestickinjuries present a major risk for infection
with hepatitis B virus, human immunodeficiency virus
(HIV), and many other pathogens.
‡Use appropriate puncture -proof disposal containers to
dispose of uncapped needles and sharps.
‡Never throw sharps in wastebaskets.
‡Never recap used needles
‡When recapping a needle, Use a one -ŚĂŶĚĞĚ͞ƐĐ
method.
 Preventing needle stick injuries

This is performed by
a) Placing the needle cap and syringe with needle
horizontally on a flat surface.
b) Inserting the needle into the cap, using one hand.
c) Then using your other hand to pick up the cap and
tighten it to the needle hub.
 Syringes

Syringes have three parts:

1. The tip, which connects with the needle
2. The barrel, or outside part, on which the scales are
printed
3. The plunger, which fits inside the barrel
 Types Of Syringes

Several kinds of syringes are available in differing sizes

shapes, and materials.
Syringes range in sizes from 1 to 60 mL. A nurse
typically uses a syringe ranging from 1 to 3 mL in size
for injections (e.g. subcutaneous or intramuscular).
 Types Of Syringes

‡Standard- comes in 3ml,5 and 10ml

‡Insulin-designed specially for use with the ordered dose
of insulin
‡Tuberculin-narrow syringe, use to administer small or
precise doses such as pediatric dosages.
‡Should be used for doses of 0.5ml or less
‡Pre-filled Single dose Syringe
‡Autoinjectors
 Cannula

A cannula is a flexible tube that can be inserted into the

body. A venous cannula is inserted into a vein, for the
administration of intravenous fluids, for obtaining
blood samples and for administering medicines.
 Types Of Cannula

Types of cannula are

‡IV cannula pen -like model.
‡IV cannula with wings model.
‡IV cannula with injection part model.
‡IV cannula -ytype model.
‡Butterfly Canula
Pen like Model Canula
Canula with Wings Model
Canula with Injection Portal Model
Y-Type Model of IV Canula
 Parenteral Drug Packaging

‡Ampuleʹglass or plastic
container that is sealed
and sterile (open with
care)

‡Vial ʹsmall bottle with

rubber diaphragm that can
be punctured by needle
 Advantages of the Parenteral Route
‡The IV route is the fastest method for delivering
systemic drugs
‡Preferred administration in an emergency situation
‡It can provide fluids, electrolytes, and nutrition.
‡Patients who cannot take food or have serious
problems with the GI tract
 Advantages of the Parenteral Route
‡ It provides higher concentration of drug to
bloodstream or tissues
‡Advantageous in serious bacterial infection.
‡IV infusion provides a continuous amount of needed
medication
‡Infusion rate can be adjusted.
‡To provide more or less medication as the situation
dictates
‡ Drug action can be prolonged by modifying the
formulation
Disadvantages of the Parenteral Route
‡Traumatic injury from the insertion of needle
‡Potential for introducing:
±Toxic agents
±Microbes
±Pyrogens
‡Impossible to retrieve if adverse reaction occurs
‡Injected directly into the body
‡Correct syringe, needle, and technique must be
used
‡Rotation of injection sites with long
-term use
Disadvantages of the Parenteral Route
Sensitivity or allergic reaction at the site of injection
‡Prevents scarring and other skin changes
‡Can influence drug absorption
‡More expensive and costly to produce
‡Trained person is required.
‡Require specialized equipment, devices, and
techniques to prepare and administer drugs
‡Requires strict control of sterility & non pyrogenicity
than other formulation
 References

‡Fundamental of nursing by Erab & Koizer

th edition)
(6
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